Accident Investigation Blind Spots
Causes You Don’t See
Are you blind to some potential root causes? Are there things in an accident investigation that you just can’t see? I call these accident investigation blind spots and there are several that we will discuss…
- Don’t Know What You Don’t Know
- Favorite Cause-istis
- Fatigue
- Management System Root Causes
- Don’t Tell on Yourself
Of course, if you don’t know what a root cause is, every root cause is a blind spot. Learn more about the modern definition of a root cause (HERE) before you read on.
Don’t Know What You Don’t Know
Socrates said:
“True wisdom comes to each of us when we realize how little we understand about life, ourselves, and the world around us.”
In accident investigations, people have a blind spot for what they don’t know.
This lack of knowledge is particularly troubling when a human error seems to be the “cause” of an accident. Why? Because most accident investigators have no formal training in the causes of human error (human factors).
Thus, in many accident investigations, the investigator’s blind spot is that they can’t see the causes of human errors that need to be corrected to achieve outstanding human performance. What do they do? Stop at human errors and apply one of the three standard corrective actions:
- More training
- Discipline
- Write a procedure (or make it longer)
Or maybe one of these “Re” corrective actions…
- Re-train
- Re-emphasize
- Re-place a part
- Re-mind people about rules
- Re-qualify (after you disqualify)
- Re-write the procedure
If you see these types of corrective actions in your company’s accident reports, you probably have blind spots that are hindering your investigators and your improvement efforts.
Favorite Cause-istis
Favorite cause-itis is one of my favorite blind spots. Why? Because I’ve seen it exhibited so many times. And also because it affects experts more than novices.
Why is it so common? Because we all have favorites. And root causes are no different than ice cream flavors.
If you are like me, even when you are presented with dozens of choices, you have one, or two, or three favorites. Favorites that you will try again and again. What about the other flavors? You may occasionally sample one, but it is highly likely that you will choose one of your favorites.
And so it is with root causes. Investigators have several favorites that they will tend to look for and find. And the more of an expert they are, the more fixated they become on a favorite root cause.
I know a human factors expert who was a consultant on a major investigation. His research specialty was fatigue. In this major accident, guess what he looked for and found? You guessed it … fatigue was a major cause of bad decision-making.
Simple root cause analysis techniques let you pick your favorite causes and ignore others. I suppose this is why I see the blind spot of “Favorite Cause-itis” so often. Investigators just don’t look beyond their favorite causes.
Fatigue
This blind spot has nothing to do with investigators being fatigued. Instead, investigators don’t recognize fatigue as a potential cause of human error (including bad decisions or poor performance).
When I was in the Navy, I had a petty officer make a really stupid decision. He hooked up energized leads the opposite way they were supposed to be connected and almost got another sailor electrocuted. This person was well trained (in fact, he trained others to do this work). He was very experienced. But after 30 days straight of locked-in shiftwork (in his case, noon to midnight), he made an inexplicable mistake. This wasn’t a simple error. It took him eight hours to set up the trap for the other sailor. And it wasn’t malicious. He was trying to do things the right way.
When I asked him why he did it, he had no idea. I thought that fatigue might have been a cause, but in the Navy, fatigue couldn’t be a cause. Why? Because everyone was fatigued (some more than others). In the words of several Commanding Officers that I talked to, there’s nothing you can do about it. People have to learn to deal with fatigue.
Therefore, nothing was done about the fatigue, but the procedure was rewritten. Fatigue was simply a blind spot.
Management System Root Causes
Can the way people are managed and the systems (processes) used to control work cause errors? YES! In fact, that’s where many “culture” issues come from. However, I frequently see many Management System causes that investigators overlook.
In informal conversations, investigators often admit that they “can’t say there is a management system problem.” Why? Because their career would be damaged if they blamed management for an accident. Thus, a blind spot developed for all management system root causes.
But the key here isn’t to “blame” management. The key is to find ways to improve the management system. (Look in the Corrective Action Helper® Guide for ideas to improve the management system.)
If you would like to learn more about the history of Management System root causes, see THIS ARTICLE. And see if your company has a Management System blind spot.
Don’t Tell on Yourself
If you have ever studied the TapRooT® Root Cause Analysis System, you know that there is a Basic Cause Category on the back side of the Root Cause Tree® Diagram called COMMUNICATION. It is fairly common to find communication issues among the causes of an accident. However, when reviewing the root cause statistics at one company, they had zero communication-related root causes across almost 100 investigations.
I asked myself, “How could this be possible?” They must have some sort of superior way of communicating. But after an extensive review of this issue, I found a different cause.
At this facility, supervisors were conducting the investigations. And supervisors certainly were NOT going to report that they had miscommunicated with an employee and caused an accident. Therefore, there were zero communication-related root causes. That’s definitely a blind spot!
Can Accident Investigation Blind Spots Be Prevented?
Back in the 1980s, I realized that people couldn’t see the root causes that were obvious to me. I could see their accident investigation blind spots. This was mainly due to the extensive human factors training I received at the University of Illinois. I tried providing short courses in human factors to investigators, but that didn’t work. The training wasn’t extensive enough.
Next, I started developing systematic tools to help people see into their blind spots. Gradually, this became a success. Now, we can cure blindness and eliminate blind spots with the proper use of a systematic root cause analysis technique – TapRooT® Root Cause Analysis.
If you would like to learn how TapRooT® Root Cause Analysis can prevent blind spots, I would suggest attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. See the dates and locations for upcoming public 5-Day TapRooT® Courses HERE.
To schedule a TapRooT® Root Cause Analysis Course at your site, contact one of our implementation advisors by calling 865-539-2139 or by CLICKING HERE.
Don’t wait! Having blind spots means that you aren’t fixing problems that could contribute to future accidents. Now is the time prevent blindness.
