Post Accident Review - Learning From Mistakes

You should require your on site supervisors or foremen to thoroughly review any employee or public liability accident as soon as it occurs. The goal should be to identify the underlying causes of the accident and offer recommendations on what could be or should be done to prevent a recurrence. This process should provide significant insight into how your company can revise and/or establish new work practices and procedures that will reduce the likelihood of future accidents.
The process should follow every mishap or accident, not just unusual ones or particularly severe ones. Investigating (reviewing) each occurrence with an eye toward finding and correcting all the little things that contributed to each will help your company control and avoid losses and improve operations and profitability. Ignoring "minor" events or accidents is to postpone correcting a problem until it causes serious damage.
Post accident review is a problem solving activity. It is not a "witch hunt" to find someone to blame. It is an analysis of facts to find opportunities to improve training, work practices, tools, and procedures that will help your organization avoid similar accidents. The process need not be burdensome or create new paperwork. You probably already require the supervisors or foremen to gather and report the basic information about what happened, who, where, and other details necessary to process a workers' compensation claim. The same reporting form could be expanded to give them a place to report on their recommendations to management about how to avoid similar accidents. With a little training and encouragement, your supervisors can learn how to quickly examine the facts surrounding an accident and find several effective preventative approaches. Their assessments and conclusions are what you seek. How the supervisors report their findings and recommendations is completely up to you.
Of course, finding the real, underlying causes of things that go wrong is where most people come up short. When a lineman incorrectly hooks up a service drop, there is a strong tendency to believe the incident wouldn't have happened if the worker had been more careful. Thus, the "solution" offered is typically, "I told (the worker) to be more careful while connecting the service." The real causes of the accident have not been identified and, worse yet, by telling the man to "be more careful" we have essentially blamed him for his own accident.
There is a very effective technique for finding most of the real causes behind things that go wrong. We call it the "Why Flow Chart." While it is a very easy and effective technique, it requires some training. If you'd like to learn more about it, ask the Loss Control Consultant who visits your company or you insurance agent. But in the meantime, here are some relatively simple questions you and your site supervisors should always ask after every mishap or accident:

"If we fired the person involved in this accident, our company would never have this type of accident again, right?"
If the answer is "Wrong, it probably can and will happen to someone else sooner or later." then warning that person to be more careful has accomplished almost nothing to improve your company or its operations. You need to understand how he got into the situation in the first place and how you can help others avoid the same situation. Thus, the next question is:

"If this accident happened 6 times in 6 weeks, would we find a better solution than what we're inclined to offer right now?"
If you think about this question you will focus quickly on much more pragmatic and effective solutions. The erroneous believe that every accident is somehow unique blinds most managers and supervisors to the real solutions. This question is designed to get you past that erroneous belief that the incident was an odd-ball thing that you can't correct except by telling workers to be more careful. If it happened repeatedly, you would come up with a better solution. But to help you get more focused on the best possible solutions, always ask this next question:

"Did the worker involved actually need to be doing the task he was doing at the time of the accident?"
This is a more complex question and you will tend, at first, to answer "yes." Yes, the worker needed to install that cross-arm at the pole top. "Yes, the worker needed to get that pole off the rack and onto the pole trailer. But wait! If we pre-assembled the cross-arms before we set the pole, then he could do it on the ground, or even in the shop. If we planned to load poles using a forklift or ramps or even an old bucket truck that we keep in the yard, nobody would have to lift poles. Frankly, you can probably imagine many more, better alternatives to these simple situations. And, sometimes the issue isn't the task itself, it is whether this individual was the best or the properly trained person to do the task. This question deserves careful consideration.

If you and your supervisors use these simple questions, and nothing more, to probe at what you see in front of you after an accident, you will probably get far better results from your post accident reviews than you have until now. Learning from things that go wrong is what it takes to get better, and that is what post accident reviews are all about!

The purpose of this article is to share ideas, management concepts, and information which may be of interest to environmental abatement contractors. The ideas and concepts contained in these articles come from various sources and authors and are, therefore, individual opinions and/or conclusions, and should be viewed by the reader as such. Any information provided by the editors and companies responsible for these articles is believed to be accurate at the time of publication. The editors, contributors, and companies who collaborate to produce these articles assume no liability or other responsibility for the accuracy of the information or the results (or lack of results) which may be experienced by the readers in applying or using any ideas or opinions contained in the article.

