Without meaning to sound callous, workplace incidents can and should be seen as opportunities for system improvement and implementing a more robust risk management process.
In an Insight article from a number of years ago, we discussed that rather than focusing the blame on the poor old worker, we should be optimising the lessons to be learned from our incident investigations. Here we build on that advice with some specific areas to focus on.
There are three critical areas where lessons learned from incident investigations frequently are not fully identified or implemented.
- Identify all Contributing Factors
We would all like to think that modern organisations have accepted that workplace incidents don’t typically occur just because “somebody didn’t follow the procedure”. Whilst this may be part of the story (or not at all in many cases), the reality is that the vast majority of incidents occur due to more than one contributing factor.
There are many incident investigation models used today, and one of the core objectives for all of these models is to identify all of the contributing factors to the incident’s occurrence. Despite this, frequently factors such as fatigue, the weather on the day, the worker’s state of mind at the time and what was happening in the lead up to the incident are either not captured at all, or are buried within witness statements and not recognised as contributing factors.
- Action all Contributing Factors
This may sound like common sense, but it is critical that each identified contributing factor be allocated an action to address why it was present and how it contributed to the incident occurrence. Often the only corrective or preventative action resulting from an incident is to provide further training to the employee, leaving most contributing factors unaddressed.
- Identify and Review Other Areas Where the Same Incident Could Occur
If there is the potential for the same incident to occur elsewhere within the organisation (e.g. in another team or department undertaking the same or similar work activity), then it would make sense to alert that area and ensure they implement preventative actions or safeguards. That’s what Safety Alerts (or similar communiques) do, right? Well, yes and no. Safety Alerts are typically produced and distributed upon first becoming aware of an incident. At that point in time, the investigation is yet to commence and contributing factors (whilst some may be obvious) may not be all identified. It is when the investigation is complete, and all contributing factors have been identified, that other areas and activities where these factors exist should then be communicated with for their review and action if necessary.
Obviously, there is far more to incident investigations than the three areas identified above. That said, the opportunities for greatest improvement and learning lie largely with these three critical areas, and they prove highly effective in achieving the overall intent of why we do incident investigations in the first place: which is to prevent their recurrence and further injury to our people.
Please contact QRMC for more information.
