Everyone hates to hear that an employee was hurt on the job, no matter the severity. If someone is injured, can you say that you are doing everything in your power to prevent the incident from happening again?
For many of us the answer is yes, but for quite a few others it’s not clear. Investigating incidents and preventing them from recurring is be everyone’s goal. After all, no one wants to see others injured.
Unfortunately, scientists still haven’t figured out time travel, so going back in time to prevent incidents from occurring is impossible. But we do have the power to be proactive with safety protocols and prevent incidents from occurring in the future. Gordon Graham has a saying: “If it is predictable, then it is preventable.” To make incidents preventable, we need to study them, determine the root cause, and then put measurable corrective actions in place.
Root Cause
Typically, the root cause of an incident falls into one of these four categories:
- Unsafe Conditions (e.g. a ladder is inadequate for the job and an employee falls)
- Unsafe Acts (corners are cut to increase speed or convenience)
- Lack of Communication or Training (new employees aren’t told what to do or have no training on the task)
- Uncontrollable Events (e.g. an employee is at a stop light and a vehicle hits him from behind)
Root causes are not always easy to figure out, but with a little investigative work, you can determine what led to the incident. One easy route is conducting the “5-whys” analysis method that was developed by Toyota engineer Sakichi Toyoda sometime in the early 1900’s. 5-whys is a process where you start with the incident and ask “Why?” until you to get to the root cause. Rather than simply accepting the first answer that you arrive at, 5-whys forces you to examine further, possibly finding more critical causes. You could keep doing this exercise up to 100-whys, but 5 was found to be enough to get to the root of most any issue.
Measurable Corrective Actions
Developing corrective actions is an essential part of preventing incidents from recurring, and it doesn’t have to be difficult. The goal of your corrective actions is to prevent your root causes from showing up again down the line. These corrective actions need to be measureable and not generic like “train employees” or “review the incident.” When determining your corrective actions, think about what you can implement by following the safety hierarchy. Follow these steps for each root cause:
- Eliminate the hazard
- Substitute a less hazardous substance or process
- Apply engineering controls
- Utilize administrative controls
- Provide effective personal protective equipment
- Train employees
For some, you might be able to apply something to each one of these steps, but regardless, the more root causes and risks you can address from the top of the list, the better.
Safety Committee
The final step to preventing incidents from recurring is to review the incident. This can be done in two stages.
First, a safety committee or other committee that represents each department of your organization should review the incident report that includes your investigation, root cause, and corrective action. In this review, you are asking questions to make sure that nothing was missed and that the corrective actions address the root causes.
Second, review the incident with the right people and implement your corrective actions. Keep all names out of the incident report and the material that you want to present to your team. This step is crucial because you do not want to go through all of the work of your investigation and then withhold what you discover.
Without investigation and follow through, you are bound to see repeat incidents year after year. Investigations are one piece in the grand scheme of things that help your district manage your organizational risk. By managing risk and preventing injuries, you will ultimately save your district money, help your employees work more safely and be more efficient, and show your employees your commitment to the safety of your district.
Join us on May 21st for our webinar, “Fool Me Once: Preventing Accident Recurrence” with Adam Johnsen. Sign up today at csdpool.eventbrite.com.
