Detailed Accident Analysis Can Prevent Future Problems
- Published: Tuesday, 01 April 2008 08:00
RANDY K. LOGSDON
The primary purpose of your accident prevention systems is just that: accident prevention. Your organization probably employs any number of accident (injury and property damage) systems. Some of the more traditional systems are:
- Safety Meetings
- Posters, Signs, Bulletin Boards & Slogans
- Safety Suggestion Box
- Safety Committees
- Established Safety Rules
- Disciplinary Procedures
Some organizations employ more interactive accident prevention systems:
- Behavior-Based Safety (observations)
- Job Safety Analysis (or equivalent)
- Participatory Management
- Risk Assessment (analysis)
- Safety System Audits
- Preventative Maintenance
- Performance-based Rewards
DON'T LEAVE OUT THIS SYSTEM
One management system was left out (above). It's important, but you may not consider ìaccident investigationî as an accident prevention system. After all, it is not applied until after the accident (injury, property damage or near-miss) has already occurred. But, remember that the investigation is supposed to identify primary and contributing causes. By addressing those causes, future ìaccidentsî will be prevented. Let's restate that a bit differently.
An accident investigation should really be thought of as loss analysis focused on system errors. You've often heard that during an ìinvestigationî we're looking for facts, not fault. In reality, we are so accustomed to focusing on fault that, in the end, we place fault on someone or something. Loss analysis (although post-accident) can truly be classified as ìsaccident prevention.î
Hurricane Katrina was a natural disaster responsible for billions of dollars in damage and more than 1,400 deaths. Of the nearly 12,000 persons reported missing, 135 were still missing 11 months after the storm.
Someone had to be held accountable ó FEMA, the governor, the mayor, the president. The focus should have been on identifying the system errors and making corrections. While the press was looking for someone to blame, the Department of Homeland Security was quietly analyzing system errors and implementing changes to those very systems that would really improve natural-disaster planning.
As a result, similar events in the future will be preceded by improved warning and evacuation procedures. Post-event emergency response will be better organized. Both human and equipment resources will be more readily available. Fewer casualties will occur.
An analysis (not investigation) needs to be objectively conducted after a loss, whether it's from a catastrophic disaster, a serious injury or damage to equipment. Your organization has systems in place that are supposed to prevent these events. Yet, this is not as simple as it seems.
People are accustomed to blame-focused investigations. Certainly, human error is a common factor in system error and self-preservation often conflicts with open cooperation. A good loss analysis requires serious effort, especially when system errors under the control of management are identified. More on this next month.