What’s The Problem?

With all the life experience you’ve had, odds are at some point you’ve found yourself under the hood of an automobile. Back in the day when a new car might last all of three years, it was commonplace. Nowadays, automotive design and reliability being what they are, things are a lot different.
 
Still, assuming you’ve been there and done that, you can appreciate the thought line for this edition of the NEWS: before sticking your head and torso under what some might view a suspended load, there are things to be thought about.
 
Not that many of us would, particularly when there are more pressing matters at hand. Like trying to figure out why the car won’t start when it’s time to head off to work. There was a time when propping up the hood required raising an iron rod and putting it in place; now springs and hydraulic arms take care of that for you.
 
Picture it’s your car, sitting in the driveway, you doing the troubleshooting: could the hood come down unexpectedly? Could you get hurt? Hurt seriously?  
 
If you hadn’t bothered to fully raise the hood, something like that certainly could happen. If it did, and you got hit on the head, who would you blame?

The Blame Game
 
That blame word is perfectly capable of provoking quite the reaction: “Do not go blaming the problem on the people who get hurt.” “Fix the problem, not the blame.” I know of places where using the word blame is objectionable, even verboten. 
 
Fair enough. But get hit on the head by your hood, you’d probably be asking yourself what you did to cause the problem. Or why you didn’t do something to have prevented it from happening. 
 
A rose by any other name is still a rose, isn’t it?
 
A mature and reasonable person like you wouldn’t blame the problem on gravity or bad luck. Tempting as it might be to point the finger at the automotive engineer who designed the hood, you know good and well if you’d bothered to fully raise the hood it would have functioned as designed. This was a problem solved a long time ago. You’re bright enough to know things like this can happen, ruling out your own ignorance.
 
Ruefully, you’d admit, “I have nobody to blame by myself.”
 
Thanks for being honest.
 
Investigating Problems
 
Your car; your hood; your head: your bad.  That’s the beauty of this thought experiment. If only real life were that simple. Change the venue from the driveway to the jobsite; the person harmed from you to someone you’re responsible for managing, it’s anything but simple. Procedures, regulations, management practices, culture, and yes, even punishment conspire to complicate matters.
 
“Punishment” you say? “In matters of industrial safety, a totally unacceptable term to employ!”
 
A nice thought, but time to get real. Surely you guessed our little thought experiment was prompted by a real-life case. The difference: the hood weighed more than a ton, and it was dropped on the job. In a fire station, of all places.
 
The partially raised cab of a fire engine fell on someone who only wanted to check out the battery type. The apparatus was parked inside the garage, making it impossible for the cab to be fully raised and locked in place. The partially raised cab fell, nearly killing the emergency responder perched below.  As to what caused it to unexpectedly drop, a failure in the hydraulic system was the culprit. 
 
Headlines in the local news prompted a visit by the state safety regulators. They noted the hydraulic lines were original equipment and found no record of inspection. They fined the fire department for lacking an energy control plan and not reporting the incident. Is there any way to look at that fine as anything other than punishment? 
 
I know: it’s the law, and the agency was only doing their job. 
 
The Point of It
 
This case is not your problem. But cases like this raise all sorts of questions about hazard recognition, safety culture, and the investigation process – and those are your problems.  So, let me raise one: if not to play judge and jury, what exactly is the purpose of the investigation? What should the purpose be? 
 
Wouldn’t it be nice if the first line of every investigation procedure read, “The purpose of an incident investigation is to ….” Perhaps yours does: if so, it would begin to set the standard by which the quality of an investigation could be measured and graded. Of course, that would also require someone going back to evaluate the reports. I’ve done a fair bit of that, finding significant flaws in the majority of investigations I’ve read.
 
 I am sure you are shocked by that finding.
 
At the fire station, the investigator got out a tape measure and proved it was impossible to fully raise the cab when the fire engine was parked in the garage. Insufficient clearance. He noted the presence of kitty litter under the engine, soaking up leaking hydraulic fluid, taking pictures to document the findings. Hydraulic system failure. Equipment records? No documentation of inspections.
 
Those are facts, explaining how the event took place. Obvious as some might be, they’re still useful to the process. But those facts reveal little about the problem: someone climbing under a partially raised cab when the locking bar was not secured. Or the failure to move the fire engine to a place with sufficient clearance so that the locking mechanism could be deployed.
 
There was a warning label on the hydraulic system controller: “Remain outside the cab until the locking bar is secured into position.” No mention in the report of the failure to comply. The agency would probably point out, “That’s somebody else’s job.” 
 
“That” being actually explaining what happened.
 
Speaking of: there was a second overlooked fact in the report: “a maintenance worker and the employee were prepping the truck.” So, two people involved, not just one. 
 
One more real-life factor complicating matters.
 
“Root Cause” Investigations
 
We’ll leave it to the Fire Chief and the Mayor to sort through their issues; I’m sure they will. Our interest is to learn from their case, thereby gaining the benefit of understanding without suffering the pain of the loss. 
 
One lesson to be drawn is that the facts matter. Facts should explain how something went wrong: the who, what, when, where and how of the event. Facts must be accurate – and accurately reflect the truth. There is a big difference between “no inspection conducted” and “equipment inspected but findings not written down.”  
 
The primary function of the investigation is to determine all the relevant facts that can be found. That is the first duty of the investigator. Think about it this way: if, for every investigation performed in your operation, you were given all the relevant facts and all the correct facts, you wouldn’t be unhappy, would you?  “Just give me the full story about what went wrong and let me draw my own conclusions about what went wrong.” 
 
Like you did with that bump on the head in the driveway.
 
Conclusions – yours, or anyone else’s – amount to what is known in the trade as “the root cause.” I am sure you are familiar with the term. People clammer, “What’s the root cause?” In a case like this, you can round up the usual suspects: management system failure; poor equipment maintenance practices; complacency; non-compliance; culture.  
 
Convenient and simple as they are, root causes like these are no more than labels. Useful for a sorting exercise, but producing little of value in understanding the problem. 
 
Frankly, you’d be better off skipping that step in the process and instead doubling down on effort to understand the problem. Doing that requires getting all the facts: the easy ones and the tough ones.
 
All The Facts
 
By now, it’s probably occurred to you that you already know more than enough about the investigation process to be able to tell a good report from a poor one. Something bad already happened and nothing can change that. With the proper understanding of the problem, you can change the future. Without that, good luck.
 
Getting all the facts demands asking the tough questions that need to be asked in the aftermath of failure. It also requires honesty as to the answers. Easy to do when it’s just you and your car in the driveway; drop the cab of a fire engine on somebody at work, it’s nothing like that. 
 
At the fire station, the questions begging to be asked are obvious: What were the maintenance practices? What caused the hydraulic system to fail when it did? Why wasn’t the fire engine moved outside where clearance was sufficient?  What did that other person say or do about the situation? 
 
To be sure, tough questions. Will they be answered as honestly as you did at the house? No telling. 
 
Find all the facts and you will understand the problem. That’s half the battle.
 
Paul Balmert
September 2024