Improving Risk Management Through Incident Investigations

Dec. 22, 2006
When an investigation of an incident is completed, what are the corrective actions saying to workers?

By Wayne Vanderhoof, WSO-CSS

An investigation into a property damage incident in which a forklift operator hit a pole that protected a piece of equipment finds there were no injuries or property damage other than minor damage to the pole. The damage to the pole in no way compromised the integrity of the pole.

At the time of the incident, the immediate area was congested with a stack of boxes, although the area still was open to forklift traffic. The operator of the forklift is certified by the company and is experienced. The incident occurred during the middle of the afternoon shift.

As part of the investigation, the shift inspection log of the forklift was checked by a member of the investigation team. It was noted in the incident report that the inspection record on the forklift showed it had not been inspected at the beginning of the shift. It also was noted that the operator promptly reported the incident to his supervisor.

The corrective actions section of the incident investigation report only notes that the operator needs to operate the forklift "more carefully" in the congested work area. The supervisor coaches the operator on the importance of operating the forklift in a "safe manner" in a congested work area and documents the coaching session for the operator's personal file.

Why isn't this enough to reduce future risks and change behavior?

Generic Terminology

The findings of the investigation team - that the operator needed to operate the forklift "more carefully" and the supervisor needed to coach the operator to operate the forklift in a "safe manner" - seem on the surface to be good recommendations and coaching points.

But what is meant by "more carefully" and "safe manner?" Does the operator know what is meant by these terms? If the operator knows what safe operation of the forklift entails, then why didn't he operate the forklift accordingly? If he knows and did not operate accordingly, then more discussion needs to center on his attitude and the resulting behavior of operating a forklift unsafely.

These two generic phrases, "more carefully" and "safe manner," are subjective terms. They can mean different things to different people.

Corrective actions need to be specific. The specific corrective actions should include:

  • Operator needed to move the boxes out of the area to make it less congested.
  • Operator needed to determine how and why the stack of boxes were placed in a forklift operating area in the first place.
  • Operator needed to slow down and take extra time to operate in a congested area.

These corrective actions are specific and describe the behavior that is desired of the operator in order for him to be more careful and work in a safe manner.

Effective Follow-Up

At the weekly safety meetings that each shift is required to attend, this incident is reviewed and discussed by the supervisor. The supervisor mentions the findings of the investigation team, saying the work area was congested with boxes but still open to forklift traffic, and that the inspection of the forklift that should have been conducted at the beginning of the shift was not completed.

The discussion at the meeting centered on the congested work area and how to keep the area from becoming congested, which is very good discussion, generating opportunities to improve working conditions.

However, that is where the discussions stopped. There were no discussions on the importance of conducting an inspection at the beginning of the shift to ensure that the forklift was in good operating condition nor on the importance of the operator promptly reporting the incident to his supervisor. The working conditions were discussed, but not the behavior of the forklift operator.

The supervisor has reinforced the need for workers to keep the work area free of congestion. Just as important as workplace hazards are worker behaviors and attitudes. The supervisor did not address the need to conduct the inspection at the beginning of the shift, nor did he say anything about the prompt reporting of the incident. The supervisor unintentionally reinforced the idea that the inspections were not important.

The supervisor also missed an opportunity to reinforce the benefits of prompt reporting of incidents. The supervisor should have led a discussion on why the inspections are important and what could happen if the inspections are not completed. This would reinforce the idea and encourage the workers to perform the inspection at the beginning of the shift.

Changing Behaviors to Reduce Risk

Encouraging positive behaviors and behavior change involves teaching workers about expected behaviors through training, observations and coaching. If workers do not know what the desired behaviors are, then how do they know how to perform those behaviors?

Say you want a machine operator to use the lockout/tagout procedure correctly. You train the worker on the procedure, including an actual scenario - walking them through step-by-step if necessary. Let the worker do the task in the training scenario as they would on the job. This gives you the opportunity to reinforce good behaviors, correct unsafe behaviors and retrain the worker if needed.

The worker returns to his work area, and in the course of doing his work, discovers he needs to do a lockout/tagout.

This is an opportunity for the supervisor to observe the worker and provide coaching, both positive and negative. By coaching the worker, the supervisor opens up an avenue of communication with the worker by giving the worker positive and negative feedback. Along with any negative feedback, the supervisor can review opportunities for improvement along with a plan to realize the improvements.

There should be opportunities to give only positive feedback or coaching - letting the worker know he is doing a specific task correctly, that he is exhibiting safe behaviors or performing a task correctly or that he is exhibiting a good attitude toward work and his safety as well as the safety of the workers around him.

Corrective actions found in an incident report need to address both specific workplace hazards and workers' behaviors, and include follow-up with workers about desired changes in the work process or behavior. This will facilitate both the reinforcement of the desired behaviors as well as reduce risk to prevent similar incidents from occurring in the future.

Wayne Vanderhoof, WSO-CSS, has been involved in workplace safety for more than 15 years in manufacturing environments at various companies in Southwestern Pennsylvania. He can be reached at [email protected].

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