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?