I've had a summer with a major investigation underway and as
well, running training sessions. Delivering investigation training
during the summer holiday season may be a good sign that companies
are gearing up for a busy fall and winter season.
Here's something that offers a little humour and has an investigation
message including overlooking obvious evidence, jumping to conclusions,
interviewing technique, and discipline. How many more do you see?
For what it's worth, the dog days of summer:
Jeff
What Went Right?
Investigations by their very nature tend to focus on what
went wrong and we seldom give much thought to what positive safety
practices were in place. As excessive, uncontrolled energy is
involved in every workplace accident an effective investigation
technique is that of Energy & Barrier Trace. It walks
you through a series of questions about an incident and focuses
on the type of energy involved and what barriers (work practices,
training, supervision, PPE etc.) were in place to keep the energy
under control.
The process requires us to answer the following questions:
What type of energy was involved? (gravity, electrical, chemical
etc.)
What barriers (safeguards) were already in place?
Which of those barriers failed?
How could the failed barriers be improved?
What additional barriers might be added?
Questions 2 & 3 ask what controls or barriers
were in place to keep the worker safe and which of these failed.
We tend to hone in on system failures, but there were likely barriers
that did not fail and we seldom look at these closely, as for
the most part they are doing their job.
The failed barrier usually is quite evident, and we are quick
to fix it by making it stronger and that's what Question
4 is asking. So while you are fixing the obvious failures,
there may be an opportunity to substantially improve the level
of safety by strengthening other existing barriers. Completing
a written list of all existing barriers as part of your investigation
will encourage you to think not just about any failed barriers,
but also those that did not fail.
Question 5 requires us to look at new ideas
or practices that could be put in place. I find workers are very
good at brainstorming new fixes, as they intuitively seem to understand
the concept of energy. Next time you have an incident, get front
line workers involved and walk them through the questions.