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CAP Safety Tip of the Week

Mishap Reviews: Key principles

Contributing factors may be previously undetected hazards, or inadequately controlled risks, that should be addressed with corrective actions.

Why is this important?

  • We look for the cause; we don’t find fault. Safety mishap reviews are conducted solely to determine what went wrong and what can be improved to prevent it from going wrong again.

  • The amount of energy expended in discovering the causes of mishaps has nothing to do with the amount of damage they cause. A minor injury may reveal the same hazards as a serious injury.

  • Our goal is to analyze the sequence of events leading up to a mishap and determine what improvements can be made to prepare members to respond should the situation occur again.

Do this:

  • Look at every element in the event chain that led to the mishap and drill down using the 5Ms and the 5 Whys to determine if there are opportunities to "break" the chain

  • Share your review with your Director of Safety and be open to their feedback on improving both the review and the recommended mitigations

Not this:

  • Assume that a mishap, no matter how small, is unpreventable
  • Think you "know" the cause of a mishap without conducting a review 

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