I have recently been part of industry conversation with respect to preventing injuries and occupational illness. Part of our discussions has raised the issue that industry must move pass deferring to the immediate cause(s) of events/incidents to focus on determining the indirect/root causes of events/incidents to improve how they answer – why events/incidents occur?
Understand Why Events and Incidents Occur
The control measures and counter-measures organizations implement must focus on the gaps in management systems and those indirect or root causes. It is easier to focus on substandard conditions or blame an individual for a substandard act(s) then determine the “WHY”.
The worker’s mind was not on task…they made a mistake…impaired decisions…distracted driving…or fell asleep at the wheelare all terms we have heard to explain why an event/incident occurred. A typical investigation focuses too much on anecdotal information, peer discussions and personal experience.
Does your investigation ask if the individual was “Fit for Duty”? Does the organization have a Fit for Duty model or standard? Was this a contributing factor? Or the indirect or root cause?
“Fit for Duty” is a term used by industry to describe the individual’s physical, mental or emotional state and how it enables their job performance in a manner that optimizes safety and performance.
What should be included in “Fit for Duty?”
- Physically capable to safely perform the work duties.
- Mindset, mentally and emotionally capable to perform the work duties.
- Not impaired by drugs (alcohol, legal or illegal drugs).
- Medically capable to perform work duties (chemical sensitivities or exposure risks).
- Human Factors (communication, language, cultural, social aspects).
- Not impaired by fatigue (personal and operational).
- Not impaired by cognitive distraction.
Ultimately, it is about having the capacity to make the correct decisions when required and the ability to preform the work activities safely. Usually, there are multiple causes and contributing factors to an incident and considering the aspects of a workers’ emotional, physical and mental state as well as the many aspects of their work environment will help point uncover the WHY.
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