Why People Get Hurt: A Case for Exploration Why do people keep getting hurt? It’s a question every leader has probably asked sometime in their career, probably more than once and probably in frustration. The fact is: people get hurt because something made contact with them (biological, chemical or physical) that had more damaging force than their body or mind could tolerate. Not a very satisfying answer I suspect. This leads to a question behind the question: What’s the explanation for how the person and this damaging element came together? Now that’s a wonderful question and an interesting challenge. The only real way to answer the question of how the elements came together is through an exploration. For our explorer, one must always enter with a mindset that the explanation could include behavior, conditions, culture, and systems. In the end they could find all four, sometimes a combination of two or three, and sometimes only one of those factors. One trick to an exploration of this nature is knowing when you have explored far enough. The answer isn’t when you find the first contributing behavior or condition, it is when the story you present on how the elements came together passes the believability test. Sometimes this can be done very quickly as with example #1 below or it may take quite a bit more discovery as with example #2. Let the exploration begin. Same Injury, Different Causes Here are three examples of employees who ended up with the very same injury to their wrist while walking into work, but where an exploration of causation leads to dramatically different stories: 1.An employee arrives at work and while walking to his work location in the designated walkway takes a tumble and strains his wrist. In exploring the incident, one finds that the area where he was walking was well lit and the surface was level and free of tripping and slipping hazards. In the post-incident interview, the worker reports that he was well rested, had a good night’s sleep, and was not late or hurrying. The employee was physically fit and had no vision impairment. The employee stated he was looking where he was walking, but that he did have his hands in his pocket. It was a warm morning and not cold out. The employee says that while walking he just failed to pick up his feet; his shoe got caught and he took a tumble. Because his hands were in his pockets he was unable to maintain his balance. We can conclude from this information that there was no immediate conditional factor, but that there is an immediate behavioral causal factor (walking with hands in pockets). With this, a reasonable explorer would likely not proceed further with trying to uncover root cause. So for this incident there is one cause, a behavior and the explanation for how the incident happened is believable. 2.An employee arrives to work and while walking to her work location in the designated walk way she takes a tumble and strains her wrist. The investigation finds that the area where she was walking was poorly lit with several of the walkway lights burnt out and the walking surface was uneven where the asphalt had buckled. We can conclude from this incident that we have two immediate conditional factors that need to be explored to uncover root cause. Both elements will undoubtedly lead to the discovery of underlying system and cultural factors. In the post-incident interview, the worker reports that she was well rested and had a good night’s sleep. The employee was physically fit and had no vision impairment. The employee stated she was looking where she was walking, but that in the area where the incident happened it was particularly dark due to the burnt-out lights. The employee also says that she tripped on a piece of asphalt that was sticking up and took the tumble. She had considered taking another route, but the alternative route, walking through the parking lot with lots of vehicle traffic at that time of day, was more dangerous. We can reasonably conclude that there is not an immediate behavioral factor. From the exploration of root cause we would find both system (no methodology for inspecting the walkway condition and lighting and/or a breakdown in the system for getting these conditions fixed) and culture (no upward communication about hazardous conditions and normalized risk to mention two) factors. The explanation is believable and the actions taken to correct the immediate and root causes would need to be much more robust. 3.An employee arrives to work and while walking to his work location, he decides to take a shorter route by stepping across a short fence. While stepping across the fence his foot got tangled, and he took a tumble and fell, straining his wrist. The designated walkway was well lit, with all the lights operational, and the asphalt was level and even. From this information we find there are no conditional immediate causes and one immediate behavioral cause (taking a shortcut). In the interview, the employee states that he was late, so he had decided to take a shorter, more direct route to the work area. The employee says that he didn’t want to be late because the foreman had recently been giving the crew pizza when there was 100% on time attendance. The employee says that if he were late then everyone in the crew might lose a pizza lunch. From this interview we can determine that there are root causes to the employee’s behavior that include both personal factors and system factors. From a believability standpoint the story holds together. While these three events had the same outcome and are simplistic in nature, they do illustrate that when we look at just the outcome (an employee falls walking into work and injures his wrist), there are different immediate and root causal factors. It is easy to jump to conclusions about causation based on the outcome and the superficial characteristics of an event, but to really understand causation we have to be curious and be that explorer who is open to all the possible immediate and root contributing factors. Discussion: Let’s assume that in all three instances we did a complete and thorough exploration of causation and those involved were thoughtful and honest in their responses. Now let’s change the outcome from a minor sprain to a fractured wrist. How differently would our findings be? What if the outcome was no injury at all? Would our findings be any different? We would hope your answer is that the findings wouldn’t change at all because one must remember that the severity of the injury doesn’t impact what really led up to the incident. Having an investigation system where the level of investigation is based on the severity of injury isn’t logical, and there is certainly room for improvement in the initial setup.
Posted on: Sat, 09 Nov 2013 14:05:17 +0000