The Investigation


An unsafe act or unsafe condition is an indication that something is wrong in the safety management system and disciplinary action never corrects that problem. We know that many factors contribute to an incident. That’s why I don’t like using the term “root cause” because it implies only one cause. That “root cause.”

As a supervisor, handing down disciplinary action was easy, it made me feel good because I took action and fixed the problem, or at least I thought I did. Hey and besides, as a supervisor, it couldn't be my fault. There was always pressure to discipline someone to show we were serious about safety. That only chips away at the trust they may have in us.

Are you getting pressure from operations to punish someone for a safety infraction? Then ask the following questions first:

  1. Was there a documented procedure?

  2. Was there training?

  3. Was the procedure communicated?

  4. Was the training reinforced?

  5. Was compliance measured?

If you can answer “yes” to all 5 questions, you might however slight, have a case for disciplinary action. I have yet to see an incident where that was the case. There is always a break down in the management system somewhere. Our job is to find it and make recommendations to correct it and avoid disciplinary action. It only erodes trust. Trust from the people we depend on to help create a safe work environment.

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