Forensic Engineering and Organizational Safety

In the field of forensic engineering, when a major incident occurs, I have come to learn that there are always three areas main areas where operations could be improved, and the incident avoided.  During the completion of an investigation, if I find causal factors in only one or two of these three areas, I know my work is not done and it is ‘back to the drawing board’. 

First area for causal factors is engineering and design, a facility or process design can always be more robust, and hazards are best designed out rather than to rely on safety barriers or personal protective equipment.  Second area I look to is execution of the construction or operational work tasks; job-tasks can be simplified, execution can be more consistent, and communication between supervisor and workers can be improved in most cases.  The third area is human behaviours, was the workforce properly motivated, rested, thinking clearly and on task?  Unfortunately, not always.  For a major incident to occur, deficiencies in all three of these areas have simultaneously happened, corrective actions are required to eliminate the possibility of a similar reoccurrence. The management, executives, and board of directors need understand the causal factors for the incident and fully support the corrective actions to prevent a future reoccurrence.