Answering curiosity's call

Pit & Quarry, August, 2004 by Carl Metzgar

When something bad happens in a plant, people start to ask questions. Loss control textbooks list the costs of having an injury or no injury incident. Traditionally, supervisory investigation of the incident is listed as one of the indirect costs of manufacturing an accident. This idea it is wrong despite the traditional attraction to it.

It is a supervisor's job to make observations of the mining and manufacturing process and to be comparing those observations to company standards. The regular report of tons mined per day or product loaded for sale are both part of the price of making product and selling it. Supplementing time card data by showing work assignments is a part of cost accounting and maintaining the work force. Tracking these details is not considered unique. Investigating an injury or noninjury incident is a part of the job with no unique cost to be tracked.

To build maximum value into the investigation and report, the supervisor and everyone else in the investigation process should take advantage of the best tools. There is comfort in the results of accurate measurements and finite descriptions of strength of materials. However, these are not the only tools.

There is a set of tools in a little poem written by Rudyard Kipling in 1909 at the end of a children's story called "The Elephant's Child."

   I keep six honest serving men
   (They taught me all I knew):
   Their names are What and Why and When
   And How and Where and Who.

Powerful tools

These tools are so practical, powerful and profitable that no incident cause can escape them provided adequate resources are provided for their use. These six questions will isolate data. The data will become information, which will become knowledge. The knowledge forms a basis for action.

Adjusting the order of these six questions makes them more pertinent by forcefully redirecting attention. What, when, where and who are deceptively easy to apply to an incident situation. These are essentially multiple-choice questions.

"Who" is the beginning question in an injury incident. The employee injured is an identifiable victim. There are 45,000 plus nameless people killed in automobile crashes every year. The 45,000 fatalities do not generate much of a response. The death of a neighbor or family member is an immediate identifiable victim and causes more serious pain than the 44,999 unidentified victims combined.

The seriousness of the injury to an identifiable victim is a very special "who" and demands a significant response. The facilitating "whos" in the chain of command, with corresponding responsibility for manufacturing an incident, are identified as the investigation goes forward.

Time frame

"When" is generally easy to answer because a quick look at the calendar and a watch will identify the moment of the immediate or proximate cause. As more and more detailed questions are asked, the time frame of actions, and failure to take action, expands backwards. The injury, property damage or interruption of process occurred in the present, but the confluence of factors that generated the force for harm started before the incident.

An incident is not the last link in a chain. There are many factors that fall into place over time and ultimately result in an incident. Many things come together and the accumulation causes the incident. Sometimes the factors start to fall into place a very long time before the proximate cause precipitates the incident.

"What" is usually easy. A good look around will locate the physical things involved in the energy transfer to a body or structure. The nature of the injury is often a notice of what kind of device to look for. A smooth cut directs attention for something sharp, for example.

"Where" is a partner with "when." A prompt look around will locate the spot or particular piece of machinery or other exposure. Eyewitness testimony in this case is usually reliable but, just as in every other instance, eyewitness testimony has to be confirmed with physical evidence.

Sound answers to these four questions are absolutely imperative and have to be as complete and accurate as resources will allow. All of these items are facts. Facts are like atoms. There may be smaller parts that make up the questions, but they are there for all to find and the particular arrangement makes up what can be seen.

Essay questions

"How" and "why" are the two serving men that generate the most difficult answers. "How" and "why" are the essay questions in this examination with all the entailed challenges that go with them.

These answers are so telling that senior managers fear them far more than an aging quarterback fears a hot, first-round draft choice. If "why" and "how" are answered and written down in the incident report, seasoned managers and skilled attorneys quake. The "how" and "why" questions cut to the body, mind and soul of management.

Who, what, when, where answers result in facts for anyone to find. "Why" and "how" are explanations that often include opinions and often expose failures in the management's systems. There is no incident report form, in general use, that has a Miranda warning at the top.