We recently began a meeting to perform a root cause analysis in which one of the participants felt that the discussion was pointless because we already knew the cause. This happens often when, at first glance, there seems to be a simple clear cut cause for an incident.
In this situation a person had been distracted from the work task at hand and was injured. It seemed pretty obvious. The person was reaching out with a pole while standing on a cat walk. While this individual was freeing a piece of debris from a conveyor system, the pole released suddenly and struck the person in the shoulder.
This was a little confusing as they described this over the phone. So, based on their verbal description, we drew a diagram on the screen as the team watched through a WebEx link.
The key discussion was that this was a smaller person who was not as physically strong as the other co-workers. Imagine this argument… “If we just had a bigger person doing the job this (the incident) would have never happened.” Empirical statements like this are tempting, but rarely true.
As we worked together to create the diagram, something became clear. Due to the location of the platform, length of snag pole, and angle of the vibrating table it was nearly a requirement that the pole be fully extended with one hand. This full extension would put any individual of any height or stature at risk.
We directed the conversation back to body position as opposed to the size of the person performing the task. In order for the pole to strike the person’s shoulder the shoulder had to be in the line of fire. Here’s where another diagram can be useful.
Adding more detail also allows for specific solutions.
The actual root cause analysis investigation had a lot more detail. But even this early on in the process, the discussion had shifted from blaming the physical attributes of the worker, to putting simple procedures in place to ensure that a similar incident could be avoided. Clearly, the diagrams changed the discussion. Most of the shapes used in the above diagrams are auto-shapes and lines built into Excel. I cheated a bit and downloaded the stickman figure from the internet.
The diagram changes the discussion.
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