In Order to Not to Let It Happen Again

We need to make sure this can never happen once more

Tin you lot picture this scenario?

Manager: And then Ben, I've just read through the incident report and I see you injured your back when yous ran the forklift into the bollard. I need to ask you a few questions as we need to make sure this type of incident never happens again. Information technology's not acceptable that any of our squad is hurt at work. So lets start by looking at your forklift license?

Ben: Certain here it is, I renewed it merely ii months ago. Hey dominate, you know that information technology's not the kickoff time the bollards take been hit, don't you?

Manager: That'southward great, your license is current. Let'southward not worry most any other incidents now Ben, it will just distract us from reviewing this incident. 1 of the things that makes a good investigation is focus. Now lets look at your training records, when was the last time y'all did a forklift re-consecration?

Ben: We did one of those 'Toolboxy things' a couple of weeks agone, it's all adept I signed the grade. Do you recollect information technology matters that sometimes I have trouble seeing that bollard, information technology'due south kind of in an awkward spot?

Manager: This is not bad, looks similar we are compliant with your license and training records and that'southward important. I'll need to take copies for our file. Like I said, we can look at the bollard later. Correct now, we need to focus on this investigation.

Manager: OK, last thing we demand to practise is complete the section of the course that asks what nosotros are going to practice to make sure this blazon of incident never happens again. It'due south important that we consult with our employees Ben, and then do you take any ideas?

Ben: Sure dominate, I remember I merely demand to take a bit more than care when driving, I'm a proficient commuter and I will be more careful next time. Although that bollard does seem to be a problem, oh and there are some times when the brakes seem a bit spongy, possibly we can wait at them as well?

Manager: That sounds groovy Ben, we know you're a good bloke and y'all didn't mean to do this, information technology was an accident and yep you just need to be more careful mate, these forklifts can be dangerous machines.

So let's wrap this upward at present that nosotros have got to the bottom of things. Nosotros know you have a license, and that yous take been trained and re-inducted, and we at present have an improvement idea to make sure this type of incident never happens again. Thanks for mentioning the brakes, that'south a good one. I'll make sure that the terminal maintenance report for the forklift is on the file, that will prove that the brakes were checked according to the schedule. I think we are all done at present, the form is consummate, that's slap-up.

Oh by the manner Ben, if your dorsum keeps playing up allow me know, but I'm sure you'll exist ok. You lot know nosotros accept a Physio who tin aid and I can arrange everything so you can stay here at work beingness a productive and valued member of our team.

Ben: Thank you boss, I'm sure it will exist all-skilful, I don't want to cause any problem.

Manager: Well done Ben, thanks for existence honest and involved in this important process. I'm confident that yous will be more careful from now on. That is all I really demand from you now Ben, thank you.

What did Ben'south manager learn from this investigation?

Have yous ever been involved in an incident investigation that was really just a checklist of organisational processes? Have in that location been times when you might have missed something because you became besides focused on 1 attribute and weren't open up to exploring?

I've been in these situations. I've written reports that were focused on checking off on corporate procedures rather than on understanding what really went on. I've prepared reports that were 'protected' past legal professional privilege and so that what we learnt could not be shared with others. I've written reports where I know that there were a range of other factors at play, only I had neither the time nor resources to explore them, so I 'parked them' for later (they are still parked!). Is this normal in hazard and safety, or is this just my experience?

If this is our arroyo, what gamble exercise nosotros really have of learning anything?

Alternatively, does an investigation ever have to be considered 'complete', or is it only the starting point for thinking and reflecting? If nosotros accept that most of our decisions and judgments are made in our non-witting, are nosotros e'er really able to 'get to the bottom of things'? What does information technology really hateful when we propose to 'brand sure this type of incident never happens once again'?

If nosotros are left with more questions than answers, could this be a 'good' investigation?

I was reminded of how clinical the 'incident investigation' processes can be when I received an e-mail from a friend this week request for my thoughts on an investigation that they are involved in. The aid they were seeking was about how to raise the issue of a less clinical incident investigation procedure with a team of managers whose focus is on compliance.

One manner to explore things differently is by considering Dr Robert Long'due south 'Workspace', 'Headspace' and 'Groupspace' fashion of exploring which he recently wrote about HERE. I've used this approach myself to follow upwardly on an event that also involved a forklift and I thought information technology might exist useful to share my experience.

