Basic reverse engineering of accidents is an iterative process which uses facts uncovered by investigation and interviews, and attempts to recreate events leading up to industrial accidents.
Usually, several levels of safety redundancy must fail to lead up to an industrial accident. Supervision is weak. Employees are poorly trained. Equipment is not maintained properly. Leadership values production over safety. Proper operational protocols are not in place.
Reverse engineering helps prevent future incidents by diagnosing weaknesses in training or process.
Begin with the task itself. What was being attempted? Was this action in the scope of normal employment or employee horseplay?
Did a roofer fall from a roof while stapling shingles down, or did he jump off the roof while attempting to dunk a basketball?
Was the employee trained for his job? Was a first-day employee stapling these shingles or a seasoned employee?
Were safety devices used? Was the employee tied off and in a harness or was the line too long for the fall?
Where was the supervision?
In double checking the information received against the field conditions, you can determine what is the likely truth. Some forensics may be required for vehicle wrecks or building collapses.
Utility markers make errors. Did someone follow up on the physical markings and compare them to utility drawings or field markers?
Reverse engineering teaches vigilance. Redundancy will reduce damages and injuries.
Leadership, management, labor, equipment, and machinery conspire to create accident scenarios. Quality management changes leadership direction, trains the labor force, maintains equipment properly, and teaches proper use of machinery to avoid problems which increases overall efficiency.
Leadership envisions the big goals of the business, the forecasts. After an accident, this forecast can be used to model the hindcast. Where did the process go wrong? Obviously the goal was not to create an injury scenario, so where did leadership fail to communicate its vision?
The employee certainly does not want to sustain an injury. Where did those actions go wrong? Did the employee fail to ask for help? Was the employee not trained properly? Were they just messing around? These facts, once confirmed, need to be confronted.
Wherever the failures are found, the proximate causes of the incident require intervention. Perhaps the investigation finds a series of events not anticipated. Find the avoidance practice and retrain. Perhaps a supervisor simply failed in their duties. Rehabilitate that employee or dismiss them.
Reverse engineering is about finding the causation and rehabilitating the system to avoid future problems.
