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