Organizations today thrive on information. Information about hazards, skills, successes and failures serve as the blood that keeps the system alive. Each piece of information has its own way of providing insight into how the organization runs. Accidents normally measure failures that occur along with the associated injuries and property damage. In addition to these expenses there are those that are indirect such as insurance costs, labor costs and training costs. With all these costs associated with an accident it would seem that an investigation of each accident would be warranted. And if we investigated each accident wouldn't it be beneficial if we could identify weaknesses in the management systems of the organization? I believe it would be of great benefit and that is why this presentation will address these issues and a few others that together provide a management approach to investigating accidents.


Most organizations want an exceptional safety program. Unfortunately many do not know how to get from where they are to where they want to be. First it takes identifying where you are. What programs are in place? Which ones are providing a service to the organization and which are not? Secondly, it takes a vision. Where should the safety program go? What should it look like when it is done? And how will we know when we are done? We then take the answers to those questions and develop a plan to get us where we want to be, success will be there waiting for us. This plan is developed around short-term objectives. Each objective should be a sub-program of the safety program. As we improve upon one program the safety program is also improved. It works like a child with building blocks. You start with the base of building blocks, your objectives, and build upon them the improved safety program. As we improve the sub-programs or elements of the safety program we can also make use of what is called synergy. Synergy is the total improvement of all the elements being more of an improvement to the safety program that if each one was added separately.

One of the objectives of your plan must be to have an effective accident investigation program. Your objective will be to develop and implement an exceptional accident investigation program that not only looks at the root causes of accidents but also the errors in the management systems that created the root causes or allowed them to exist. This requires a new way of thinking about the organization as well as how the safety program works. Management develops the systems used to produce products or services for the organization. Management purchases the equipment and material.

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