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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters

Safeguard Magazine

Comment—Idiot in the room

Ever been tempted to declare “What an idiot!” after reading an investigation report? LES BAK suggests a different approach would promote better learning.

Over 32 years in forestry and wood manufacturing I have seen many incidents and injuries to workers doing their daily tasks. I have myself been injured at work. These incidents result in investigations using a rigorous process with the intent to learn to prevent it from occurring again. These outcomes are then shared via safety alerts and bulletins so others do not make the same mistake.

When these learnings are shared it amazes me how often the first response is “What an idiot!” or “What was the person thinking?” These statements give a true indication of our maturity and safety culture – they blame the person for their actions and seek to reinforce that the speaker would never do such a stupid thing. Yet over and over we see the same injuries and incidents occur, even to those who have made these statements.

To learn from incidents and create a culture where people want to report and share, we must change our perception. This requires us to understand that everyone can be a genius in hindsight, and that the person involved in the incident was doing exactly what they thought was logical and safe at the time.


For example, I received an incident report that read “Operator accidentally bumped controls causing the head to move, almost striking another worker”. The actions listed to prevent this from happening were “Operator to be more aware” and “Never assume that the operator has seen you”. These preventive actions assume the two individuals were doing something wrong and/or not following the rules. Unfortunately, most incidents get this type of analysis and we believe we have solved the issue.

Now let’s look at it from a human factors perspective. I went back to the crew and asked questions to make sense of what had happened. When taking this approach, the truth about the incident reveals itself. Turns out the operator had been parked in front of the smoko hut because it was the end of the day and he was greasing and fuelling. There were multiple machines parked by the smoko hut as this was where end of day maintenance was performed. This made it a congested area for workers and machines. The machine was hydraulically locked out but the operator was getting ready to park the machine. He unlocked the hydraulic lock-out and then realised he had grease on his hands. He reached behind the seat looking for a rag, causing him to bump the controls.

The worker crossing the skid was also a machine operator so he did not have a hand-held radio to call for permission to walk past the machine. He looked up and saw the operator looking behind the seat and felt safe, as the operator did not look like he was about to move.

It was also noted that during the day the skid plan had designated zones and radio authorisation rules that kept people and machines away from each other. However, the risk of people and machine interaction at the end of the day in this congested area had never been identified.


This incident now makes sense. We can see that the decisions and actions of the people involved were completed with safety in mind. We also learn that the situation and the environment was a significant contributing factor to the situation.

The actions to take now are clearer. Stagger maintenance, or better yet, move the machine maintenance area right away from the smoko hut. The rules for zones and safe areas should be clear at all times and situations of the day. Workers could wear gloves to keep from getting grease on their hands.


Here’s a question to ask next time you are looking at a safety alert or incident report: “What would have made these actions or decisions make sense at the time?”

When we engage to understand how work gets done when multiple risks, procedures and rules are involved, we will learn that these procedures are designed for perfect situations, and cannot cater for all possibilities. Workers face conflicting procedures and rules every day and make the best decisions that make sense to them at the time.

I ask you all to have these conversations. Imagine how many fewer supposed “idiots” we would have out there.

LES BAK is health & safety facilitator with Nelson Forests Ltd.

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