Recently I was involved in a discussion about the cause of an incident that resulted in a serious injury.
It was interesting to me that the people involved in the investigation, had all been through this process many times, before. We had been in claims meetings where the objective was to discuss strategies to mitigate potential losses and we had all been involved in lengthy litigated cases during our careers.
After a few minutes of relaying the facts and displaying the evidence related to this incident, collectively, the group concluded that the individual was non-compliant in violating a safety regulation - and that was the reason the individual was injured. I will tell you that pointing the finger at the injured party is usually not where safety professionals find causation, but sometimes groupthink can be a real phenomenon.
Then, someone in the group mentioned the Titanic. It might have been easy to blame the Titanic’s captain for the disaster. He was going too fast in waters known to have icebergs… he didn’t order his watchmen to use binoculars, which limited the distance they were able to see… he ordered a turn to starboard instead of port… a host of reasons. Clearly the captain’s fault, then.
The Titanic was actually compliant with the maritime safety regulations of the time, yet carried only enough lifeboats to hold one third of her passengers and crew. What if safety regulations had required the Titanic to have enough lifeboats for all of her passengers and crew? Clearly the captain’s fault, then?
This struck a chord with the group. The room got quiet as we considered the possibility that perhaps we might be choosing the easy answer. The group decided to reconvene in 24-hours to take a fresh look at the facts.
When we reconvened, the discussion centered around the question of what non-compliance was really telling us about the incident. Yes, the individual was non-compliant, but were they properly trained? Did we perform employee observations to determine if there was a knowledge gap or perhaps a behavioral issue? After all, nobody comes to work in the morning with the intention of sabotaging their well-being. The point of our investigation was not to find bad apples, it was to find ways to improve the organization’s safety approach in order to prevent injuries.
I left the meeting thinking about something Sidney Dekker, professor, author and safety scholar often reminds us of, which is… being mindful. If we set out looking for non-compliance, we will probably find it.
For anyone who deals with these kinds of challenges as I do, we should be mindful not to let the bad consequences of an incident, automatically lead us to the conclusion that the incident must have been caused by an individual’s bad actions, alone. There is always a process or system in place that should be examined - looking past the easy answers.
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