"It was 2001, and I remember it as the moment I realised here was a big missing piece in safety".
I was working as Group HSE Manager at a large Sydney manufacturing facility. In that time, I came to know an experienced operator called Trevor. I remember him because he was a good guy, always followed safety procedures - you know the type: really competent, always good to deal with.
I was surprised then, when I got a call from the shift supervisor one Tuesday afternoon...
He said, “Trevor put his finger where he knew it didn’t belong and lost it from the knuckle down. ”My initial thought was “why would he do that?”. He knew better. Then came “what was he thinking?”. Probably not much, at least not much to do with what he was doing at the time.
We investigated the incident and identified corrective actions. The General Manager insisted Trevor had to be re-trained because, as he put it, “forgetfulness had set in”. I didn’t really agree with it, especially considering Trevor wrote the Safe Work Procedure for operating the machine, but it got included anyway.
The corrective actions were completed, the incident closed off and the General Manager considered it resolved. But not me.
What kept gnawing at me was that Trevor had operated this machine for 20 years without incident, he knew exactly how he could get hurt, and most importantly, he was known for always doing things safely. It just didn’t add up, there was something missing!
What I wanted was an answer to “what was different for Trevor this time?”
As it turned out, Trevor was having troubles at home and his pre-occupation made him inattentive enough to do something he would have never otherwise have done.
That was the first time I came to realise the significant role inattention plays in incidents. The interesting thing for me was that up to that point, I had only ever looked for inattention when there was no hazard, no system deficiency or anything else to be found.
From that day on, I started looking for inattention and found it everywhere, in just about every incident!
And why wouldn’t it be? It’s part of the human condition.