The author:

Olga Semenchik|👏1|104

March 24, 2022Russian FederationOpinion

Repeated Incidents

Do you like incident investigations? In my experience, people can get very excited about them. There are many techniques for Root Cause Analysis, some going together with fancy tools and long spreadsheets. If the incident is serious, management can spend many hours on the investigation, ensuring that they like the wording and that all minor details are correct. And after the investigation and all presentations are over, the boring part begins. Do you know what it is? If you are an safety professional, you probably do. Actions! Say, the investigation revealed issues with PPE storage conditions. An action was given to the storage to install proper shelves and improve heating and ventilation within three months. In three months the safety professional checks the implementation. Nothing is done; moreover, the manager says that he was not aware of the action. After you show him the three-months old email (and involve his manager in the discussion), he reluctantly agrees to commence implementation. The action is extended for another three months. In three months the safety professional checks the implementation. Everything is ordered but there have been difficulties with choosing the vendor and the materials have not arrived on time. The action is extended again. In another three months all materials are there. But the previous manager left, and the action was never transferred to the new manager. The safety professional has to explain everything again. Finally, the job gets implemented. After a few years, the same incident happens. Why? Because this time the PPE was stored in a different location which was never upgraded.

Why do they happen?