Why is it that nearly every time I’ve conducted an accident investigation interview, the person being interviewed almost always comes up with ‘I knew that something was going to happen’?
If they knew it was going to happen, then why did they let it happen in the first place?
The answers tend to include:
“It’s not my job.”
“Nobody told me to say anything about it.”
“Everyone would laugh at me if I said I had a ‘feeling’ about it.”
Traditional root cause analysis requires the investigator to find a management failing, whereas, essentially, it’s a personal failing.
The law says that the root cause of all accidents are management failings, so in these cases the failing is to do with culture of the organisation, which is created by management, that has encouraged people to stick blindly to the rules.