Incident Investigation Basics
Accidents, illnesses and near-misses do not "just happen." These incidents have definite causes, traceable to a specific sequence of events. But you and your employees may not fully understand those causes, so you may fail to take action to prevent an incident from happening again. You can solve this problem by having your supervisors conduct an incident analysis.
What follows is a brief look at incident investigation. If you are a policyholder, you can get more information and a helpful form by calling (800) 859-5995.
What Employers Can Do
Make it a standard to investigate all accidents, illnesses and near-misses in your workplace as soon as possible (after getting medical aid for injured workers who need it and restoring order to the scene). Begin your investigation while the facts are still clear to those involved and before physical conditions change.
An incident analysis has four primary steps:
1. Gather facts
Gather facts about what happened. Interview those involved and any witnesses. Keep the interviews private and listen carefully. Ask open-ended questions, one at a time. Continue investigating until you are satisfied that you understand the circumstances and causes of the incident--don't stop just because someone says the injured worker was "careless."
Examine materials and equipment. Be sure to follow safety procedures and use personal protective equipment if necessary. Take photos or make sketches when possible.
2. Analyze the Facts
The most important part of the investigation is analyzing the facts to determine why the incident happened. This task is difficult because there is almost never a single, simple reason. Concentrate on underlying causes, usually a combination of factors. Consider which of the following categories may be contributing causes:
Equipment--Examples are machinery, raw materials, inadequate safeguards.
Methods--Examples are rules, procedures, supervision, work methods.
Personnel--Examples are physical condition, training, fatigue.
Environment:--Examples are noise, heat, cold, lighting, ventilation, road conditions.
3. Take corrective action
If you identify causes from a number of the categories described above (equipment, methods, personnel, environment), then plan ways to correct each cause. Examples might include physical changes, procedural changes, more training or a better safety program. Be sure that management, supervisors and employees follow through with the appropriate measures.
4. Follow up
Just because you assigned corrective action tasks doesn't necessarily mean your staff completed them. Furthermore, it doesn't mean the corrective actions were effective. Follow up to make sure all corrective actions are in place and that they eliminated the root cause.
Collect data on the costs of the incident. You may be able to use this information to evaluate whether the cost of the incident justifies the purchase of new equipment or changes in production methods.