AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |
Back to Blog
When an incident occurs, it is important to learn from the individuals involved what happened and why, so that the causes can be understood and addressed. If we looked at a group of investigations and saw several examples of various corporate policies emanating from different corporate departments that each in its own way impeded safety, we might recognize a need to systematically address the process used for policy setting. In the example used earlier, the investigation identified a corporate policy that had gotten in the way of safety. Failing to look longitudinally can result in addressing one manifestation of an underlying issue without addressing the underlying issue itself. When that happens, the opportunity is missed to conduct longitudinal analysis – looking across multiple incidents and incident investigations to identify common themes and common factors. In most organizations each incident investigation is conducted, reviewed, and communicated as an isolated event. Review the status of the action plan and see if it is adequate or if it was fully implemented. If another high-potential incident happens, determine if the incident(s) involved the same root causal factors. For high-potential incidents, investigate each one, but apply more rigor to the investigation and development of the action plan. For low-potential incidents, an abbreviated investigation is used to assure there are no immediate items that need to be addressed to prevent recurrence, or collect data and on a routine basis look for a high number of low-potential incidents that have similar causes.Ĥ. A mechanism is created to evaluate whether the incident had serious injury or fatality potential.ģ. The expectation is set that all incidents are to be reported, but clarify that all reports do not necessarily mean there will be a detailed root cause investigation.Ģ. Finally, the supervisor must consider the cultural issue implicit in an employee encountering barriers to safe performance but continuing with the job.ġ. #KNOWLEDGE OF INCIDENT INVESTIGATION METHODS IN OHS HOW TO#In addition to the policy issue, the supervisor must look into why equipment is being left in such poor condition and consider how to fix that system. The supervisor goes to the accounting manager who says that the inventory policy came from corporate to help control cash flow. The supervisor responsible for doing the incident investigation goes to the storeroom supervisor who says there was a change in the inventory policy, and that the policy came from the accounting department. The employee reports that she was not wearing goggles, because when she went to get a replacement for the scratched and oil-smeared ones, the storeroom said that they didn’t have any in stock. The limitations of this approach can be seen in the following example:Īn employee reports being sprayed in the eye when a line she was breaking released a chemical. However we need to consider the unintended consequences of setting up a process suggesting that a high quality investigation is desired, but is limited to that brief time frame. Another reason this rule might exist is belief that it demonstrates management’s seriousness about safety. This requirement may have begun due to the importance of collecting as much information as possible within a 24-hour window because things like people’s memories and conditions at the incident location can change. An interesting and confounding aspect of many incident handling processes is the requirement that an investigation be completed in 24 hours.
0 Comments
Read More
Leave a Reply. |