CONTEXT Root Cause Analysis

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I know what it is like to get injured on the job.  When I was 18 years old (1987), I worked for a small contractor that performed work in industrial environments.  I was “summer help” and I did what I was told.  We performed work at a textile mill in South Carolina and my supervisor asked me to move some platform grating from inside the plant to the back of the plant.  I loaded the sheets of grating onto hand trucks.  The grating was heavy, awkward, and unstable.  As I transported the load through the plant, I bounced over uneven surfaces.  The grating started to fall off the hand trucks and I reacted to stabilize the load.  I placed my right hand between two sheets of grating.  The pinch point lacerated the top of my hand and I could see the tendons and veins.  Five stitches later, I became an OSHA Recordable injury.

 

 

As a Safety Professional, I also know the frustration you feel when you analyze an event like the injury I had when I was 18 years old.  The two ends of the spectrum provide unique insight.  I look at my past injury and ask, “What was I thinking? That was dumb!”  But, when I was 18 years old, everything I did leading up to the event made perfect sense.  As a Safety Professional, I have learned there is value in CONTEXT because context can help you focus on influencing future decisions.

 

How do you put an event in CONTEXT? 

Step 1: Start with the Storyboard

Map the critical steps that lead to the event.  Tell me what happened that day.

 

1.     I reported to work.

2.     We traveled to the worksite from the company office.

3.     My supervisor told me to move the platform grating.

4.     I found some hand trucks and loaded the grating.

5.     I transported the grating through the mill.

6.     The sheets became unstable.

7.     I reached to grab the grating and pinched my hand causing a laceration that required stitches.

 

Do we have all of the information we need to prevent similar events from happening in the future?

 

I have witnessed work cultures that accept similar timelines as sufficient information to complete a report.  They put the blame on the employee and continue with their day.  Blame is quick and easy. When you take the blame approach, you do not consider the decision will make since to someone else in the future.  How are you going to influence the next person?

 

Step 2: Build CONTEXT for the Root Cause Analysis

The storyboard is a critical first step that gives you a factual timeline for the event.  It does not explain what the injured person thought at the time of the event.  The CONTEXT of the event describes why it made sense to perform that task.  The CONTEXT describes the details associated with each critical step of the day.

What did the CONTEXT look like?  I worked for a small company that did not have a structured safety program.  I did not have any safety training.  We did not have specific rules to follow.  We did not have a requirement to wear gloves.  There was no formal preplanning or pre-job briefs.  No one ever mentioned safety.  We just did basic contract work and I never thought about getting hurt.

When you are inexperienced, you get the jobs no one else wants to do.  I did what I was told and I did not ask questions.  I had minimal direction, oversight, and experience.  The morning I got hurt was a normal day.  My supervisor asked me to clean up and move some platform grating.  That was the extent to my instructions.  I found some hand trucks to move 4 sheets of (4’x4’) grating. They were heavy and awkward but I thought I could move all 4 sheets at one time with the hand trucks.  That made logical sense because I did not want to take more than one trip to move the grating.  My supervisor did not provide specific instructions so I proceeded with my plan.  I took the most direct route through the plant without consideration for the uneven surfaces and unstable load.  I did not anticipate the load would shift and I never thought I could get hurt. I was confident I could accomplish this task in one trip and there was no one around to provide safer direction.

 

If I were performing an investigation today, what would I learn?

 

Step 3: Analyze the Facts

The Individual – The fact is that I overloaded the hand trucks to save time.  I did not consider the safest route to take the grating and I did not have a last line of defense; gloves.  I did not anticipate any mistakes and I did not think I would get hurt.  My decisions led to my injury.

Would you conclude your analysis with these facts?

Tip of the Day – If the focus is on the individual, your impact on sustainable improvement is limited to that one person. Is that your goal?   

The Organization – The fact is that my supervisor did not conduct any type of pre-job safety brief.  He did not give specific instructions and he did not monitor my work.  There were no formal safety rules, safety training, safety tool box topics, safety audits, or general safety communications.  I was inexperienced and my supervisor expected me to learn on my own.

What responsibility does a supervisor have in this situation?  Should a company have tools and techniques that help an inexperienced worker perform their job safely?

Tip of the Day – To drive sustainable improvement for more than one person, organizations have to identify tools and techniques that will produce safe decisions and judgement. 

 

Step 4: Choose Points of Influence

 

Where do you have the most influence?  How can leaders in an organization take an inexperienced worker and help them make good decisions?  There are 7 critical steps in the storyboard.  Based on the individual and organizational facts, look for points of influence that impact decisions and judgement in the future.

 

General Influence:

·                Establish the tone of the safety culture with basic safety training required by OSHA.

·                Conduct weekly safety meetings that reaffirm safety requirements.

·                Teach supervisors and workers the importance of preplanning safety into every task.

·                Talk about hazard identification and risk reduction in the workplace.

 

These general requirements may not have a direct impact on my incident but safety culture influences how we make decisions.  The absence of these critical elements in a safety program will have an overall impact on safety results.

 

Specific Influence:

·                Conduct a pre-job safety brief before each shift.  Cover critical steps, hazards, and controls.

·                Monitor safe work practices with safety audits and walkthroughs.

·                Coach and mentor employees that do not have experience.

·                Implement work critical safety rules and guidelines such as the proper PPE.

 

The benefit of an intuitive root cause analysis process is that it improves organizational tools and techniques that prevent errors in judgement that lead to injuries.  The context of the storyboard will provide insight for a supervisor.  They can choose points of future influence using the right tools.  Pre-job safety briefs, audits, coaching and basic rules are tactical tools a supervisor could have used in my situation.

 

Conclusion:

I obviously made some bad choices and I own the results.  The owner held me responsible for my actions and I did not make that mistake again.  The problem was solved… correct?    Do not forget that when people get hurt, the decisions they made at the time of the injury made sense!  There was a reason I made the choices that lead to the injury. I wanted to take one trip and save time.  If one person will make that choice, I can guarantee others will make the same choice without the right tools and techniques to mold their judgement.

 

Our goal in an event analysis is to create a storyboard that describes the context of the event with facts and not fault.  If we know what motivated the decisions that caused the injury, we can initiate a plan to influence the future with ALL employees that may fall into the same trap.  The future impacts more than the person that was injured.  The influence impacts the organization!

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