Learning from failure is expensive,
but not doing so costs even more
Much of this issue of the Resource is devoted to investigating accidents - particularly those that result in hospitalization or death. For many of us committed to preventing workplace injury, illness, and death, focusing on accidents is a difficult topic. We prefer, for very good reasons, to talk about prevention.
I know that many health and safety professionals prefer to avoid the word "accident." While I share the frustration when a first responder or company official describes a predictable result as a "freak accident" in the news media, I think we confuse the topic when we say it wasn't an accident because it could be predicted. When law enforcement or the medical examiner calls it an "accidental death," they are talking about intent - not about predictability. The truth is that an "accident" refers to an unintended outcome, however likely or predictable it may have been.
In most contexts, I used another word: failure. When I see a fatality or hospitalization report cross my desk, I want to know how the system failed. In some sense, I want to know how I and the organization I lead have failed that worker. Because whatever else we may call them, and however good our programs and efforts are, the loss of life or the experience of a life-changing injury is certainly a failure. What else can we call it? And all of us - workers, employers, and government - need to understand those failures if we are to work together to prevent them in the future.
At its best, our efforts to understand the reasons behind our failures also reflect an understanding that this was not simply an "event" or an "incident" or a "statistic." Each of these occurrences has very real human consequences, involving individuals, their families, and their friends. Every fatality leaves a hole in the workplace, in the family, and in the community. And those holes must be acknowledged even as we go about our work.
In an article elsewhere in this issue, you can read about one of our primary investigators, Mike Riffe. I know from repeated experience that Mike never loses sight of the victim and the victim's family. The lost worker plays a central role in every investigation Mike does, and even the educational efforts Mike develops based on the accidents he investigates are perhaps best viewed as a memorial to those who lost their lives.
That's what we all should be working toward every time we set out to investigate, whether we are looking at a fatality, a hospitalization, or even a non-injury near miss. It is difficult to focus on those times that the system didn't work the way it should. It is a challenge to study our failures. But, it is part of the job. If we turn away, and we refuse to learn the lessons these events offer, we simply compound the tragedy.
So we will study. And we will learn. And we will do better.