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April 7, 2015

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Fatalities and serious events

By Dr Todd Conklin


Fatalities and serious events are incredibly unusual in our workplaces. For the most part workers don’t die at work. Many more workers don’t die then do die. It is very difficult and rare for a serious event to happen in a facility. Yet, our concern over the prevention of every one of these serious and fatal events is a noble endeavour, a righteous cause, and absolutely the right thing to do.

I am not certain we are bad at stopping serious and fatal events. I am not convinced the problem is nearly as important or as gigantic as we may think it is. The statistics would seem to support the idea that we are actually very good at not killing and seriously injuring our workers.

Yet people are seriously hurt and die in our organisations. Our work is not done.

Importantly, we don’t know why these events happen.

Is a fatality the logical top of they Accident Pyramid?

This is the problem that we must first tackle. We have been hoodwinked over time in to the belief that accidents are some how connected by both frequency and severity. This notion would mean that a fatality or serious event is simply the normal sum of a series of smaller, less significant events.

This notion of a fatality or serious event being a mathematical summation of the grand total of all bad things that happen our companies, I fear, is flatly wrong.

What scares me is this thinking has biased our thinking. Perhaps even more frightening, this thinking has biased the way we have framed the problem statement we have used to understanding fatalities and serious events.

I would submit three questions for your thinking the next couple of days. I am certain these three questions are vital to increase the body of knowledge we are amassing around this type of event and this type of thinking. I would caution you that at this point in my thinking, the answers to these three questions are not the same. The challenge is to think about these questions, as individual ideas to be considered, not magically connected ideas.

Here are three questions to ponder:

  1. Are fatalities and serious events probable?
  2. Are fatalities and serious events predictable?
  3. Are fatalities and serious events preventable?

Our Challenge

Good, highly qualified and experienced worker don’t come to work to die or become seriously injured. Yet, in most of the fatal and serious cases that I am included there is a very strong theme: Good, highly qualified and experienced workers. That must mean something. I am surprised more “green hats” aren’t seriously injured or killed.

The other theme I see is a surprise outcome to a relatively normal (although often high risk and extreme) work activity. The idea that some surprise condition caused harm must be important and must be a part of our thinking about fatalities and serious events. Surprises are very difficult to prevent…they’re surprising.

Perhaps, what I consider the most important part of our discussion is the cognitive bias around fatalities and serious events. I feel we are thinking about this problem incorrectly. This incorrect bias is so strong and so normal we have unfortunately narrowed our thinking over the last several years.

The problem with being wrong is that before you realise you are wrong it feels exactly like you are right.

We need better questions

Our challenge is to not think of ways to repackage what we have always done. We will not be served by thinking of better, more automated ways to count things that are present, but not predictive. Our challenge is to rethink the problem.

We will not find answers. I am not sure we would know the answer if it his us in the face. What we want to explore and discover are the questions. We must ask better questions. Remember, the power in reliable operations always lives in the questions we ask each other and ourselves.

The answers are never the same.

Dr Todd Conklin is senior advisor for the Los Alamos National Laboratory. He is speaking at the IOSH conference on Wednesday 17 June at 9.30.

Todd publishes a regular podcast on pre-accident investigations.

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Bob Wallace
Bob Wallace
7 years ago

This is a good article and the 3 questions posed depends entirely upon which industry you work in, which part of the world you work in and the cultural and social expectations of the population. I work in underground mining in West Africa, with operations in Ghana, Mali and Burkina Faso and the answers are yes, yes and yes! 1. It’s a high risk environment and it is impossible to remove the human factor from the workplace activities. a. Handling explosives b. Heavy and light vehicle interaction c. HV electrical systems 2. The culture within these countries means taking risks… Read more »