April 9, 2012 | Mark Paradies

Monday Accident & Lessons Learned: One-Off?


Three weeks ago, I posted a hypothetical question about this picture as a Monday Accident & Lessons Learned article:


I asked the question (paraphrased):

“What would you do?”

Several people mentioned that they hoped this was an isolated example … a “one-off” incident.

That got me thinking about “one-off” events and Generic Causes.

If you’ve been TapRooT® trained, you know that a Generic Cause is a “big picture” cause of the specific root cause of an incident.

Let’s just say that there was no pre-job brief, planning, or hazard assessment for this work.

In TapRooT®, you would follow up that discovery with:

“Is this the exception or the rule?”

If it is an exception (normally we do a good job planning work), then there is not a Generic Cause. But, if people occasionally or frequently don’t do good pre-job preparation, the question is, “Why don’t they?”

This is getting at the Generic Cause of the overall problem.

So my question to you, the reader, is …

Do you:

a) assume each incident is a one-off event until it is proven to be otherwise; or

b) assume each incident is indicative of a bigger problem (a Generic Cause) until proven otherwise; or

c) not assume anything, you prove whether each accident is a “one-off” or a Generic issue.

I’d be interested in hearing which approach you take.  Please leave your comments below.

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