Normalising Versus Fixing & Preventing


This is a fascinating video (and hard to watch for the car enthusiast!).

The long and short of it is the car had been rebuilt and heavily modified as part of that project.

Except for the brakes.


They identified during the interview and walk-around that the brakes really should be upgraded to suit the new build and power of the car.

While driving, they make a conscious decision to not wear the full harness system.

As they continue to drive, it is identified that the accelerator sticks, and it's also a known ongoing issue.

Further along the drive, they identify that the brakes smell bad from overheating because the driver is riding them because of the sticking accelerator issue.

Lo and behold, the brakes overheat and they fail, ending with a significant crash, resulting in injuries (that could be life-changing), as well as damage to multiple vehicles.

What About The Workplace?

How many times are we aware of modifications done to plant and equipment, outside of the manufacturer specs?

How often do we see deviations from procedures?

Jumping back to the video, if we look at this from an organisational perspective, I see issues here with Design, Hardware, Incompatible Goals, Management of Change, Maintenance Management, Organisational Culture, Organisational Learning, Risk Management and Vehicle Management.

Shall I go on?

At what stage do we stop normalising problems identified, and putting in place workarounds, versus doing something about the issue and preventing an incident from occurring?

There's no doubt this incident was preventable....

#safetywise #icam #investigations

Interested in Knowing More?

Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/

Additional ICAM Related Services

Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:

  • Quality review of incident investigations using ICAM

  • Participation in investigations as an external/independent party

  • Investigation coaching


 

ABOUT THE AUTHOR- Luke Dam (Chief Executive Officer)

Luke has worked in various industries over the years including pharmaceutical, retail, manufacturing, and transport including iconic brands like WesFarmers, Goodyear, CSL Limited, and Incitec Pivot Limited.

His work in OHS and learning and development has seen him deliver services to clients, both internal and external as well as managing service delivery teams around the world.

Luke holds a Graduate Certificate of Management (Learning) as well as a Diploma of Occupational Health and Safety, a Diploma of Training and Assessment Systems, a Certificate IV Workplace Training and Assessment, a Certificate III in Mine Emergency Response & Rescue and a Certificate II in Public Safety (SES Rescue).

Luke is passionate about online OHS and incident investigation communities, moderating a number of large LinkedIn groups boasting over 12,000 members globally.

#icam #death #fatality #investigation #regulator #media #family

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