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Carola Mittag – 
Happy April, the harbinger of Spring. I love using uncommon words, reading catchy phrases and spinning them into meaningful thoughts and messages. While I have personal and unique reflections, I come across many thought-provoking quotes that make me pause and think about what they really mean.

This morning I read this: The Invisible Obvious. Credit goes to Robert Fulgham, one of my favourite writers.

What could I possibly make of this statement? How could I relate the invisible obvious to health and safety?

But, before I begin my rumination, here is how Mr. Fulgham explained what he was thinking in his own words. Imagine that Sherlock Holmes and Dr. Watson are far out in the English countryside in pursuit of a unique case involving an agricultural mystery. They have settled down in their sleeping bags in a small tent for the night. Just before dawn, Sherlock nudges Dr. Watson awake, and says, “Watson – look up and tell me what you notice.” Dr. Watson tells him that he sees the stars – that the clear sky means the weather will be good in the coming day – that the very faint light in the east says it is almost dawn. “What do you notice, Holmes?”
Holmes sits up. “I notice that someone has stolen our tent during the night.”

When I read this for the first time, I saw only what Watson saw when looking up, the sky, the stars and signs of good weather to come. It took the good detective Holmes to see the invisible obvious first, that the tent was gone making it possible for Watson to see the sky and the stars.

And that brings me to the importance of thorough and detail-rich investigations of accidents and incidents.

It is obvious that accidents must be investigated for several reasons; firstly, to discover the cause and secondly, to report to the Ministry of Labour and the WSIB as required by law.

Why should we investigate incidents, after all, nothing happened; but isn’t an incident an “almost accident”, something that could have had a totally different and catastrophic outcome? And that is why we also investigate incidents thoroughly!

Let’s investigate a plausible accident scenario.

An employee is working on a ladder and the ladder seems to collapse. The employee falls off the ladder and breaks an arm.

Because there is an injury, a full and thorough investigation is required.

The investigation reveals the following details:

  • Employee had worked seven, 12-hour shifts in a row.
  • Accident happened at end of shift.
  • Employee was standing on the top step of the ladder (an unsafe action).
  • The employee was approximately 10 feet above floor level.
  • No fall arrest or restraint system was used.
  • A ladder inspection policy is in place, but there is no evidence that the ladder hds ever been inspected.
  • Investigation reveals the ladder was damaged and did not provide a stable working platform in any environment.
  • Interview with facility manager reveals that he did not inspect the ladder when it was due for inspection. He was aware that ladder needed to be inspected.

Factors and Possible Causes Affecting Incident

  • Extended work hours may have caused employee to be tired and not clear-headed.
  • Employee violated safety rule (standing on top step).
  • No fall arrest system in place (required at 6 feet above floor level).
  • Ladder was defective and unusable.
  • Ladder had not been inspected.
  • Facility manager was aware that ladder needed to be inspected but did not adhere to the existing policies and procedures for ladder inspections.

What is the Root Cause?

Which factor, if not present, could have prevented the accident?

If the facility manager had inspected the ladder and discovered the defect, the ladder would not have been used, and this accident would have been prevented.
Failure to follow established ladder inspection procedures is the root cause.

What about the Other Factors?

  • Extended work hours might contribute, but there is no statistical evidence available that indicates extended work hours increase the risk of accidents.
  • The safety rule violation could be a contributory cause in this accident, but not the root cause. However, if the ladder had been used properly, it is possible that the incident might have been prevented.
  • The existence of a fall arrest system may have prevented or reduced injury. This could be a contributory cause.
  • The fact that the ladder was defective is certainly a contributory cause. But if the facility manager had followed procedures and removed the ladder from service, the accident would have been prevented.

The root cause of this accident could even be tracked deeper than just finding the facility manager’s failure to inspect the ladder. With more in-depth analysis, it might be found that the real cause (invisible obvious) was a failure in the system itself. Perhaps the safety system in place had no means of ensuring the facility manager actually carried out these inspections.

It is for reasons like this that accident investigations are best conducted by a team. This can ensure that as many possibilities are explored until all causes are discovered.

When an accident or even an incident occurs, we cannot depend on obvious causes, it is the invisible root causes that must be uncovered so that future tragic events can be prevented.

Watch for next month’s Blog published in the first week of May.


Carola Mittag

Consultant and Editor for Mentor Safety Consultants Inc.