One of the cardinal rules of incident investigation is never to recreate an incident up to the direct causes or you will recreate the incident again. Direct causes are substandard acts and conditions that precede the loss or the incident. This dry, somewhat academic rule was illustrated in the southern USA when, in a mill, a worker woke up bruised and battered and could not remember how this sad situation could have occurred. The team investigating the incident asked him what was the last thing he remembered and he complied. “The last thing I remember is doing this” he said, sticking his foot in the conveyor belt system. It promptly dragged his foot in and then him, and flung him twenty feet in the air where he landed on a pile of lumber, knocked unconscious. The team now knew how he obtained his mysterious bruises and battered body. Never, ever, recreate an incident down to the direct causes or you will recreate an incident.
I teach the definition of a hazard: something which has the potential to cause harm or injury. An incident, then, is that potential realized. Often when I am teaching hazard assessment I have my overhead projector plugged into a power source and the cord is stretched taunt about six inches off the floor, an excellent example of a tripping hazard. It should be, of course, taped down, or an extension cord used but often, these are not available in the venues that I teach in so I have to be careful, use common sense and watch what I do. Frequently, students comment on this obvious oxymoron of a situation that I am facilitating hazard assessment and have to contend with so obvious a hazard. Little do they know what lies in the deepest, darkest corners of my psyche:
I fear one day I will be teaching a class in accident investigation and I will trip over the cord bringing the TV, VCR, Overhead projector down on my outstretched limbs and then the class will have an actual working case study to apply their learning on. In the deep, dank corners of my psyche I can see me writhing in agony while some wag pulls out a ruler and measures the angle of the objects striking me while another draws my outline, in chalk of course, on the floor. The others will determine the direct causes of the accident, which will be an unsafe act: the cord not plugged in properly or not using an extension cord and the fun begins. Several students will get into a spirited discussion of what incident theory to utilize to determine the root cause and whether the tap root system or the systemic failure of the management system works best to explain this sad occurrence.
Then other students will work on determining the multi-causational nature of my incident, tracing the factors that lead to me tripping over the cord. Was it improper motivation? Was it fatigue? Physical limitations.the list goes on. Meanwhile, moaning in agony I will cry out for first aid training and then remember.. I never taught that as the students decide how best to set my leg!
In saner moments it reminds me of the old bank machines.. I remember you had to insert your card, key in your pin number, then the amount you wished to withdraw, take the money then take the card and your record. Under this system the bank was finding that a great many cards were being left behind and it was most expensive to the system. They hung signs exhorting their clients to be careful and to remember their cards.it had little effect. Finally, someone examined the system and said.let’s do a change: in the new system you insert your card, key in your pin number, then the amount you wish to withdraw, remove your card then take your money and the record. What was happening in the old system is once a number of people got their money they were finished and left, leaving behind their cards. In the new system, this is impossible to do, you must remove your card before you can take your money.the number of cards left in the machine is now close to zero.such a simple change.. and so powerful. Getting back to the nightmare scenario in my soul.the easiest thing to prevent this from happening is to bring a spare extension cord or to tape the cord myself, therefore eliminating the hazard..
Yes, incident investigation can be a hazardous process but a very necessary and fulfilling one as well ( and I have something on my to do list!).
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