I have recently taken part in conversations about preventing injuries and occupational illness. Part of our discussions have raised the issue that the industry must move past deferring to the immediate cause(s) of events/incidents to focus on determining the indirect/root causes of events/incidents to improve how they answer – why events/incidents occur?
The control measures and counter-measures organizations implement must focus on the gaps in management systems and those indirect or root causes. It is easier to focus on substandard conditions or blame an individual for a substandard act(s) than determine the “WHY”.
The worker’s mind was not on task…they made a mistake…impaired decisions…distracted driving…or fell asleep at the wheel are all terms we have heard to explain why an event/incident occurred. A typical investigation focuses too much on anecdotal information, peer discussions, and personal experience.
Does your investigation ask if the individual was “Fit for Duty”? Does the organization have a Fit for Duty model or standard? Was this a contributing factor? Or the indirect or root cause?
“Fit for Duty” is a term used by industry to describe the individual’s physical, mental, or emotional state and how it enables their job performance in a manner that optimizes safety and performance.
Ultimately, being Fit for Duty s about having the capacity to make the correct decisions when required and the ability to perform work activities safely. Usually, there are multiple causes and contributing factors to an incident, and considering the aspects of a workers’ emotional, physical and mental state, as well as the many aspects of their work environment, will help uncover the WHY.
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