Free Safety Information
How Accidents are Caused and How to Investigate Them
Invariably accidents are caused by a number of shortcomings, failures, oversights, omissions, didn't do's, should have done's etc etc.
In every accident I have investigated there has been no single cause - there is always a number of causes or contributing factors, each interacting with the others in a complex way.
Most accidents are caused by a combination of poor communication, poor leadership, poor or inadequate training, tiredness, boredom, no procedures, failure to follow procedures, lack of experience, poor design, inadequate maintenance, lack of time and money, work pressure, the corporate culture ..... and the list goes on and on.
When you look at the contributing factors above it will be seen that most of them are the result of poor management (there are, I grant you, a few exceptions.)
The secret of effective and useful accident investigation is to establish the Root Causes of the accident in question (Root Cause Analysis).
And how to do Root Cause Analysis - easy, just ask "Why?" and keep on asking, "Why?"
"Why did he trip over the box?"
"Because ..........."
"Why?"
"Because ...........""Why?"
"Because ...........""Why?"
and keep on asking Why? (but not normally more than four or five times) until you can't ask it again - by this time you should have probably got a good idea of what one or more of the root causes are. Then repeat the process, "Why was the box there?" "Because ....." Why?" Because ..........."Why?"
Those of you who are familiar with Cause and Effect or Fishbone diagrams can use this Total Quality Management (TQM) technique to establish root causes because, essentially, it uses a very similar process. Sure, we can make Root Cause Analysis a lot more fancy if you want, but just using the above processes is a massive leap forward in understanding how and why accidents happen.
Accident prevention is all about systems which work, procedures which are prepared, understood and used. It's about leadership, motivation, of having the will to fix the root causes of accidents rather than embroidering round the edges.
In many organisations the same type of accidents happen over and over again to the point where they are predictable. When this happens it is usually a clear indication that the root causes of these accidents have not been fixed - and if they are not fixed the accidents will continue to reoccur.
And the point is that management has all the tools necessary to fix these problems of accident prevention and reoccurrence - it is just how to use the tools so you get Productivity with Safety that many people find confusing.
Bottom line:
- accidents always have a number of Causes
- keep asking, "WHY?" and/or
- use Cause and Effect or Fishbone diagrams to establish Root Causes
- fix root causes permanently to prevent accident reoccurrence
- management already has all the tools necessary
AchieveSafety - www.achievesafety.com
