Resource Newsletter
December 2012

A problem with accident investigations

"People do not fail, processes do…"

Manuele found that a large proportion of serious accidents happen when:

  • Unusual and nonroutine work is performed
  • Normal operations become abnormal because of an unanticipated problem
  • Maintenance work is performed
  • Sources of high energy are present
  • In-plant construction work is performed by in-plant personnel

These are also situations where tasks are often unique, making established routines difficult or unworkable. Any deficiencies in an organization's safety culture – including its technical, operational, and managerial systems – can increase an operator's risk of exposure, the possibility of operator error, and the probability of a serious accident. Latent conditions are the root causes of many serious accidents and can be deeply imbedded within an organization's safety culture.

The accident investigator's task is easy to describe: define the accident; develop a causal understanding of why the accident happened; identify ways to control latent conditions; and monitor the effectiveness of the controls. The problem is that the investigator's task is not easy to accomplish and, as Manuele suggests, it's not always done right.

So, what do you do if you're a small-business owner and you're faced with the task of participating in an accident investigation at your workplace?

There are many techniques to evaluate the root causes of accidents, but perhaps the most useful (now) is the "5-why" technique. It's relatively easy to use and it doesn't require advanced statistical analysis or data collection. The technique follows a structured question-and-answer sequence that contains a feedback loop to the previous question. By asking enough times why an event happened, the technique is supposed to "peel away the layers of symptoms" associated with a problem. The process continues until another answer cannot be justified and the root cause is narrowed to the last question or answer set.

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