Have you ever reflected on the moment when an accident or injury occurred? During that period of reflection, did you think about the decisions you made that may have played a part in the incident? A common thread I have discovered among many incidents is that we sometimes make the choice to proceed with a certain step in a process or activity despite the fact that we are unsure of exactly how to safely and correctly do so.
In retrospect, we know the step is one that we obviously should not have taken. It’s that simple. Instead of moving forward, we should have stopped and asked, am I really sure about what I am about to do? Do I fully understand what is going to happen when I perform this step?
Far too often, we find ourselves in a place of uncertainty and talk ourselves into going ahead with an action. Based on various root cause evaluations I have reviewed over the past several years, it has become more evident that we are creatures of habit who want to accomplish our tasks without failure. It has also become clear that many organizations have not provided enough resources to thwart this and related issues. The root cause of an incident is found to be human error and we leave it at that. But what about organizational weaknesses, such as failing to identify the need for more specific guidance or to provide stop-work criteria?