Safety Consultant and Author David England says understanding minor safety transgressions can potentially reduce harmful situations.
Credit: David Pisnoy/Unsplash
Bird’s triangle of accidents created in the 1970s following Heinrich’s earlier work in the 1930s shows us the correlation between major harmful events and those where less harm, or no harm, were realised. Although the numbers are often disputed, this correlation demonstrates how the frequency of minor events can escalate into far more serious ones. It clearly establishes the reasoning behind preventing the risk of a harmful outcome at all levels, thereby reducing the potential for a harmful outcome at the highest level.
This does not mean, of course, that we should spend inordinate amounts of time, money, and effort on risk-assessing the most mundane tasks, or establishing control measures for the most unlikely of risks. Instead, we should see the accident triangle in terms of culture: an organisation that is unaware of – or unwilling to recognise – the many minor failings in its undertaking is more likely to suffer from a major harmful event.
Culture in this sense is not an organisation’s devotion to assessing every last-minute detail of its risk profile, but an acceptance that things sometimes go wrong and it is these events that require careful investigation. By establishing how and why small failings in safe systems of work were caused can help to prevent them from escalating further next time. This should be the case especially where an event has caused no harm, what might be referred to as a ‘near miss’ or ‘unsafe act’.
If training is one of our control measures for a certain task, we should ask what if the training company stops trading, or what if the training register becomes corrupted, or what if the training manager leaves and no one has access to the files?
Credit: Sergii Gnatiuk/ Alamy
In accident investigation we are generally dealing with the consequence of a harmful event having been realised. It is too late to prevent harm occurring because it already has. In most investigations, as we work through the methodology of the causative actions that led to the harmful event – perhaps using the ‘five whys’ process – we often establish that the root cause is some failure of management. If we accept this as the case, then we must also accept that culture is the area where we should focus the most effort in developing control measures against risks becoming harmful events. Time, money, and effort expended here therefore becomes an investment in preventing harm, rather than a cost in treating it.
Rather than asking ‘why’ five times (or however many are necessary) after the event, we should be asking ‘what if’ a number of times beforehand in order to see how risk can develop into a harmful outcome. If training is one of our control measures for a certain task, we should ask what if the training company stops trading, or what if the training register becomes corrupted, or what if the training manager leaves and no one has access to the files? From this, we can establish appropriate control measures further along the route of the risk. These measures may be relatively simple to establish but will provide additional layers of prevention that would, normally, only be identified after a harmful event has taken place.
Understanding how minor safety transgressions occurred builds the foundation of a culture that is proactive in preventing potentially more harmful situations from happening.
David’s new book, Effectively Managing the Case for Safety, co-authored with Andy Painting, is published by Taylor and Francis and available to order online.
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