As a health and safety auditor there are so many times I review company’s incident investigations and become frustrated with the effort put forth. Improperly completely investigations, beg the question “why bother?”. Yet a properly completed investigation can bring about meaningful change and a healthier, safer work site. Reasons to investigate a workplace incident include:
It is important to note, incidents that involve no injury or property damage should still be investigated to determine the hazards that should be corrected, and to identify trends and needs.
Why look for the root cause?
An investigator who believes that accidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine some underlying factors in a chain of events that ends in an accident.
The important point is that even in the most seemingly straightforward accidents, seldom, if ever, is there only a single cause. For example, an “investigation” which concludes that an accident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as:
An inquiry that answers these and related questions will probably reveal conditions that are more open to correction than attempts to prevent “carelessness”.
What are the steps involved in investigating an accident?
The accident investigation process involves the following steps:
As little time as possible should be lost between the moment of an accident or near miss and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses. The tools that members of the investigating team may need (pencil, paper, camera, tape measure, etc.) should be immediately available so that no time is wasted.
Why should recommendations be made?
The next step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar accidents. Recommendations should:
Resist the temptation to make only general recommendations to save time and effort. For example, you have determined that a blind corner contributed to an accident. Rather than just recommending “eliminate blind corners” it would be better to suggest:
Never make recommendations about disciplining a person or persons who may have been at fault. This would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future accident investigations.
The Written Report
If your organization has a standard form that must be used, you will have little choice in the form that your written report is to be presented. Nevertheless, you should be aware of, and try to overcome, shortcomings that might impede the reports professionalism, and overall completeness.
Your previously prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of the accident that you have, so include all pertinent detail. Photographs and diagrams may save many words of description. Identify clearly where evidence is based on certain facts, eyewitness accounts, or your assumptions.
The last and most important step of the investigation is to communicate your findings with workers, supervisors and management. Present your information ‘in context’ so everyone understands how the accident occurred and the actions in place to prevent it from happening again.
ISMS offers a team of well-trained incident investigators and can help at any point in the investigation process. We can also assist in training your incident investigators.
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