Traditional incident investigation
Traditionally and due to misconceptions of employees, executives, managers & supervisors, incident investigation was always focused on (b), (c) & (d) of the timeline.
This resulted in a focus on symptomatic causes.
Some common examples from incident investigation reports are:-
- The employee failed to wear protective equipment.
- The guard failed.
- There were no guards in place and the employee lost their fingers in the machine.
- Human error.
Issues & problems with this traditional approach are still linked with insufficient training
Deeper questions were rarely asked as a way of trying to understand management systems & the dynamism of workplaces.
- Why was the employee not wearing their protective equipment?
- Why did the guard fail?
- Why were there no guards in place?
- Why was there human error? For a good example of this often cited subjective statement & an ineffective initial investigation see – Air New Zealand Flight 901
Only management control & systems can:-
- Train employees how to use & care for protective equipment (PPE).
- Design machine guarding to be safe.
- Create continual improvement in performance.
In Part 8 we start looking at how these concepts are linked with & can be used to understand incident investigation for the identification of root causes.