To understand the context, I prepared the written report for an organisation I was working for (and not under legal privilege!) and we really shared it with the health and safety Regulator (WorkCover NSW). The study followed a serious incident where someone at work had their foot run over by a forklift. The person subsequently spent the following six months receiving specialist medical treatment. Some exerts from the written report I prepared are outlined below:

"WORKSPACE":

This Event (the proper name this visitor gives to 'incidents') highlighted that there were few formal controls in place to protect against the take a chance of mobile equipment (e.g. forklift) and pedestrians colliding. The forklift operates in tight spaces on some occasions and there are peak times when the forklift is required to exist used.

The team at the site identified that the time clock was located in an area that required people to walk into the path of the forklift. The team also identified the number of times that people walked through the share space could be limited. They implemented a gate that is now used when the forklift is in performance and too changed the location of some of the racking that was commonly used so that information technology was in an area where pedestrians don't go. All of these ideas came from people working at the site.

"HEADSPACE"

There are many factors that impact on the way people make decisions and judgments, a lot of these occur in the not-witting, a-rational heed (as opposed to rational, logical and analytical decisions). Some 'headspace' factors that may have contributed to this Consequence include the operator of the forklift being distracted; Mary (injured worker) not existence aware that the forklift was about to motility on and (non-conscious) determination making and complacency and over confidence by the forklift operator.

This should not exist confused with deliberate intent or neglect, rather acknowledgement that the decision to drive in the direction of Mary was not likely a conscious 'choice' just rather based on the physical 'cue' that Mary was walking. These factors can exist difficult to predict and control. The key way to deal with 'headspace' factors is to encourage a civilisation of open up questions and 'entertaining doubt' that assists in dealing with the possibility of complacency.

"GROUPSPACE"

Groupspace factors are those where the different departments on site work together. One of the fundamental recommendations agreed to past both departments (operations and sales) was to regularly take hold of up with each other (in Weick terms 'updating') which will help to develop a culture and surroundings where relevant information is shared and learning is maximized.

We also considered some aspects of culture at the site. For example, we explored the words and phrases that are ordinarily used and discovered that 'we only get things done' was a common phrase people utilize on site. Another was 'everything nosotros do is nearly the customer'. We sat and idea for a while about what these phrases could actually mean and do to united states. We've agreed that they probably do impact on how go near things and decided to think nearly this for a while longer and come up back in a month and talk through again.

Ah, the power of reflection!

What is your arroyo to investigating incidents?

Practice you extend your line of thinking beyond the typical approaches to incident investigation and 'explore', 'imagine' and 'listen'?

Is understanding and coping with ambivalence and equivocality one of the key skills we need to larn if we are going to do an constructive investigation? In fact, should we use the give-and-take 'investigation' at all? What is the discourse ordinarily associated with the word 'investigation'. What other words do you think we could use that would better describe a process that is focused on exploring and learning?

Do nosotros 'satisfice' when nosotros make decisions and judgments? Can nosotros ever really 'preclude this from e'er happening again'? What are the trade-offs and by-products of this approach? There are so many questions.

Do we need to find answers to all questions, or are nosotros comfy with ambiguity?

Every bit usual, I'd beloved to hear your thoughts, experiences and comments.

Author: Robert Sams

Telephone: 0424 037 112

E-mail: robert@dolphyn.com.au

Web: www.dolphyn.com.au

Facebook: Follow Dolphyn on Facebook

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Rob is an experienced safety and people professional, having worked in a broad range of industries and work environments, including manufacturing, professional services (building and facilities maintenance), healthcare, send, automotive, sales and marketing. He is a passionate leader who enjoys supporting people and organizations through periods of alter. Rob specializes in making the challenges of take a chance and condom more understandable in the workplace. He uses his substantial skills and formal grooming in leadership, social psychology of take a chance and coaching to help organizations empathize how to better manage people, adventure and performance. Rob builds relationships and "scaffolds" people development and change so that organizations tin achieve the meaningful goals they prepare for themselves. While Rob has specialist knowledge in systems, his passion is in making systems useable for people and organizations. In many ways, Rob is a translator; he interprets the complex language of processes, regulations and legislation into meaningful and practical tasks. Rob uses his knowledge of social psychology to help people and organizations filter the many pressures they are made broken-hearted about by regulators and various media. He is able to bring the many complexities of systems demands down to earth to a relevant and applied level.

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Source: https://safetyrisk.net/we-need-to-make-sure-this-can-never-happen-again/

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