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Leadership Perspectives Blog

Causes Versus Reasons: Learning from the Best

Whenever I try to better understand why accidents happen, I think back to my days in quality control, when I kept a “Would-you-believe” file of all the ways a product could be ruined or compromised during the manufacturing process.

We constantly are bombarded daily in news reports with vehicular accidents, violence and workplace accidents and can’t help but ask, “How could that happen?”

Despite laws and safety rules aimed at preventing these events, they continue to happen all too frequently. Where can we turn for guidance?

One area where progress constantly is being made is in the investigation of aircraft accidents.  Given the number of people whose lives are at risk, the aviation industry understandably stands out in terms of embracing levels of safety above all others.

Every country has an organization equivalent to the National Transportation Safety Board (NTSB). Every aircraft accident, and near-miss worldwide thoroughly is investigated (sometimes involving years of work) in order to identify the root cause(s), whether it be the result of pilot error, mechanical failure, weather, sabotage or other human errors.

These can result from a myriad of sources, including equipment design flaws, ineffective training, maintenance or operating procedures or even things such as wake turbulence caused by another aircraft. 

After an exhaustive investigation of each incident is complete, a final report is written and corrective recommendations made. Changes are then put into place worldwide to prevent recurrences.

The safety record of the aviation industry attests to the success of these investigations. With a fatality rate of 0.01 per 100 million airline passenger miles compared to a fatality rate of approximately 1.5 per 100 million miles for automobile travel, it’s obvious that the aviation industry is making the kind of strides that every industry needs to make. The National Safety Council estimates the odds of dying in a motor vehicle accident at 1 in 112 and 1 in 96,566 for aircraft travel.

Pilot error tops the list of the five most commonly identified causes of aircraft accidents.

Pilots are human.  They make mistakes, as do all humans, which can account for the inordinately high percentage of the root causes of accidents.

All of the information on the subject of accident investigation warns against defaulting to operator error as the easiest conclusion. Failure to conduct a comprehensive fact-finding investigation of an accident, incident or near-miss may settle on the cause of the event to operator error, the real root cause will not be identified, and similar accidents continue to happen. This is not so with aircraft investigations. Just watch “Air Disasters” on the Smithsonian Channel.

The incredible strides in aviation safety are the result of systematic, by-the-book accident investigations and implementation of effective remedial action.  The most important takeaway from accident investigations is to learn from each event. Other industries need to take notice.

According to the 2017 Liberty Mutual Workplace Safety Index, just 10 accident causes accounted for over 83 percent of accidents in 2014.

These causes included overexertion, falls on same level, falls to lower level; struck by object or equipment, other exertions or bodily reactions, roadway incidents involving motorized land vehicle, slip or trip without fall, caught in/compressed by equipment or objects, struck against object or equipment and repetitive motions involving microtasks.

In my work, I limited the number of causes to eight by combining all overexertions and all slips, trips and falls into single categories. The result was a six-year compilations of injuries at a large manufacturing site which showed that the eight causes accounted for 95 percent of all reported incidents and the top four: overexertion, slip/trip/fall, struck by and struck against, accounted for 72.5 percent of all incidents versus 70.8 percent in the recent Liberty Mutual study.

Accident causes are not root causes.  Root causes are the reasons that lead up to the causes. If the reasons are not addressed and acted upon, we have little hope of reducing the number of needless accidents.

Some of the reasons can include: mistakes, errors in judgment, failure to follow procedures, lack of attention, unsafe conditions/equipment, system error, lack of training, overconfidence, failure of the design process, failure to wear PPE, failure to correct identified hazards, rushing and complacency.

Each of these reasons presents risks which must be addressed by training, observation, mentoring, peer pressure and safety culture, in order to raise the level of safety in an organization.

The airline industry is a model for what can be done to reduce accidents. Why not learn from the best?

Editor’s Note: This article is a follow-up to an earlier article entitled “Causes Versus Reasons” published in the Dec. 14, 2014 EHS Today Idea Exchange

Joseph Werbicki is a safety consultant/trainer who can be contacted at [email protected]

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