When do you conduct an investigation?
All incidents, whether a near miss or an actual injury-related event, should be investigated. Near miss reporting and investigation allow you to identify and control hazards before they cause a more serious incident. Accident/incident investigations are a tool for uncovering hazards that either were missed earlier or have managed to slip out of the controls planned for them. It is useful only when done with the aim of discovering every contributing factor to the accident/incident to "foolproof" the condition and/or activity and prevent future occurrences. In other words, your objective is to identify root causes, not to primarily set blame.
ACCIDENT - The National Safety Council defines an accident as an undesired event that results in personal injury or property damage.
INCIDENT - An incident is an unplanned, undesired event that adversely affects completion of a task.
NEAR MISS - Near misses describe incidents where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have occurred.
Who should investigate?
The usual investigator for all incidents is the supervisor in charge of the involved area and/or activity. Accident investigations represent a good way to involve employees in safety and health. Employee involvement will not only give you additional expertise and insight, but in the eyes of the workers, will lend credibility to the results. Employee involvement also benefits the involved employees by educating them on potential hazards, and the experience usually makes them believers in the importance of safety, thus strengthening the safety culture of the organization. The safety department or the person in charge of safety and health should participate in the investigation or review the investigative findings and recommendations. Many companies use a team or a subcommittee or the joint employee-management committee to investigate incidents involving serious injury or extensive property damage.
Training for incident investigation
No one should investigate incidents without appropriate accident investigation training. Many safety and health consultants and professional organizations provide this type of training. Before committing resources to training, you might want to check the course contents against the information found in the National Safety Council's pamphlet, "Accident Investigation ... A New Approach."
The investigative report should answer six key questions
Six key questions should be answered: who, what, when, where, why, and how. Fact should be distinguished from opinion, and both should be presented carefully and clearly. The report should include thorough interviews with everyone with any knowledge of the incident. A good investigation is likely to reveal several contributing factors, and it probably will recommend several preventive actions.
You will want to avoid the trap of laying sole blame on the injured employee. Even if injured workers openly blame themselves for making a mistake or not following prescribed procedures, the accident investigator must not be satisfied that all contributing causes have been identified. The error made by the employee may not be even the most important contributing cause. The employee who has not followed prescribed procedures may have been encouraged directly or indirectly by a supervisor or production quotas to "cut corners." The prescribed procedures may not be practical, or even safe, in the eyes of the employee(s). Sometimes where elaborate and difficult procedures are required, engineering redesign might be a better answer. In such cases, management errors -- not employee error -- may be the most important contributing causes.
All supervisors and others who investigate incidents should be held accountable for describing causes carefully and clearly. When reviewing accident investigation reports, the safety department or in-house safety expert should be on the lookout for catch-phrases, for example, "Employee did not plan job properly." While such a statement may suggest an underlying problem with this worker, it is not conducive to identifying all possible causes, preventions, and controls. Certainly, it is too late to plan a job when the employee is about to do it. Further, it is unlikely that safe work will always result when each employee is expected to plan procedures alone.
Implications of accident investigations
Recommended preventive actions should make it very difficult, if not impossible, for the incident to recur. The investigative report should list all the ways to "foolproof" the condition or activity. Considerations of cost or engineering should not enter at this stage. The primary purpose of accident investigations is to prevent future occurrences. Beyond this immediate purpose, the information obtained through the investigation should be used to update and revise the inventory of hazards, and/or the program for hazard prevention and control. For example, the Job Safety Analysis should be revised and employees retrained to the extent that it fully reflects the recommendations made by an incident report. Implications from the root causes of the accident need to be analyzed for their impact on all other operations and procedures.