What Happened?

This phenomenon is common in scientific research and is called the paradigm effect. The term paradigm is often incorrectly used as a synonym for outlook, but in the scientific context it refers to a belief held so intently that it blinds researchers to other discoveries. This happens often in incident investigations, particularly among safety professionals who are emotionally invested in methodologies like Behavior Based Safety or a process safety tool.

A bias mentality that says, “I’ve worked a hundred and sixty years in safety and I think I know a little bit about . . . .” handcuffs too many veteran safety professionals who think they’ve seen it all. They can tell you what happened without even going out to the work area in which a hazard occurred. These safety experts are so convinced that the hazard was caused by X that they aren’t all that interested in finding facts, learning new information, or considering alternate explanations for an injury.

(4) SEEING HOOF PRINTS AND LOOKING FOR ZEBRA
The opposite of proving an assumption is the medical tendency known as ‘seeing hoof prints and looking for Zebra’, where new doctors look for exotic causes to problems. Instead, safety investigations should follow the old 14^th century principle known as Ockham’s Razor, which states that “entities should not be multiplied unnecessarily” . . . in other words, the simplest solution is usually the correct one.

(5) HASTE MAKES WASTE
Too often we do a sloppy job investigating an injury because we earnestly want to fix the situation and protect workers. But when we hurry through an investigation we usually get incomplete answers, supposition, and guesswork. Any job worth doing is worth doing right, and if anything is worth doing right it is incident investigation.

When we are investigating an incident we need to suspend judgments and make dispassionate observations about the situation. When reconstructing the situation that caused an injury, we need to think holistically and ask questions relative to:

Manpower
As much as I have devoted effort to deriding BBS fanatics who seek to find flawed behavior behind every failure, sometimes behavior does cause injuries. In most cases, if not all, behavior will – at the very least – contribute to the injury. When investigating manpower issues, it is especially important to focus on why and not what. It is also important to consider training and staffing issues when investigating the role of manpower factors in an injury.

Machines
When investigating the role in which machines played in an injury, we need to remember that some of the most basic machines – levers, pulley, gear and cog, wheels, incline plane, etc. – may not be immediately recognized as actual machines, i.e., a pencil is a form of a lever, and stairs are a form of the incline play.

Methods
The key to understand the role of a method in an injury is to discern exactly what the worker actually did differently than they normally do. This assumes there was no formal, specified change in a process method, because otherwise the worker would never have been hurt or they would be hurt all the time. Understanding how the method contributed to the injury may be the single most important element of a quality incident investigation.

Materials
Inferior materials or materials that are used inappropriately can contribute greatly to an injury. Asking how materials might have contributed to an injury, then substituting a safer alternative material, can result in widespread benefits. Take, for example, a task in which a cheap plastic ladder is used when sturdy aluminum ladder would be more appropriate. Not only does this revelation improve safety, but the next time a worker does that specific job, the change itself will remind us that other, similar danger exist where similar tasks are performed.

Environment
A hard analytical look at the overall work environment will consider contributing factors such as lighting, noise, line of site, or temperature and help us to hone in on subtle elements of the workstation that, in and of themselves, are benign. But when ‘stacked’ on top of each other for a compound impact, a catastrophic breakdown is all but certain.

Doing a good incident investigation takes time. Unfortunately, we are doing these investigations under great pressure to get to the bottom of things. But as a wise man once asked: “If we don’t have time to do it right, when will we have time to do it over?”