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54 Professional Safety SEPTEMBER 2014 www.asse.org Critical Considerations An eective investigation explores several critical points when analyzing each step o an event; describe ex- amples o: •why the action made sense to the employee; •how training impacted each step; •how communication impacted each step; •how planning impacted each step; •how procedures impacted each step; •how management and supervision impacted each step; •how employees took ownership; •how the organization impacted each step; •how work practices impacted each step; •how the work environment impact - ed each step. Utilize the value o multiple perspec- tives to answer the appropriate ques- tions. The employees, direct supervisor, manager and senior manager should always participate in the investigation process; other subject-matter experts or employee representatives should participate as well. I the supervisor and manager ail to participate, they minimize their accountability or the incident and their lack o visibility contributes to a negative saety culture. Active participation rom leadership establishes the importance o the incident. Stage 3: Corrective Action Make sustainable corrective action your goal. The investigation phase will paint a storyboard that led to the incident. Each step in the storyboard represents an opportunity to change the outcome. Corrective actions should address elements o the storyboard that ailed or contributed to the incident. Sustainable corrective actions change the appropriate details throughout the sequence o events. How do you put corrective actions in place? The event analysis will usually reveal a series o unwise choices or contributory causes that led to the fnal poor decision that caused the incident. The contributory causes can also in- clude latent organizational weaknesses. Corrective measures should address the source o these weaknesses. Critical Considerations When applying corrective action, con- sider the ollowing critical points: •Address all appropriate elements on the storyboard with sustainable correc- tive actions. •Ensure that corrective action measures address any similar circum- stances. •Track corrective actions on a log. •Include target dates for completion on the log. •Dene who is responsible for cor - rections. •Follow up every week to assess progress. •Establish a method to monitor long- term improvement. Stage 4: Communication The communication phase is easy to overlook. Once the investigation is over and the problem is solved, the natural reaction is to move on to the next challenge. Great programs maxi- mize the knowledge gained rom the incident experience and communicate the lessons learned. Incidents should not happen in a vacuum, and leaders should tell others about the event to help ensure that a similar incident does not occur. The communication goal is to learn rom the incident experience and prevent uture incidents by com- municating what happened. Make Lessons Learned Memorable Following are several ways to make lessons learned memorable: •Convince workers that it can hap - pen to them. •Make the topic vivid with the story; share a personal example o how it ap- plies to the audience. •Help people visualize the conse - quences. Share examples o related in- juries and the impact it has on amilies. •Create triggers that will prompt people to think about the incident throughout the day. •Make workers imagine, think about and eel the impact o the incident. Conclusion The same incident should not hap- pen twice. Put principle to practice and build an incident investigation process around the our pillars: report, investi- gate, correct and communicate. When organizations invest in a ull circle pro- cess that ocuses on the small things, they can turn a reactive process into a proactive tool. Do you think the two cousins in the grain silo were the frst to experience such a situation? Was that the frst time corn had crusted over an auger? Was it the frst time they had to use alterna- tive methods to remove grain? Was it reasonable to think that the corn would dislodge at some point? What would have happened i the company had investigated previous near hits—i it had recognized the potential or uture incidents through past investigations? Most certainly the situation could have been dierent i the company had. Minor incidents that occur every day have the potential to become uture tragedies. Investigate the small things with relentless consistency so that you do not have to conduct hard interviews like I did with OSHA. When organizations invest in a full circle process that focuses on the small things, they can turn a reactive process into a proactive tool. David G. Lynn, CSP, is a vice president of Signature Services, a division of Life & Safety Consul- tants. He is a professional speaker, author and improvement strategist with 20 years’ experience. Lynn’s books include Principle to Practice and Strategic Safety Plan . To learn more, visit www .lifeandsafety.com or www.david-lynn.com. Best Practices ©ISTOCKPHOTO.COM/STuarTMIleS99
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