Knowing how to conduct an effective incident investigation is an important part of your safety culture.
Too often, investigations become fault-finding ventures that neither determine the root cause of the incident nor prevent similar incidents from happening again. Incident reports often say that an employee was not paying attention to their surroundings. That is not a root cause and all it accomplishes is more paper pushing.
Purpose of an incident investigation
The purpose of an incident investigation is to identify and correct a hazard that has disrupted normal work processes and caused or could have caused harm to a person. There should be no other reason. It is not about property damage or repair costs. It is always about preventing injuries. Anything else in your investigation process fails to fulfill its purpose.
Benefits of an effective investigation
The benefits of conducting a proper incident investigation are worth the work. You should respond to any disruptive event with an incident investigation because an interruption to normal routines places people at risk.
Effective incident investigations:
- Establish safer processes, procedures, and employee practices
- Reveal shortcomings or areas of improvement in preventive maintenance schedules
- Create a more productive and efficient work environment as hazards are removed or reduced
- Create employee buy-in in ensuring the workplace is safe
- Enhance your reputation as a caring and safe place to work
- Reduce absenteeism and employee apathy because they send the message that employees are valued and safe
- Include front-line employees in the investigation and solution
- Keep equipment operating safely and employees maintaining equipment properly
A case in point
Whether you are investigating an injury, a damaged piece of equipment or property, or a near miss, the investigation should focus on how and why the incident occurred and how to prevent it from happening again. In other words, you should identify the root cause, not the surrounding symptoms.
For example, imagine a forklift operator veers from the aisle and strikes a conveyor line. It might be tempting to conclude that the employee was careless or inattentive to their surroundings. But a more thorough investigation would reveal that a water hose used for cleaning the line ruptured and was leaking water onto the forklift aisle. This immediately raises questions like:
- Was the rupture due to a poor or misaligned connection?
- Was the hose showing signs of wear or deterioration?
- Was the hose exposed to running equipment or being run over by mobile equipment? If so, is there a housekeeping issue to address with employees?
You learn that this was the operator’s fifth pass during the shift, and the floor had been dry each time previously. Contributing factors include the forklift’s speed, the ruptured hose, poor housekeeping, and skipped procedures that allowed for water pressure to remain in a hose line that was not in use.
You find that the root cause was the deterioration of the hose and learn that employees were not conducting visual inspections. During the mitigation phase, you decide to relocate the hose line to prevent water sprays and leaks from entering the forklift path again.
At the end of the investigation, the findings lead to:
- Changes in equipment
- A refresher on the importance of visually inspecting equipment before use
- Updated procedures and training on bleeding water pressure from a hose when not in use and proper hose storage
- A new procedure to help forklift operators and employees identify and address liquid spills and changing aisle conditions
Different approaches to arrive at a root cause
There are many investigation techniques to get you to the root cause. One is asking “why” repeatedly until you arrive at the root cause. Another is the “fishbone” method. If you follow the International Organization for Standardization, you might use the “corrective actions” process. Regardless of which method you use, do not lose sight of the purpose: to make your work environment safer.
The depth of an investigation may vary depending on what happened, but the fact that something abnormal occurred should demand your attention. You should always look for root causes and correct any hazard that could harm your people.
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