March 19, 2012 | Mark Paradies

Monday Accident & Lessons Learned: What Should You Investigate?

Let’s say this was your facility and you happened to walk up on this job (or is it a circus act?) …


Yes … You would stop the work (or pause the work … a new term I heard at the BST Conference).

But then what?

a) Discipline?

b) Correct them informally – no need to get them in trouble.

c) Report as a near-miss?

d) Do a TapRooT® Investigation?

I would argue for a complete root cause analysis using TapRooT®.


Because this insanity has the potential to become a high consequence incident.

Even though no one has been hurt yet, this is a near-miss with the potential for a serious injury or fatality. Therefore, it should be treated just as seriously as if someone had fallen off the ladder and broken their wrist (or worse).

Learning from this “near-miss” an important step in preventing more serious accidents.

So, today’s lesson learned is to learn from the small stuff to make sure the big accidents never happen.

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