You should require your on site supervisors or foremen to thoroughly review any employee or public liability accident as soon as it occurs. The goal should be to identify the underlying causes of the accident and offer recommendations on what could be or should be done to prevent a recurrence. This process should provide significant insight into how your company can revise and/or establish new work practices and procedures that will reduce the likelihood of future accidents. The process should follow every mishap or accident, not just unusual ones or particularly severe ones. Investigating (reviewing) each occurrence with an eye toward finding and correcting all the little things that contributed to each will help your company control and avoid losses and improve operations and profitability. Ignoring "minor" events or accidents is to postpone correcting a problem until it causes serious damage. Post accident review is a problem solving activity. It is not a "witch hunt" to find someone to blame. It is an analysis of facts to find opportunities to improve training, work practices, tools, and procedures that will help your organization avoid similar accidents. The process need not be burdensome or create new paperwork. You probably already require the supervisors or foremen to gather and report the basic information about what happened, who, where, and other details necessary to process a workers' compensation claim. The same reporting form could be expanded to give them a place to report on their recommendations to management about how to avoid similar accidents. With a little training and encouragement, your supervisors can learn how to quickly examine the facts surrounding an accident and find several effective preventative approaches. Their assessments and conclusions are what you seek. How the supervisors report their findings and recommendations is completely up to you. Of course, finding the real, underlying causes of things that go wrong is where most people come up short. When a lineman incorrectly hooks up a service drop, there is a strong tendency to believe the incident wouldn't have happened if the worker had been more careful. Thus, the "solution" offered is typically, "I told (the worker) to be more careful while connecting the service." The real causes of the accident have not been identified and, worse yet, by telling the man to "be more careful" we have essentially blamed him for his own accident. There is a very effective technique for finding most of the real causes behind things that go wrong. We call it the "Why Flow Chart." While it is a very easy and effective technique, it requires some training. If you'd like to learn more about it, ask the Loss Control Consultant who visits your company or you insurance agent. But in the meantime, here are some relatively simple questions you and your site supervisors should always ask after every mishap or accident: "If we fired the person involved in this accident, our company would never have this type of accident again, right?" If the answer is "Wrong, it probably can and will happen to someone else sooner or later." then warning that person to be more careful has accomplished almost nothing to improve your company or its operations. You need to understand how he got into the situation in the first place and how you can help others avoid the same situation. Thus, the next question is: "If this accident happened 6 times in 6 weeks, would we find a better solution than what we're inclined to offer right now?" If you think about this question you will focus quickly on much more pragmatic and effective solutions. The erroneous believe that every accident is somehow unique blinds most managers and supervisors to the real solutions. This question is designed to get you past that erroneous belief that the incident was an odd-ball thing that you can't correct except by telling workers to be more careful. If it happened repeatedly, you would come up with a better solution. But to help you get more focused on the best possible solutions, always ask this next question: "Did the worker involved actually need to be doing the task he was doing at the time of the accident?" This is a more complex question and you will tend, at first, to answer "yes." Yes, the worker needed to install that cross-arm at the pole top. "Yes, the worker needed to get that pole off the rack and onto the pole trailer. But wait! If we pre-assembled the cross-arms before we set the pole, then he could do it on the ground, or even in the shop. If we planned to load poles using a forklift or ramps or even an old bucket truck that we keep in the yard, nobody would have to lift poles. Frankly, you can probably imagine many more, better alternatives to these simple situations. And, sometimes the issue isn't the task itself, it is whether this individual was the best or the properly trained person to do the task. This question deserves careful consideration. If you and your supervisors use these simple questions, and nothing more, to probe at what you see in front of you after an accident, you will probably get far better results from your post accident reviews than you have until now. Learning from things that go wrong is what it takes to get better, and that is what post accident reviews are all about!
The purpose of this article is to share ideas, management concepts, and information which may be of interest to environmental abatement contractors. The ideas and concepts contained in these articles come from various sources and authors and are, therefore, individual opinions and/or conclusions, and should be viewed by the reader as such. Any information provided by the editors and companies responsible for these articles is believed to be accurate at the time of publication. The editors, contributors, and companies who collaborate to produce these articles assume no liability or other responsibility for the accuracy of the information or the results (or lack of results) which may be experienced by the readers in applying or using any ideas or opinions contained in the article.