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Accident a blame or learn game?

Accident a blame or learn game clide management

What is accident?
An unfortunate incident that happens unexpectedly and unintentionally, typically resulting in damage or injury.
An accident or a mishap is an incidental and unplanned event or circumstance, often with lack of intention or necessity. It usually implies a generally negative outcome which might have been avoided or prevented had circumstances leading up to the accident been recognized, and acted upon, prior to its occurrence.
Accident Investigation
A solid accident and incident investigation process is a critical component of an effective safety program. After all, if you complete a thorough investigation and determine why an accident or incident occurred, you have the information and knowledge for preventing a future occurrence. The way to successfully accomplish this critical task is by drilling down to the root cause.
Engaging in a methodical, systematic, and comprehensive root cause analysis is a proven method for achieving success. When properly structured, implemented, and followed, it is one of the most effective and efficient methods for performing investigations.

But the question is an accident is a blame or learn game.
It is observed that when an accident happens it is a hide and guide game. The first thing is how we can hide and get over it so that the good will of the organisation is not destroyed and are saved from legal action.
The second part is interesting in the process, the guide game. Many come forward to guide how the accident happened and whom to blame. In the process many important learning points get lost, which could have been captured so as to avoid further such accident.
After the accident, for few days the safety remains the priority and any violation is a punishable offence. Slowly as the days pass, safety again takes the side line and routine work starts.
Major three component to be pointed for blame game are :-
  • Equipment failure
  • Procedure failure
  • People failure
There can be many learning points such as in equipment failure :-
  1. How did it failed?
  2. Hope the inspection was not carried out?
  3. If carried out, no seriousness was maintained by the observer?
  4. If it was then why the observation was not reported?
May be the worker observed some points, but due to work pressure, priority would have remained first work than report.  In the hide & guide game many points remained unnoticed and this raises serious concern on the safety culture of the organisation.
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So Learning From Accidents is importantAccidents – “errors”, “mistakes”, “omissions”, “oversights”, etc. – are opportunities to learn from and to take steps to make sure that the same or similar will not happen again.
Unfortunately accidents are not a preferred learning source as the outcome of an accident may be major or even catastrophic, to the individual, the organization or to society.Learning from accidents with relatively minor consequences, or no consequences at all, is a better way … but you need to have a risk classification system to make them important. So that resources will be made available to investigate, analyse and take remedial actions. How many organisations have such a risk classification system? Do you? And do you have the knowledge and experience to use it effectively?
It is far better to learn from incidents, from the events that did not result in loss but could have, if the circumstances would have been different. For that, you also need a risk classification system, to assess what could have happened, just in case …..
By the way …. a risk classification system could also be used when evaluating deviations noted during inspections or behavior observations. If fact, the substandard acts or conditions observed could result in loss …. if the circumstances would have been different.
Determining the potential risk is the objective of risk classification. The outcome of the risk classification process helps to determine:
  • which levels of management should be involved
  • which investigation methods should be used
  • whether a team approach should be used to contribute to investigation and analysis; possibly including (external) expertise
  • the management level of the team chairperson
  • selecting remedial actions and deciding budget provisions
Learning from accidents – How?Create a separate team who can only focus on the learning objective from the accident when the investigation is ongoing.
Learning from unwanted events requires:
  1. Know what happened – register facts for communication and cause analysis
  2. Know why it happened – carry out cause analysis
  3. Know why the consequences were what they were – evaluate post event actions
  4. Know what to do – so it won’t happen again
  5. Carry out remedial actions – make sure they will be done well and on time; assign responsibilities
  6. Let others know – communicate and report so they will learn as well

An organisation can “learn” by storing the information in a database so it can be retrieved at a future date …. if someone remembers to check the database. Better, the reasons why the accidents occurred should be translated into safe work methods, procedures and into the management system. It then becomes part of the organisations “memory” or, if you want “the way we work”.