So what should we do with knowledge of individual actions which appear to have contributed to an accident? Clearly, we cannot ignore the information, but we do need a better process if we want to get to the root causes and prevent similar events in the future.
Some of the key points to consider in future investigations include:
- Complexity is the enemy of safety - simplify any instructions or signage which is unduly long or confusing.
- We all know what is extremely unsafe or very safe - minimise “grey” areas. Ensure clear guidance for marginal circumstances eg Go & No Go criteria.
- Demands for quick incident investigations (as opposed to prompt incident reporting which is OK) may prevent gaining a deeper understanding – resist pressure to conclude investigations prematurely, but OK to provide interim reports.
- Look for weaknesses in the system – strengthen the system, not punishment, to minimise future errors.
- Reserve “punishment” for those who deliberately and repeatedly break our rules, or are grossly negligent.
- Procedures can’t describe all circumstances and prescribe every action, so we do need good intent - implement a process of controlled authority to allow the exercise of judgement by trained and authorised personnel e.g. “Our policy is to do the right thing”.