Imagine this workplace injury scenario: A worker is seriously hurt on the job by an electrical shock. Years later, under similar circumstances, a worker is killed from electrocution. Why didn’t the company learn from the first incident? A new research paper lays out three barriers to learning from previous workplace injuries and how companies can overcome them.
Workplace injuries and other safety incidents must be understood as a source of knowledge.
That’s one of the main points in the paper, Workplace accidents as a source of knowledge: opportunities and obstacles, by Hernani Neto of the Univeresity of Porto, Portugal, published in the International Journal of Human Factors and Ergonomics.
However, here is another point that companies need to understand: Safety incidents don’t automatically become an effective source of knowledge. Companies have to work at it.
Just because a company suffered a close call or an incident with just minor injuries doesn’t mean that it will automatically learn from the incident and prevent similar ones from occurring in the future.
Specifically, companies have to work to break down barriers to the spread of information obtained from the investigation of safety incidents.
What causes these barriers? There are several factors.
In a survey of employees at one company that took part in the study, 71% said they avoided reporting smaller safety incidents that didn’t cause an injury or impede work.
Why didn’t the workers report these smaller incidents which could foreshadow larger ones? Some workers felt guilty or wanted to avoid punishment.
Culture of denial about workplace injuries
But there’s a bigger reason than that: Workers were part of a “culture of denial.” In other words, they thought a more serious incident couldn’t happen in their workplace.
Dodging a bullet in and of itself encourages workers to adopt the thinking that “it can’t happen here.”
And the culture of denial isn’t limited to workplaces that are more prone to incidents and injuries. One reason workers might be in denial is because their workplace has a lower than average rate of injuries.
Another barrier that appears: Companies don’t have a system to spread the information gained from an investigation. In other words, an analysis is completed, but the results don’t get spread to employees. Or, in some cases, the results are shared only with the employees who were most closely affected by the incident, while the learning could be beneficial to a broader range or all workers.
Finally, in some cases, incidents are reported; investigations are done; results are communicated. But training to avoid a similar incident in the future isn’t developed and provided. In other words, the learning isn’t reinforced on a regular basis.
Breaking down the barriers
How can companies break down the barriers to learning through the investigation of safety incidents?
The study recommends that companies develop systems to make sure the learning cycle from an incident is completed.
One example is a system developed by Celeste Jacinto of Portugal, known as RIAAT in Portuguese, translated as “the recording, investigation and analysis of accidents at work.”
Jacinto suggests the use of a standardized form to report the basic facts and circumstances involving an incident or dangerous condition. Included on the form:
- names of people involved
- room for a full description of what happened or what the hazard is
- any known active failures that contributed to the incident, and
- a list of witnesses.
The form is accompanied by a user’s manual with specific instructions on how to fill out the form.
The investigation and analysis occurs in four layers:
- People: analysis of human failures and individual factors
- Workplace factors: Examples are insufficient lighting, slippery floor
- Management factors: Examples are management of contractors, maintenance management, training policy, safety policy
- Regulatory factors: What safety regulations were violated?
When the investigation and analysis are completed, a plan of action needs to be developed.
Finally, it must be determined exactly how the plan of action is going to be implemented. Who are the targeted people who need to learn from the investigation of the incident?
Forms are provided for all steps of the process to serve as checklists. Have all the steps been completed?
One reaction to systematizing the incident investigation/learning process might be, this sounds like an awful amount of work.
But this gets back to one of the main findings of this study: Learning from a workplace safety incident won’t happen automatically. Companies have to take the necessary steps to ensure employees get the full benefit of any learning from a previous incident to make sure a similar, and possibly worse, one won’t happen.
Let us know in the comments section what you think about this study and how you handle learning from safety incidents at your company.
