The investigation takes five minutes:
- Worker bypassed safety device: Check
- Violated procedure: Check
- Disciplinary action: Check
- Case closed: Check
I've seen this investigation a hundred times. Different industries, different countries, same conclusion. And it's worse than useless—it's dangerous. Because here's what the five-minute investigation didn't ask:
Why did he bypass the interlock?
Production was behind schedule. His supervisor needed the job finished before shift end.
Why was production behind?
Two machines down for maintenance, but the production target hadn't changed.
Why didn't he use the lockout procedure?
Last time he did, it took 40 minutes to get the supervisor to sign off. He'd been told he was "slowing things down."
Why was his colleague in the danger zone?
They'd developed a workaround—one person bypasses, the other watches. Everyone knew. No one stopped it. It saved time.
Suddenly, we're not investigating a "stupid mistake." We're investigating production pressure, resource allocation, supervisory culture, and the gap between official procedures and actual practice.
The real question isn't whether the worker violated procedure. He did. The real question is: what made violation the rational choice?
Until we're willing to ask uncomfortable questions about our own systems, we're just creating the conditions for the next incident while blaming the last victim.
Next time: I'll show you how to ask those uncomfortable questions—and what to do with the answers.