Fix the System, Not the Blame
A successful accident investigation is not complete until the root causes (contributing system weaknesses) have been identified.
An important principle to understand is that, when the purpose of an accident investigation is considered achieved, the investigation process stops. If the purpose of the investigation is to establish who is to blame, the investigation is considered complete once the guilty party is identified. Hence, the investigation stops without identifying root causes for the accident.
According to OSHA, your primary purpose for investigating accidents is to identify their causes and provide means for preventing repetitions. OSHA is not just talking about identifying the surface causes. It’s a mistake to think the investigation is finished once the surface causes (unique hazardous condition or work practice) are identified. The primary purpose of the accident investigation should be to fix the system, not merely to establish blame. Here's what OSHA goes on to say about the investigation process:
"Although a first look may suggest that 'employee error' is a major factor, it is rarely sufficient to stop there. Even when an employee has disobeyed a required work practice, it is critical to ask, "Why?" A thorough analysis will generally reveal a number of deeper factors (root causes), which permitted or even encouraged an employee's action. Such factors may include a supervisor's allowing or pressuring the employee to take short cuts in the interest of production, inadequate equipment, or a work practice which is difficult for the employee to carry out safely. An effective analysis will identify actions to address each of the causal factors in an accident or 'near miss' incident."
Bottom line: The output of your accident investigation should not merely identify violations of safety rules and find fault. The end product should identify the underlying root causes: the safety management system weaknesses such as inadequate supervision, training, physical resources, and/or psychosocial support. Effective accident investigation reports should be silent on the question of who is to blame and it should not address the question of discipline. Competent managers (safety, human resource, and supervisory) should consider the possibility of discipline only if the completed accident report cannot identify root causes.
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6-2. What is the primary purpose of an accident investigation?
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