IN RECENT years the country has seen a number of occupational accidents resulting in fatalities, permanent disability and non-lost time injuries.
In some cases, the same accidents happen again and again, causing suffering and distress among workers and their families. However, the solace is that all accidents whether major or minor are caused, there is no such thing as an accidental accident and as such we can find means of reducing them.
The causes of accidents are complex and interactive and as such, thorough and systemic investigations are required to unearth the many causes attributed to accidents.
Each incident or accident that occurs presents a learning opportunity to put things right, but one that could be wasted unless the effort put into analysing it focuses on discovering the true underlying causes of the incident rather than focusing on the people directly involved and the immediate causes of their failure.
In order to identify the most effective course of action, the investigators should go deeper than the superficial reactive level to understand the true underlying human and organisational factors that caused the accident.
Learning the lessons from what you unearth is at the heart of preventing accidents and incidents because identifying what is wrong and take positive steps to put things right is a key component to drive continuous improvement of Safety, Health and Environment performance through the prevention of repeat incidents
To get rid of weeds you must dig up the root. If you only cut off the foliage, the weed will grow again. Similarly, it is only by carrying out investigations which identify root causes that organisations can learn from their past failures and prevent future failures.
Root causes are generally management, planning or organisational failings. Likewise, most of them are a product of the organisation itself, as a result of its design (e.g. staff recruitment and placing, training policy, consultation and communication patterns, tiered relationship,) or as a result of managerial decisions. (e.g. setting unrealistic production targets vs safety of the employees)
As earlier mentioned, the accidents occur through the concatenation of multiple factors, for this reason dealing with the immediate causes of an accident may provide a short term fix.
But, in time, the underlying/root causes that were not addressed will allow conditions to develop where further accidents are likely, possibly with more serious consequences. It is essential that the immediate, underlying causes and root causes are all identified and remedied during the investigation.
Remember the Bible teaches us thatâ€ what has happened before will happen again. What has been done before will be done again. There is nothing new in the whole worldâ€. Ecclesiastes, 1, 9 (Good News Bible).
In occupational health and safety context this means that unless the causes are eliminated, the same situation will reoccur. The fact that an accident has occurred suggests that the existing risk control measures were inadequate.
All incidents no matter how small must be investigated as valuable lessons can be learned from them. â€˜Near missesâ€™, as they are often called are warnings of coming events. We ignore them at our own peril, as next time the incidents occur the consequences may be more serious.
And when carrying out these investigations, it is important to send the message out there that it is conducted with accident prevention in mind, not placing or apportioning blame.
Attempting to apportion blame before the investigation has started is detrimental to the whole process of preventing future accidents. Studies have shown that most organisations tend to look for faults in people as the main causes of accidents; this is a signpost of laziness and cowardice on the part of management.
In this type of situation the point that is often overlooked is that the performance of those at the sharp end (people may have made errors resulting in an accident) was shaped by local workplace conditions and upstream organisational factors and these conditions have been tolerated by management.
In fact no one failure, human or technical, is sufficient to cause an accident. Rather, it involves the unlikely and often unforeseeable conjunction of several contributing factors arising from different levels of the system to manufacture an accident.
It is critically important that the investigations are done systematically to allow proper information collection and ensure that the recommended control measures are implemented and the findings of the investigations are communicated to everyone in the organisation and beyond.
The benefits of good accident investigation are many as it will prevent recurrence of accidents and prevent business losses due to disruption, stoppage, lost orders, damaged corporate image and the costs of criminal and civil legal actions emanating from accidents can also be minimised.
The author is a health and safety advisor.