When I was an OSHA compliance officer, I performed several fatality investigations. One of my early investigations involved a fatality in a grain silo. The silo’s bottom part had an auger that transported corn. The corn had formed a crust over the auger and prevented the flow of corn. Two teenage cousins entered the silo to shovel the corn to another opening in the side of the silo. They had to walk on top of the 15-ft pile of corn to do so.
While they moved the grain to the side opening, they dislodged the crust above the bottom auger. As corn began to funnel through the bottom auger, the flow created a whirlpool effect and the boys could not escape. It was as if they were stuck in quicksand. They screamed for help but the response was too slow. One boy stood on a board on top of the corn holding his cousin’s hands as he was sucked into the grain funnel. He could not hold him and he watched as his cousin was pulled into the corn where he suffocated. The incident happened in the early 1990s, and I remember the investigation as if it were yesterday. I had to relive the incident in an interview with the surviving cousin. That was one of the hardest conversations I ever had because I could picture every word he described and I could feel the pain he felt for his loss. My memories of the investigation are vivid; but can you imagine how vivid the memory is for the cousin who lived? Incident investigations are designed to answer the question “why” so that we can prevent future incidents. No one wants to investigate an incident because it is a reminder that injuries impact people. An investigation process is vital to the success of any SH&E program because it turns a reactive process into a proactive tool. Investigation processes driven by systematic urgency and discipline prevent future problems when they identify the real cause of the problem—and management takes action to solve the problem(s). We learn from mistakes to avoid future interviews similar to the one I had with the survivor.
What characteristics do great investigation programs have?
Read David Lynn’s entire article here: Incident Investigations – Four Critical Stages from Professional Safety Magazine.
What memories would you miss if someone you cared about was injured at work?
View the video below from the closing of David Lynn’s Training Course: How 2: Conduct a Root Cause Analysis. This presentation describes what it takes to be a results driven safety culture. The benefits create memories for employees for years to come.
Course Description: Seeking the REAL truth will differentiate your investigation skills with other safety professionals because many people just fill out the form…if you know what I mean. You can learn to do more by analyzing each step leading to an event!
This class will place you in a select group of professionals that do more than check the boxes on an accident investigation form. You will learn how to seek the truth and find the origin of why an event happened. The class takes a tactical approach to solving problems that result in an injury. Participants will learn how to collect information and analyze the facts using an event analysis tool. The analysis tool prompts an investigator to evaluate the conditions and behaviors that contribute to each step leading to an incident. The process generates data that you can trend and identify causes as well as specific defense failures. With the data, you can develop sustainable corrective actions.
- Introduction to Incident Investigation
- Investigating Step by Step
- Investigation Techniques
- Analysis Tools that Reveal the Root Cause
For more information contact David Lynn.
What clients are saying…
“David’s tool is deceptively simple and straight forward. It’s application can be achieved by just about anyone interested in determining the underlying reasons as to why adverse events occur.”
– Michael Weatherred, CSP, Corporate HSE Senior Manager with FLUOR
Life and Safety is being honored as one of the best performing businesses in the state of South Carolina at SC Biz News Roaring Twenties awards this year! The Roaring Twenties is an annual event hosted by SC Biz News and CertusBank where the South Carolina’s top business leaders gather to celebrate the best-performing companies in South Carolina. 20 Large and 20 small companies will be recognized at the event for a total of 40 honorees in an exciting countdown format that culminates in the crowning of the two best-performing companies in the state.
A great big THANK YOU to our clients, friends and family – and we will continue to work hard to remain one of the top performing companies in South Carolina for many years to come.