After the Incident, Do Not Stop at First Cause
Investigate an incident beyond the triggering act to find system causes.
Live decision At 4:20 p.m., a mechanic strains his shoulder lifting a pump cover. The first report says improper lifting technique, but the cover weighs 74 pounds and the hoist was locked in another bay. Your choices change both the immediate risk and what the organization learns. OSHA incident investigation; 5 Whys; learning review Incident investigation works when it asks what led to the failure. 5 Whys is useful only when it keeps widening from action to conditions: tools, time, layout, supervision, maintenance, and decision rules. Shortcut Treat the visible behavior as the whole problem. Lower exposure plus a better…
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