Magazine article Occupational Hazards

Improving Risk Management through Incident Investigations: When an Investigation of an Incident Is Completed, What Are the Corrective Actions Saying to Workers?

Magazine article Occupational Hazards

Improving Risk Management through Incident Investigations: When an Investigation of an Incident Is Completed, What Are the Corrective Actions Saying to Workers?

Article excerpt

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. …

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