What really happened?

What caused the accident?

A common problem with accident investigations is that they stop as soon as the immediate cause (eg an unsafe action) is identified. This produces endless calls for improved communication and/or better training.

In many cases, we need to dig deeper than this; to identify the root cause. Of course, both factors are crucial if the organisation is to learn from the experience. However, investigations that begin and end with the immediate cause will typically find the employee at fault.

What’s more challenging, and ultimately more effective, is to identify the organisational causes. Why did the worker feel it was okay to cut corners and/or ignore procedures? Given this, would more training really make a difference? And what does this teach us about “the way things are done around here” — the underlying culture, supervisory regime and tacit expectations?

Identifying the root cause requires a kind of free and frank dialogue — a process which “the blame game” undermines. But it is critical in making workplace safer.

The venerable Safeguard magazine has a good discussion on all this here: http://goo.gl/JCeAZC.

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