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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters

Safeguard Magazine

Look & Learn—Beyond the blame game

It’s always the worker’s fault. Yeah, right. BLAKE KYLE shows how employers can learn from mistakes by asking the right questions.

Accidents and incidents happen almost every day. These may be from mistakes made by workers, controls that aren’t working, or hazards which have not been identified.

Each year Site Safe sees several hundred real incident investigation reports sent for review. While employers investigate most incidents, the root or organisational causes of the incidents are often never found. The result is that the real causes are rarely identified and corrected and the accidents keep repeating themselves. Addressing two clear problems that keep the root cause hidden from employers helps to fix this.

But first, let’s define some terms:

  • • 
    Immediate cause: nearly all incidents and accidents involve some unsafe action by a person who did something against the rules.
  • • 
    Root cause: the reason for or the driver of the unsafe action.
  • • 
    Accidents and incidents: events that caused or might have caused harm.

Waiting until it is too late

Nearly all of the investigations Site Safe reviews are of incidents that involved some type of minor or serious harm injury. Serious injuries very rarely occur the first time an unsafe action occurs, and only a fraction of unsafe actions actually result in injuries.

All incidents which result in injuries have almost always happened before and can be anticipated and stopped if the right questions have been asked. When investigating the cause of an injury, ask “How many times did the unsafe action take place before the injury occurred?”

To prevent harm, employers need to identify unsafe actions before it is too late. Employers should put effort into investigating all incident reports. For example, people climb unsecured ladders every day and they don’t fall. Employers need to know if people are climbing unsafe ladders. If so, why did supervision or an audit fail to identify and correct the unsafe action before the injury occurred? Why wasn’t it reported as a near miss? Why wasn’t it fixed?

Blaming the worker

In nearly every investigation Site Safe reviews, the employer stopped investigating once the immediate cause – the unsafe action – was identified. Employers are not finding out the root cause of why the unsafe act was “needed”, or thought to be OK, or thought to be acceptable.

This observation is backed up by research from Aalborg University in Copenhagen which shows small business owners regard accidents as either unavoidable or the result of employee error, and there is no sense that they could have prevented what happened (as noted in the 11 March 2013 edition of Safeguard Update.)

In a recent case, the employers’ investigation determined the following:

  • • 
    What happened? An employee fell from ladder.
  • • 
    Root cause? The ladder was not secured.
  • • 
    Corrective action? Re-train workers.

Why didn’t the employer identify this and correct it before the injury? Why wasn’t it reported? Why did the workers think taking short cuts was acceptable?

Site Safe’s investigation determined that many workers had been using an unsecured ladder for almost an entire day, before one worker fell and was seriously injured. Although the company had a safety system that included audits, toolbox talks, safety plans and hazard reports, performance on these activities were not measured.

It was found that the audit programme was not working as the supervisor in charge of audits was not given feedback (checking or guidance) from senior leadership on the audits required regularly – whether they were done or not. The only KPI was on measuring lost time injuries. Workers would have thought it was OK to continue with an unsafe action and take shortcuts on this site, and not report the hazard.

As for corrective action, management must show leadership and place accountability on site leaders to measure safety performance and activities in the wider team. This sends a clear message to all workers on site to be a part of safety activities such as identifying the hazard and reporting them to management for correction before injuries occur.

Our investigation found:

  • • 
    There was a lack of leadership to demonstrate the value placed on safety performance.
  • • 
    There was a lack of accountability for the team on site completing the safety audit.
  • • 
    All of the focus was on injuries.

Look in the mirror

Employers must look in the mirror to solve most root causes. The very people who are carrying out the investigation or signing off on the completed report are the ones who share responsibility for accidents. This is the main reason employees are usually blamed for their unsafe acts. Root or organisational causes are almost always the responsibility of the supervisor and management.

The Independent Task Force on Workplace Health and Safety has recommended that the Government take up this issue in the new legislation. Inspectors will be reviewing employers’ investigation reports to ensure workers are not simply blamed for being clumsy or in a hurry.

The lesson is to stop unsafe actions before injuries occur, and to find out why unsafe acts are happening in the first place. Learn from mistakes by putting effort into non-injury investigations.

BLAKE KYLE is a senior safety consultant with Site Safe NZ.

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