The Myth of the ‘Accident’
Over a long career investigating and researching thousands of loss incidents, the author states they have never encountered an actual accident. An accident is defined as an incident that happens by chance.
In every case investigated, the incident stemmed from negligence, not chance. Even when individuals didn’t intend to cause harm, their actions or inactions were the root cause. This means a loss incident is never caused by chance.
The Responsibility is Black and White
Some people believe that if someone was distracted and caused a loss, it was accidental. It was not. That person allowed themselves to lose focus, and that choice led to the incident.
There is no grey area when it comes to responsibility. It is black and white: the incident was caused either intentionally or through negligence at the time it occurred.
Why Calling it an ‘Accident’ is Dangerous
When a loss incident is labeled an “accident,” people are essentially saying it happened by chance. This is often done to avoid taking ownership of the incident and subsequent corrective actions.
Calling it an accident has serious consequences:
- It weakens or halts the investigation, preventing the learning required to stop similar incidents from happening again.
- It obscures the behaviors that need to be addressed to avoid recurrence.
Failing to report the actual behaviors and their causes after an investigation is considered a second tragedy. It denies others the opportunity to learn and invites future incidents.
Closing the Investigation Loop to Prevent Recurrence
To truly prevent recurrence and ensure organizational learning, we must close the investigation loop. This involves three critical steps:
- Never use the word “accident” when describing a loss incident.
- Accurately report all loss behaviors and the reasons for them. This educates others on what led to the incident and reinforces that repeating such behaviors will result in further loss.
- Rigorously implement all corrective actions. Without them, the same incidents will happen again.
By working together and taking ownership of both the behaviors and the learning process, loss incidents can be prevented in every environment where hazards exist.
Jim has long experience in chemical plant operations, engineering, consultancy, capital project development, review and implementation.
In the areas of design, operations, construction, and technical support of developed and new alumina projects in Ireland, Africa, the USA, and other parts of the world.
He has applied asset management and capital project expertise from the alumina industry to other sectors with significant effect. He has developed “Zero Loss” systems for plant operations, capital projects, asset management, due diligence assessments, and safety.
