Hi, Bryan McWhorter here with Safeopedia and another safety moment. I'd like to talk about chains of events. I've done over 500 accident investigations by this point in my career and when doing the root cause analysis for an injury, property damage, or any type of incident or near miss, I often find that there were a chain of events that led up to the incident. Like what caused me to cut the tip off my little finger with a pair of scissors here a few days ago, but we'll get to that in a moment. Give you an idea of chain of events. I can remember one injury I investigated where a person on a factory shop floor had slipped in some water on the ground and tweaked his back. Now when I did, the investigation, I actually found that the story started the night before. They had a newborn in the house and he hadn't gotten much sleep the day before, so he's a little bit tired.

The line had gone down for some maintenance and he'd washed off part of his machine and hadn't had a chance to clean up the water yet. He'd grabbed some, product that he was going to test, at that point an alarm went off. So he, while holding a product off the production line, he wanted to answer the alarm quickly, a little bit tired, slept on the wet floor and went down. So again, the cause of the incident were really all these factors combined. You could say complacency was a part of it. And again, when I'm doing accident investigations, I'll usually list one of those three leading one of those three leading indicators for accidents, shortcuts, snap decisions, and complacency. If I find one of those is a actual factor as well.

For me, complacency is probably there when I cut my finger. But there was a chain of events the day before this happened. I had actually done a really strong leg workout, really worked my legs hard to wear. The next day they were like rubber. I went to make myself a sandwich and as I opened the door for the refrigerator, I leaned against it because of my wobbly legs and actually push against the ice maker and it's shot some ice cubes out onto the ground. You see kind of a "Final Destination" moment kind of happening here? Well, I grabbed the stuff that I needed to make my sandwich was sitting it on the counter. They lettuce was wrapped in plastic. I grabbed some scissors to cut the plastic off while I'm watching our Cocker Spaniel chase ice cubes. My mind is on here, not on here, and snip there goes to the tip of my little finger. Complacency definitely a factor, but it was a chain of events that led up to it. If my legs weren't a wobbly, I probably wouldn't have leaned on the ice machine. Again interesting to see what we find when we start really doing our root cause analysis.

So how about you when you're doing your incident investigations, do you try and go beyond just that point and look at all the contributing factors that led up to that? Even leading to possibly the night before or the day before the incident? Make sure you get to the true root cause. And if one of those leading indicators for injuries, shortcuts, snap decisions, and complacency is a factor, be sure and list it as well. Until next time, Bryan McWhorter with Safeopedia. Stay safe.