Proactive Consulting Services Ltd.
Despite your best efforts with supervision, training, and inspections, unexpected problems are still going to occur on your work site. Your safety system can dramatically reduce your company’s losses due to injuries or property damage, but it may not eliminate them entirely. Incident investigation is an essential step towards making changes that can prevent recurrence of accidents from similar causes.
Incident investigations are critical in identifying, controlling, and eliminating hazards that exist in the workplace. For an investigation to be effective, it needs to be structured and systematic. It will require the use of trained investigators that can separate themselves from the incident.
Most companies conduct investigations as a part of their safety system. Yet, the purpose of doing investigations is often poorly understood. As a result, they can degenerate into finger-pointing, blame-fixing, and fault-finding exercises which seldom determine the real reasons for what happened or arrive at any effective solutions to the problems involved. Even when the purpose is properly defined, investigations are often poorly done. Perhaps the greatest reason for this is not understanding the many real values to be gained.
Historically, safety managers have told us that any incident should be investigated promptly and thoroughly. This includes injury, occupational illness, damage, spill, fire, near misses, etc. Many people will have interest in such losses and their effects on the organization. Suffering, cost liability, and lost production cause concern. Such losses may also point to serious deficiencies in the safety system which needs to be corrected.
In practice, it is often difficult to convince employees to investigate all near misses, as this can create a bureaucratic nightmare. What should be done is an evaluation of the potential severity of the incident. Taking into consideration that resources inside each organization are limited, we would want to ensure that they are being used effectively. The cause factors make the incident occur. The severity of the actual loss in each event is often a matter of chance and may vary according to very slight differences in circumstances. So, the practical approach is to first identify the potential loss of each incident, as this will dictate the level of investigation that is required. Each organization, of course, must define what potential losses are significant to its resources, its people, and its public relations.
After establishing the level of investigation that is required, designating the investigator or investigation team is the next step. As with any type of problem solving, the person with the most interest in the problem is the obvious first choice. The person with a vital interest finds solutions that work. There is also another important consideration in the choice of the investigator. The person must be able to stay objective and not have any conflict of interest. The findings must be truthful and relevant, or the problem isn’t really solved.
Where does any manager or supervisor get the time to conduct a thorough investigation? The time used in an investigation is part of the cost of an accident. If that is true, then why spend that time and add the cost? It’s not an easy decision. While we must work toward minimizing the costs of accidents, they will repeat if the investigation fails to identify the causes. Managers simply must provide the time, understanding that inadequate investigations will cost them even more time.
The purpose of an investigation is to find out what caused the incident so it and similar occurrences can be prevented in the future. The primary goal is to gather information for the future, not to assign blame for what has already happened.
Investigations also help measure the effectiveness of the company’s safety system. The examination of actual events can reveal hazards not previously discovered; comparisons across time can reveal trends that might otherwise be missed.
An investigation should answer the who, what, when, where, why, and how questions that will surface as a result of an incident. The why and how are subjective and will help the investigator to formulate conclusions and corrective actions to prevent recurrence.
To be effective, corrective action must be applied to each cause identified during the investigation. Each corrective step should be assigned a target date for completion. The corrections may be implemented in stages, depending on the hazard priority, training priorities, budget, and so on.
An incident is not something that just happens unexpectedly. It is a signal that something is out of order with conditions on your work site or with what your employees are doing. An investigation is necessary to find out what that “something” is.
It should be a thorough examination that tells you not only what happened in this case, but also how and why it happened this way. The goal is not to find someone to blame for what happened, but to get information you may not get in any other fashion. With thorough reporting and analysis over time, investigations can reveal important trends, and point to valuable corrective actions.
An investigation, therefore, is not just a reaction to a specific incident. It has a much broader role in the health and safety of your people. By providing information about what happens on the work site, it can improve the quality of your training, the effectiveness of your supervision, and the overall performance of your safety management system.
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