Accident Incident Investigation
When it’s made known that an incident has occurred, as safety professionals, we are eager to get into the details and figure out the basics. What, How, When, Who and Why…? The end goal, after an injured worker is taken care of or property secured, is to ensure it doesn’t happen again. A more realistic outlook is that the risk will be reduced and the probability of a repeat very low. Everything we do in life has a certain level of risk associated with it.
The chances that an investigator/s meets their end goal is based upon how they approach the upset condition. In my experience, work activities in operations have been looked at in two different ways: Routine and non-routine work. Routine work in a mature and well managed safety program should be designed such that all hazards for all tasks performed are identified, and effective controls at each step of each task implemented to reduce the risk to acceptable levels. The maturity of safety programs and having effective controls is a whole other subject that we will not get into today, but they both have a profound impact on risk management. So, when an incident occurs while performing routine work and the basics are known, it’s imperative that we ask ourselves; What changed? What was different today? Did the environment in which work was being performed change? Did we change raw materials? What tool/s did we not have available? What was the condition of the tools available? The idea here is that there was something different because routine work and its outcomes should be predictable.
Non-routine work on the other hand creates its own challenges, as it’s not an everyday task. One would not have the familiarity like one would with routine work. Non-routine work in most operations will not have a standard operating procedure (SOP) or Job Task Procedure (JTP) and for that matter it needs to be well planned out. Field Level Risk Assessments (FLRA) or Pre-Job Hazard assessments (PJHA) coupled with work specific permits are the norm in most operations. These processes are used to capture how the work is to be performed and managed. The premise behind this non-routine work management (FLRA/PJHA) is that the work will be performed by a “competent/qualified” person/s, the right tools are being used, the conditions are appropriate for the work, effective controls will be implemented for each potential hazard description, work is authorized by a “competent” person/s, to mention but a few. When an incident occurs while performing non-routine work, one would need to look at every aspect of the planning and management of the work and the folks performing the work. In my experience, scope change has to some degree been a factor in most incidents. The scope can change in a variety of ways. The methods by which the work was to be performed, the environment in which the work was taking place, someone else other than the original workers came in to help with the task; Something different from what was expected came about. The devil is in the details. Having said that, scope change in a mature process should be accounted for. The key is how a worker or group of workers approaches a scope change. Do they know, or are they instructed to “STOP” and reassess? Do they know to consult or seek help from a subject-matter expert?
Within the scope of routine and non-routine work, situations out of the norm may come about. What makes a difference is how workers react to those changes. Remember the aphorism, Error is to Human. We are human, after all, and we will make our fair share of mistakes. How organizations manage everything else around us humans is all so important!
