Workplace injuries can strike unexpectedly, leaving a trail of challenges and questions in their wake. In this blog post, we will explore the risk control perspective of incident investigations, highlighting the importance of documentation, reporting, and root cause analysis. By following these procedures, organizations can effectively manage risks and prevent similar incidents from occurring in the future.
Incident Investigation Questions
When an incident occurs, it is crucial to answer four fundamental questions:
How did it happen?
Why did it happen?
What needs to be corrected?
Incident Investigation Procedures
To conduct a thorough incident investigation, it is essential to follow these procedures outlined:
When a personal injury occurs, the injured employee(s) should receive the appropriate first aid and subsequent medical treatment as soon as possible. Necessary actions to protect the injured from additional injury should be taken.
Complete an accident investigation form. Be objective throughout the investigation.
If the cause of the accident/incident is readily apparent, initiate whatever action is necessary to prevent a similar occurrence in the future. If necessary, initiate a site-wide safety standdown (safety meeting).
Preserve any physical evidence that may help reconstruct the circumstances of the accident or incident for any investigation. I recommend properly dating and labeling photographs to document the accident/incident.
Obtain an employee statement as soon as possible. In addition, attempt to identify any witnesses of the accident/incident and obtain witness statements as soon as possible. Be sure to include contact information (name, employer, telephone, home address).
In the event an accident/incident involves a subcontractor or a third-party, document everything-equipment, vehicles, circumstances, etc., anything that may have been contributing factors.
Root Cause Analysis
By addressing the core issue, your company can substantially or completely prevent the same or a similar incident from recurring. Conduct a root cause analysis on all incidents, including but not limited to property damage, employee injury, liability claim, fleet incident, or chemical spill.
The root cause analysis should:
• Identify and eliminate hazards
• Expose processes and/or equipment deficiencies
• Identify unsafe acts or need for retraining
• Expose policy gaps
Documentation of Incident
Documentation is a must. This includes documenting the incident itself, as well as the investigation. This step is essential because it helps capture all relevant information so that it can be used in trend analysis.
Every accident/incident should require a formal review. The designated safety administrator, the employee involved, and the employee’s direct supervisor should have a formal conference to discuss the incident. The goal should be to find consensus on the root cause and allow the employee an opportunity to relay what happened and answer questions if clarifications are needed. Lastly, corrective actions should be developed, reviewed, and finalized. The committee should review the circumstances involving the accident and determine if the accident was preventable or non-preventable.
Disciplinary procedures for preventable incidents should be outlined in a company’s policy. A word of caution- do not make employees the scapegoats. There are times when an employee is obviously responsible, and they should be held accountable. Some good examples include removing guards, not wearing PPE, or violating safety rules that cause the incident. In situations where it is unclear if the incident could have been prevented, no disciplinary action should take place.
Implementing corrective actions is essential in preventing future incidents. Corrective actions should start with the hierarchy of controls - elimination, substitution, engineering, administrative, and then PPE. The preferred practice is to eliminate or alter the condition or operation that led to the incident. If there is a safer method for performing the task, it should be implemented.
I recommend implementing three corrective actions following an incident. Corrective actions can include (but are not limited to) replacing, repairing, or upgrading equipment, altering a process to make it safer, and retraining (if the root cause is lack of knowledge or behavior). As an additional corrective action, a site-wide safety meeting (or standdown) should be initiated to ensure that other employees understand the incident’s root cause and steps they can take to prevent being involved in a similar incident. Other corrective actions can include Job Safety Observations (JSOs) to verify that an employee understands how to perform a task safely or a driver observation if the incident involves driving to confirm that the employee practices safe driving. All corrective actions should be documented. Someone should be designated to follow up on all corrective measures to ensure completion.
In conclusion, incident investigation and root cause analysis are important tools for managing risk in the workplace. They help identify the underlying causes of incidents and provide a framework for preventing similar incidents from occurring again. By following the steps outlined above, organizations can create a culture of safety and ensure that incidents are properly addressed and prevented in the future.