Recently we worked with an organization that was struggling to control its risks around the use of ATVs and UTVs. After several serious accidents involving these machines, we were asked to review their “Barriers,” “Controls,” and “Safeguards” in place to control the risks associated with these machines. We found a program and training on the said program that failed to DEFINE and QUANTIFY safety expectations. For example, the program stated that these machines could only be operated in “designated areas,” (a trendy phrase used in poorly written programs), yet the term had not been defined nor quantified. Thus these machines were being used in all locations of the properties regardless of risks. The failure to DEFINE and QUANTIFY what a “designated area” is was foundational to the safe operation of these machines and was clearly an organizational failure; however, in each event, management wanted to find fault in the decision-making of the operator of the machine(s).
But if the program states “only in designated areas” and the training program uses the exact phrase, yet no areas have been assessed and designated, where is the failure in these events? Active failure (operator’s decision) or Latent (organizational management system) failure?
