An article in Professional Safety, the journal of the American Society of Safety Engineers (ASSE), found that a majority of occupational health and safety (OHS) professionals and their companies focus solely on incidents without looking at the underlying factors that may have contributed to the incidents.
Michael Behm and Demetria Powell, the authors of the article titled “Problem Solving, Are Higher-Order Controls Ignored?”, reviewed 249 valid investigation reports from seven organizations, the ASSE said in its press release.
The ASSE gives the following example to illustrate the point the article makes: If a worker is injured slipping from a ladder while accessing an electrical panel, does this incident warrant more training on the employee’s part on how to properly use a ladder or does it call into question larger organizational issues that should be addressed?
By not including larger organizational issues, “an opportunity for organizational learning about possible future design and redesign changes has not been documented and, thus, is lost”, the authors say.
The authors discovered OHS professionals and their companies used administrative controls (such as warnings and protective clothing), known as lower-order controls, in 87% of the reviewed investigation reports, suggesting that they may be fixated on identifying single causes close to the work operations. By contrast, higher-order controls include elimination; substitution for less hazardous materials, processes, operations or equipment processes; and engineering controls.
“When investigators look beyond the immediate failures and into the system they will initiate true organizational learning and be impactful for risk reduction on both the micro and macro scales”, the authors say.
Here is a summary of the main points from the article:
- Incident investigations can be a valuable source for organizational learning. Deficiencies in risk mitigation can be identified, leading to meaningful solutions.
- While organizations have begun to solve problems with an eye towards higher-order controls, the focus remains squarely on a single source and on those closest to the operation. Solutions are focused on administrative controls.
- Safety professionals and their organizations should look upstream into the management and work systems during investigations as sources for organizational learning that will ultimately improve safety.
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