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.

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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.