Resource Newsletter
December 2012

A problem with accident investigations

"People do not fail, processes do…"

Most serious workplace accidents – accidents that happen infrequently but have catastrophic outcomes – are the result of a series of seemingly unrelated events, rarely perceived and never controlled or constrained. Such events persist as part of an organization's daily activities until someone makes a "mistake" – a subtle label for "operator error" or "human error" and the result is a fatality or catastrophe.

The task for investigators is to determine what went wrong. The problem with many accident investigations, however, is that they do not probe deeply enough into those seemingly unrelated events to determine why a fatality or catastrophe happened.

According to safety expert Fred A. Manuele, who has written extensively on the subject, such investigations often identify the technical reasons for an accident rather than addressing underlying causes. Because humans are inevitably connected with these events, it's easy for investigators to identify what the worker did wrong – the so called "operator error" – and call the investigation complete. Manuele argues that's not good enough; identifying technical defects and operator errors may not prevent future accidents and may lead to the belief that the problem is solved.

Operator errors are contributing factors in workplace accidents, but such errors are often linked to latent conditions within an organization as well. Manuele and others have used the term to describe problems such as "poor design, gaps in supervision, undetected manufacturing defects, unworkable procedures, clumsy automation, shortfalls in training, and inadequate tools and equipment," which may be present for years before they "penetrate an organization's defenses." Accident investigations that focus on operator error rarely consider the latent conditions that may have influenced what the operator did wrong.

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