There are many reasons why serious incidents occur.
In our experience there are always very common causes to serious incidents and surprisingly these are almost universally involved. Normally there is more than one failure that has led to the incident and it's important to understand this (the Swiss Cheese Model illustrates this).
Learning from lessons is key, check these Top 10 out and see if any of these ring a bell. If they do - get ahead of the curve and design these out of your health and safety system.
Remember, if you are blaming incidents on people, then you are probably not looking deep enough into why your incidents are occurring (Root Causes). Rarely are workers the cause of the incident, even if they made a mistake.
Breaking it Down: The Top 4 of 10.
- Management of Change - Workplace change is a key risk factor and a common cause of serious accidents. This is the number one reason serious incidents occur that we investigate. Two types of change can occur that induce serious incidents. Firstly, a short notice change in the scope of work (work hours, number of tasks etc.) or environmental conditions (wind, rain, terrain, machinery & equipment etc.). Second, a more strategic change in the business-like addition of a new loading yard where traffic management was not adequately planned as an example. Plan your short notice operational or strategic changes deliberately and factor all risks through the life cycle of the process. Manage change or it could manage you! Are You Managing Change Effectively? - Intesafety Workplace Safety
- Risk Assessment - High risk work or design must be planned well in advance and risk assessment must occur at this time. In conjunction with management of change, this is the number one reason serious incidents occur that we investigate. Two risk factors are critical. Firstly, the higher-level risk assessment to understand the job / design / operational processes and potential risks. This helps whole of process risk understanding and subsequent planning and control. Secondly, worksite job safety analysis (JSA) should help plan, identify and control workplace risks. This type of assessment should always be completed for high-risk tasks and all PCBUs involved should understand and sign off on it in a shared workplace environment. Both these two areas of risk do not operate in isolation, they must work together to be effective. Identify and control your risks or they could end up controlling you!
- Contractor Management - Managing contractors is a key risk and an area we find contributes to many serious incidents. We find the more contractors involved in the contractor chain the more likely a link in this chain can be broken leading to serious incidents. High-risk contractors should be prequalified to ensure they can work safely, where doubt exists, they should not be engaged. Clear standards are required (even in highly regulated industries) and these should be understood throughout the PCBUs engaged. Don’t leave it up to your contractors to define your work standards, make sure you do as the engaging PCBU and make sure you monitor compliance. Our experience is that even though pre-qualifying your contractors is important, it’s not as important as monitoring them to ensure they are working safely. We’ve seen so many organisations achieve 100% in various pre-qual standards and yet not be working safely when we visit a site. Monitoring is arguably much more important than pre-qualification (that’s a different discussion for a different blog).
- Safety by Design - Safety starts with the design of facilities and equipment. Always ensure both are designed to a standard and all design and operational risks are comprehended throughout its lifecycle. If you are importing equipment / machinery, ensure guarding is specified in the purchase or installation agreement. Retrofitting guarding can be very expensive. Lack of fit for purpose guarding is the leading cause of incidents we investigate in the safety by design space. Design safety in at the start, it’s so much easier and actually less expensive that retrofitting after the fact.
The 6 Left of 10.
- Training & Competency - Workers must be trained for their tasks and must also be competent to complete them. Make sure that competency is tested for high-risk equipment and processes. Trained and competent workers are the cornerstone of safe organisations. And remember, trained and competent are two different things. Invest in your people. Never Shoot a Hostage - Intesafety Workplace Safety
- Fatigue Management - Working long hours is a key cause of accidents. Factor travel time into fatigue hours and make sure cumulative fatigue is factored. Many accidents occur at the end of the week, end of the shift or between the hours of 2am and 4 am and 1pm to 3pm. Shift workers are more at risk. Accidents occurring at these times / periods are a key indicator of fatigue. Driving is a key risk for fatigue and watch this very closely when this risk is in your business. Fatigue is a disproportionate root cause of many vehicle accidents. Understand fatigue and manage it, especially at those at-risk periods.
- Supervision & Assurance - Worksite monitoring and supervision needs to occur routinely and formerly for high-risk work so that unsafe conditions and behaviours can be identified and corrected. Supervision is so important to safe work and so often overlooked. We can all remember those supervisors which helped us in our early years in the workforce by offering helpful advice and supervision as we found our legs. You cant place a price on good supervision.
- Calibrated Equipment - All calibrated equipment should be tested to confirm it operates according to its designed parameters. Failure to calibrate specialist measuring equipment does not provide the required assurance for high-risk work requiring tolerances to be measured. You may be surprised to learn that multi-meters, data testers, laser equipment, torque wrenches, thermometers, scales, micrometeors, callipers, pressure meters & many more may require calibration depended on what industry you are in. Understand the requirements for calibration, you might be surprised.
- Incident Investigation - Always align your investigation threshold to near misses (where something serious could have occurred but didn’t – i.e., a load was dropped from height and didn’t hit somebody but nearly did). This gives you an opportunity to get in front of the incident chain and rectify any gaps to prevent an escalation to incidents. Often, we have found when conducting serious incident investigations that repeat near misses / incidents of a similar nature have occurred but have not been investigated correctly, leading to further near misses and incidents. Repeats also occur because, root cause analysis is poor, corrective actions are insufficient or not implemented, from poor analysis and ability of organisations to learn lessons. Sadly, we see a bit of this. Don’t be this kind of organisation.
- People - Accidents invariably occur because people are involved and sometimes a mistake is made. We all make mistakes. Its important not to adopt a blame culture when investigating (and generally) to also have a process to establish what kind of human factors were involved to ascertain culpability. A deliberate violation is very, very different from an inadvertent mistake and this importantly also dictates what kind of HR actions may or may not be required. Remember, rarely are people the root cause of incidents, look deeper than this. This is the single most common mistake most businesses make. Try not to be this business.
To reduce the safety clutter, this is the end 😊.
In summary, try to avoid the top 10 reasons why “shit happens” and you will be well on your way to working safely. Interestingly, if you want to know how to operate a good health and safety system, understand how to conduct a good investigation. It really teaches you how things can fail and hence how things wont in the reverse.