December 18, 2018 | Nancy |

How to Reverse-CSI Your Safety Program | A Book Review of Pre-Accident Investigations

An iceberg didn’t sink the Titanic; a missing pair of binoculars did. More on this later…stay tuned.

The Titanic case study is one of many used throughout Pre-Accident Investigations by author Dr. Todd Conklin, a Senior Advisor at Los Alamos National Laboratory, to demonstrate how major catastrophes are typically the result of a series of seemingly innocuous events that, in hindsight, could have been identified.

To understand the crux of the book’s message, it is important to learn the following definitions.

Performance: the degree to which you get what you expect from a person, a machine, or a process.

Failure (or event): a deviation from an expected outcome.

Safety: the ability to perform work in a varying an unpredictable workplace environment.


Looking at Safety Differently

You don’t have to be a genius to know that something seems oddly wrong about the way we measure safety success. We count the number of people we hurt, and totally discount all the people we are keeping safe. The problem is, and always has been, you can’t count what doesn’t happen.

Conklin points to the auto industry as a great example of how looking at safety differently can actually keep people safer.

Do you know how many highway fatalities there were in the U.S. in 1960? How about 1990? What about in 2000?

The answer to all three is approximately 38,000.

Despite an astronomical increase in drivers and road hazards (faster cars, larger highways, etc.), fatalities remain relatively steady. Conklin explains this as follows:

Everything in our highway and vehicle system is better engineered, smarter, and safer. In fact, the auto industry has done everything but change the driver…in many ways on our job sites, we have taken the opposite approach. We have tried to get to safety performance by “leaving everything the same except fixing the worker”…We rarely fix the system around the worker. We almost always try to “fix” the worker – as our sole corrective action.


Accidents Happen

Because you cannot prevent all accidents, you must assume that accidents will happen, and use your time, energy, effort, and resources in dramatically reducing the consequences of the accidents that will happen in your workplace. You must build systems that allow our workers to fail safer. Start thinking like the car industry, and make your systems safer.

No system, instruction manual, or other defense can protect against human error. Your worst performing employees will make mistakes, your top performing employees will make mistakes, and even you will make mistakes – the only surety is that at some point, human error will lead to a failure of some sort. The idea of “investigating” accidents before they happen is much like playing an episode of CSI in reverse. Instead of discovering a crime and working backward to find out how it happened, the idea is to look at all the different processes in your company and think forward as to what could go wrong and build safeguards into your organizational programs.

A great example of this process in action is rumble strips on highways. Rumble strips are designed to provide a warning to drivers when they are veering off the road; instead of expecting drivers to always drive safely (which of course, won’t happen) the auto industry created rumble strips as a defense against the consequences of a vehicle accident.


Inspiring Organizational Change

Pre-accident investigation isn’t simply a new concept or process – it’s an entirely new way of thinking. As such, it’s one of the more difficult changes to implement as it involves altering the way people think and potentially, their core beliefs.

Unlike most safety books that simply espouse theories, Pre-Accident Investigations dedicates much real estate to providing a blueprint of how you can successfully implement pre-accident investigative thinking into your organization. From selling the concept to top brass, to dealing with various personalities (such as the “I am too busy” Manager and the “I have to have a way to hold workers accountable” Manager), to actually executing the process, this book includes steps and guidance to help you along the way.


What Really Sunk the Titanic

Of course, a missing pair of binoculars was not what sunk the Titantic, but neither was it an iceberg – at least not in isolation.

The case study of the sinking of the Titanic is among one of the many fascinating case studies included in the book and it discusses how a multitude of small, seemingly insignificant, events all worked together to produce one of the greatest nautical disasters in history.

Yes, the Titanic did hit an iceberg, but a here’s a list of some of some of the other events happening at the same time:

  • The hull had sixteen separate cells designed to contain emergencies, such as flooding; however, to make them watertight made certain parts of the ship impassable to crew and passengers. To correct this, doors were added to the bulkheads, then making the watertight bulkheads not so much.
  • In the crow’s nest of the ship, where lookouts went to spy for hazards, there was supposed to be a pair of binoculars. Because of a last minute change in personnel, there were not enough binoculars on board; only the highest ranking officers received binoculars while the lookouts went without.
  • The iceberg the Titantic hit was said by witnesses to not be your ‘typical’ white iceberg – it was in fact almost invisible, like black ice, against the dark ocean water at night.
  • While there were more lifeboats on board than required by law (enough to hold 58% of crew and passengers), there were not enough for everyone.
  • Reports of icebergs came in over the wireless cable machine run by The Marconi Company; however, priority was given to passengers sending cables as this is where the money was made, and those warning cables never reached the captain.
  • A nearby ship, the Californian, mistook the Titanic’s distress flares for fireworks from a party they assumed the giant ocean-liner was throwing; had they known there was trouble, they could have reached the Titanic before it sank.

The Titanic was built to be unsinkable; yet it sank. Despite your best efforts and intentions, it is highly unlikely that you will be able to run a zero-injury company. What you can do is take the focus off your employees and onto your organizational systems to “investigate” accidents before they happen.

The ability to detect and correct all the conditions that normally exist as precursors to failure is not easy and, most importantly, not accidental. A pre-accident investigation is a deliberate and purposeful attempt before a failure to discover these normal conditions that could combine to set the stage for failure. What is important in the decision to be deliberate and purposeful is to change the way your organization gets to better, more reliable performance. Remember: simply asking workers to be more careful does not equate to more careful workers.

Nancy Laviolette
About Nancy Laviolette