I heard this phrase from an expert discussing the Egyptian plane crash: “Accidents are a sequence of circumstances. Not an isolated event.”
A debate that occurs often is whether all accidents can be avoided. Certainly some are, one will say. Some accidents are a fluke. That’s why they call them accidents.
But, I think the expert’s comment bares consideration. Most accidents that occur in our locations are a result of circumstances which converged.
We need to dig deep on every accident and consider the circumstances.
Was our maintenance faulty?
Had our training been done well?
Was our housekeeping up to speed?
Had we ignored a frequency of machine breakdowns?
Had we been loose in our discipline with irregular practices?
Was there a true team environment where teammates supported each other and held each other accountable?
Did we survey well our environment to assure conditions were conducive to safety?
You get the point. We get lax on the details, circumstances grow and converge.