DES PLAINES, Ill.--(BUSINESS WIRE)--Company supervisors who lead incident investigations are not qualified to offer recommendations for improving operating systems because they lack sufficient knowledge of hazard identification and analysis, and risk assessment.
That’s the conclusion Fred Manuele, author of the cover story “Incident Investigation” draws in the October issue of the American Society of Safety Engineers’ monthly journal, Professional Safety, after reviewing 1,800 incident investigation reports to assess how causal factors were identified and corrected. Reports were often biased in favor of selecting an employee’s unsafe act as the casual factor and did not proceed further into the investigation.
Manuele says supervisors who lead incident investigations can’t identify contributing factors that derive from inadequacies in an organization’s culture, operation system, technical application and upper management errors. Many are reluctant to report deficiencies in the management system when writing performance appraisals on themselves and the people in the reporting structure above them.
Instead, Manuele favors using the five-why analysis system, a problem-solving technique he says is easy to learn. Given an incident description, the investigator or team would ask “why” five times to get the contributing casual factors and outline the necessary corrective actions, he writes.
Having analyzed incident reports in which the five-why system was used, the author offers several observations: 1) management commitment to identifying the reality of casual factor is necessary for success; 2) Ensure that the first “why” is really a “why” and not a “what” or a diversionary symptom; 3) Expect the repetition of five-why exercises will be necessary to get the idea across; 4) Be sure that management is prepared to act on the systemic causal factors identified a skill is developed in applying the five-why process.
Read this article at: http://www.asse.org/assets/1/7/F1Manuele_1014.pdf
For more than 50 years, ASSE’s Professional Safety journal has been sharing the latest technical knowledge in SH&E—information that is constantly being developed through research and on-the-job experience. Each issue delivers practical guidance, techniques and solutions to help SH&E professionals identify hazards, protect people, prevent injuries, improve work environments and educate management that investing in safety is a sound business strategy. For more information please visit http://www.asse.org/professionalsafety.
Founded in 1911, the Des Plaines-based ASSE is the oldest professional safety organization and is committed to protecting people, property and the environment. Its more than 36,000 occupational safety, health and environmental professional members lead, manage, supervise, research and consult on safety, health, transportation and environmental issues in all industries, government, labor, health care and education. For more information please go to www.asse.org.