Post Accident Review - Part II - Hurtado & Associates

By Dean B. Wisecarver

The first installment on this subject covered the fact that an employee accident is a manifestation of some internal problem (actually, in most cases a series of problems) that management should desire to identify and correct, and that the post accident review process is simply an organized, logical method of identifying the problems so they can be corrected. It also suggested that the site supervisor is the logical and, perhaps, best person to take the first shot at assessing the circumstances of the accident to determine the underlying problems and to make recommendations to management on how the company might improve its practices and procedures. In this installment, I will address your role as executive in supporting and sustaining the important post accident review process. I will also describe the analysis techniques you can teach your supervisors to help them gain the most from the information they have following an accident. In many ways, it is a technique which overcomes most people's shortcomings in doing post accident reviews.

Top management's role.

Simply stated: Your primary executive role in the post accident review process is to provide feedback to those who offer their assessments of what the company can do better to improve operations and avoid similar mishaps (accidents).

Okay, that's a pretty basic role. Sure, you or another of your managers may further evaluate what happened and arrive at your own conclusions, but unless you plan to take on all the responsibility for assessing and correcting problems in your organization, you will have to rely on others to do so, too. If you want them to apply their best effort, skill and knowledge to the process, they must clearly understand that you see this activity as important.

Demonstrating commitment to the process.

So, how do you make it clear that you see a supervisor's analysis of and recommendations for preventing accidents as important? You could tell them so in a meeting. You could include a statement to that effect in your company's policies/procedures manual. You could get on their backs when they don't do it. Sure, you could do these things -- many executives do. But after some 28 years of management consulting, I don't believe these approaches work very well. I believe "actions speak louder then words" and "what gets measured gets done."

The most effective and, fortunately, the simplest way to get your supervisors to do a thorough, honest job of assessing an accident situation and coming up with good ideas to correct the underlying problems is for you to be certain that each of their reports reaches your desk, that you read it, and that you find time to tell each person who wrote such a report that you did, in fact, read it. Even if you do nothing else, you will be making a significant statement about how important the reports are. After all, if the President and/or a senior manager of the company took time to read the report, it must be pretty important, right?

Of course, I believe there are ways to be even more effective. Perhaps you could say something like, "Hey, John, I read your report on Bill's accident. You did a nice job thinking it through. We can't do the first thing you recommended, at least not right now. But I think the other two recommendations are very good and appropriate." If you said something like that, what do you think that supervisor will do the next time he has to analyze and report on an accident situation or similar problem? This kind of feedback tells John you are measuring what gets done, an action on your part that rings louder than words spoken at a meeting or recorded in a manual.

Other benefits of reviewing all reports.

Are there other reasons you should read the reports? Yes, I believe there are. Post accident review reports are an important form of "upward communication." If you want to know what's going on out in the field and what your own people think you should do to support them in doing things right the first time, you should find it in the accident reports and the post accident reviews. Also, if you want to see which supervisors demonstrate the analytical skills, problem solving ability, and good business sense to be potential candidates for promotion, you should read their assessment reports on difficult situations, like an accident in their area of authority.

So, as an executive, your role in the post accident review process is pretty simple -- and pretty important! Read the reports. Then, tell everyone you read them! Don't ever nail anyone for what you find in a report, and thank the daylights out of the people who do a good assessment. After all, it's those people who are helping turn a bad situation into a learning opportunity for your entire company.

Post accident review challenges - narrow focus and blaming.

The biggest problem most supervisors have in trying to arrive at anything meaningful when reviewing an accident after it has happened is sorting through all the facts and seeing more than one cause or solution. Most supervisors look at a situation and zero in on the most obvious cause and the related single solution. Also, perhaps by human nature, they also tend to blame the accident or mishap on the person involved.

As an example, I recently saw a post accident review report which said, "The lineman jumped down from the bucket truck cab and sprained his ankle." The truck, it turned out, was parked near a roadside ditch, and ground sloped away from the passengers side of the truck. The supervisor's recommendation for prevention was, "The lineman should use the step, and not jump, when he gets out of the truck." The supervisor's solution to accomplishing this was, "I will advise this employee to always use the step." As an executive, does this sound familiar to you? Does it really do anything to either reduce the likelihood of similar accidents or to improve the way your people work? Will asking the one person who had the accident to "be more careful" really help others who may face the same situation? Will the supervisor's actions improve the entire organization? Probably not. So, how can you help a supervisor get at process and procedural improvements that will help the entire organization? We have a technique.

The "Why Flow Chart" technique.

Finding all the contributing factors behind an accident or mishap takes a little sifting of the information. To help, we have taught supervisors how to use a technique we call "back-tracking" or the "Why Flow Chart." It is a very simple technique. Since it does not have to be done to perfection, and since only the results are what the supervisor passes on in his/her report, it can be done by scribbling on any handy piece of paper. It looks fancy and neat below, but that's so I can explain it. In real life, the charts often look messy -- but they work.

Here is the technique, in a nutshell.

Start with a very basic statement describing the accident. Avoid using individual names. Use simple action statements, such as:

"Employee slipped and fell in front of sink." "Lineman sprained back lifting crossarm." "Warehouse worker tripped over extension cord."
Using a blank piece of paper, place a box near one edge and write the basic statement in it.
Convert the statement into a question beginning with the word "why." In this case it might be, "Why did the worker trip over the extension cord?"
Come up with as many factual answers to the "why" question as you can, based on what you know of the situation. Keep your answers as simple and direct as possible. Put each answer in a box linked to the first one by a line.
Each new box in the example above becomes another starting point. Taking one box at a time, convert the statement it contains into a "why" question. Come up with as many direct, simple answers as possible, putting each into still another grouping of boxes, all linked to the box that formed the question.
Continue to take any box, convert its statement into a "why" question and record the answers in new boxes. Keep going until you can no longer answer any of the why questions.
When you get to a box for which you can not answer the why question, you have arrived at a point where you either need more information or you have an opportunity to make a recommendation to improve operating practices.

Let's assume that you have three places marked with the circles and question marks. These represent "why" questions you can not answer and each one represents a typical end-of-branch situation.

A? -- Lack of details- Perhaps this is a situation where you need more information. You might decide to go and ask follow up or clarifying questions, "How did the problem occur? Was the worker properly trained in the task? Was this a normal activity or was there a special problem? Can we make physical changes to prevent this type of event? There may be some good answers, and thus additional boxes on your chart.

B? -- Lack of options- There may not be any easy or affordable solution. It may not be possible or reasonable to change the material, or the operations to make it impossible for a item to break.

C? -- Lack of timely action- Why wasn't this fixed when first broken? Was it reported? Was a repair ordered? Did it happen within the hour before the accident? This may represent an opportunity for a direct recommendation or a direct action by you. For example, if the repair wasn't reported, you might need to design a process to have damage reported immediately.

The end of each branch (that is, the point where you can not answer the "why" question) represents a chance to make a recommendation or dig further. The more "why" answers you come up with for each block, the more branches you will create. The more branches, the more opportunities you will discover to help avoid the same or similar accidents and the more ideas you will have for improving your operation.