Investigating Incidents: Why to Investigate
#incident #investigations #accident #events
What is incident investigation?
An incident investigation is the account and analysis of an incident based on information gathered by a thorough examination of all contributing factors and causes involved. It is widely accepted that incidents occur as a result of a chain of events.
Investigating a Worksite Incident
Investigating a worksite incident—a fatality, injury, illness, or close call- provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents.
Incident investigations that focus on identifying and correcting root causes, not finding fault or blaming, also improve workplace morale and increase productivity, by demonstrating an employer's commitment to a safe and healthy workplace.
Incident investigations are often conducted by a supervisor, but to be most effective, these investigations should include managers and employees working together, since each brings different knowledge, understanding and perspectives to the investigation.
In conducting an incident investigation, the team must look beyond the immediate causes of an incident. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone was the cause of an incident. To do so fails to discover the underlying or root causes of the incident, and therefore fails to identify the systemic changes and measures needed to prevent future incidents. When a shortcoming is identified, it is important to ask why it existed and why it was not previously addressed.
For example:
- If a procedure or safety rule was not followed, why was the procedure or rule not followed?
- Did production pressures play a role, and, if so, why were production pressures permitted to jeopardize safety?
- Was the procedure out-of-date or safety training inadequate? If so, why had the problem not been previously identified, or, if it had been identified, why had it not been addressed?
These examples illustrate that it is essential to discover and correct all the factors contributing to an incident, which nearly always involve equipment, procedures, training, and other safety and health program deficiencies.
Addressing underlying or root causes is necessary to truly understand why an incident occurred, to develop truly effective corrective actions, and to minimize or eliminate serious consequences from similar future incidents.
Refer : https://www.osha.gov/incident-investigation
Why investigate?
- There are hazards in all workplaces; risk control measures are put in place to reduce the risks to an acceptable level to prevent accidents and cases of ill health.
- The fact that an adverse event has occurred suggests that the existing risk control measures were inadequate.
- Learning lessons from near misses can prevent costly accidents.
- You need to investigate adverse events for a number of reasons.
Reasons for Incident Investigations / Function of Investigation Team
(Why do Incident Investigations ?)
Reasons to carry out investigations of an accident :
- To identify the immediate causes of the incident.
- To identify the underlying causes of the incident.
- To identify the root causes of the incident.
- To identify & implementation of the corrective action
- To prevent a recurrence. (Prevention of similar losses in future)
- To record the facts & evidence of the incident.
- For legal reasons and legal compliances. (MHSWR 1999, regulation 5)
- For claim management
- For Insurance Purposes.
- For Lesson Learning – specific & general ( e.g. to identify the training needs, further recommendation)
- For increasing staff morale.
- For disciplinary purposes.
- For data gathering & analyzing purposes.
- To Review / update risk assessments/
- To Review SSW/ update SSW
- To Review PTW / update the PTW
Legal reasons for investigating
(Refer : www.hse.gov.uk)
- To ensure you are operating your organisation within the law.
- The MHSWR 1999, regulation 5, requires employers to plan, organise, control, monitor and review their health and safety arrangements.
- Health and safety investigations form an essential part of this process.
- you are expected to make full disclosure of the circumstances of an accident to the injured parties considering legal action. The fear of litigation may make you think it is better not to investigate, but you can’t make things better if you don’t know what went wrong!
- The fact that you thoroughly investigated an accident and took remedial action to prevent further accidents would demonstrate to a court that your company has a positive attitude to health and safety.
- Your investigation findings will also provide essential information for your insurers in the event of a claim.
Benefits of carrying out investigations of an accident :
- helps to identify and eliminate the hazards)
- Discover trends & patterns of Accidents .
- Helps in developing safe/Safety culture ,
- Stakeholders satisfaction, ( Customer Satisfaction, Insurance agency, Vendors, Supplier, Workers etc.)
- Increase in business reputation ,
- Financial benefits as avoid the reoccurrences, ( to avoid the further financial losses)
- Improve HSMS system performance, integrity, creditability, assurance ,
- Review the system HSMS ,
- Helps to reduce the accidents/ incidents , ( Reduce the Accident rate)
- Reduce injury and Severity rates
- Reduction in fines ,
- Reduction in penalty ,
- Reduction in compensation claim,
- Reduction in Human sufferings (pain and injury)
- Helps in developing safe system of work ( developing PTW)
- Helps in continuous improvement process
- Demonstrate improvement & ownership of outcomes
- Development of managerial skills – can be applied to other areas of the organisational
Which events should be investigated?
All events should be investigated.
For Example:
- Accident.
- Injury accident.
- Damage-only accident.
- Near-miss. (e.g. undesired circumstances, potential or significant NM)
- Dangerous occurrence.
- Work-related ill health.
- LTI (Lost Time Injury)
- MTC (Medical treatment Case)
- etc.
NEGATIVE OUTCOMES OF ACCIDENTS:
- Injury & possible death ( Fatality)
- Disease
- Damage to equipment & property
- Litigation costs (Legal costs), possible citations( court judgement), Enforcement notices, Legal Actions
- Lost productivity,
- low Efficiency,
- Low Morale (Staff & workers)
- Financial Losses, e.g. Compensation
- Loss of reputation
POSITIVE OUTCOMES OF ACCIDENTS
- (it leads to )Accident investigation
- (it helps into)Prevent repeat of accident
- (it helps to improve) Change to safety programs
- (it helps to improve) Change to Policy , procedures, system & rules
- (it helps to improve) Change to equipment design
- Lesson Learning
- Training required./requirement
Having been notified of an adverse event and given basic information on what happened, you must decide whether it should be investigated and if so, in what depth.
It is the potential consequences and the likelihood of the adverse event recurring that should determine the level of investigation, not simply the injury or ill health suffered on this occasion.
For example:
is the harm likely to be serious?
Is this likely to happen often?
Similarly, the causes of a near miss can have great potential for causing injury and ill health.
When making your decision, you must also consider the potential for learning lessons.
For example, if you have had a number of similar adverse events, it may be worth investigating, even if each single event is not worth investigating in isolation.
It is best practice to investigate all adverse events which may affect the public.
In RoSPA's view, some of the major pitfalls in accident and incident investigation include:
- No reporting of accidents and near misses (often due to employee fear of consequences)
- No investigation at all (coupled with massive under-reporting to enforcing authorities)
- No clear procedures for investigation (and/or no managerial involvement)
- No workforce involvement (trades union safety representatives have a legal right to investigate accidents)
- No scaling of the level of investigation (everything investigated in the same way rather than matching investigation effort to safety significance or learning potential)
- Failure to gather all the relevant facts (particularly as a result of inadequate approaches to witness interview)
- No use of structured methods to integrate evidence
- Distortions in evidence gathering and analysis due to uncritical biases
- Concluding the investigation too early (not going far enough)
- Simply focusing on the errors of individuals
- No search for "root causes"
- In that context, no examination of safety management system failures
- Failure to think outside conventional rules and operating systems
- Poor communication of lessons learned
- Failure to secure closure on resulting recommendations.
Frank Bird Accident Triangle (Safety Pyramid )
The accident triangle, also known as Heinrich's triangle or Bird's triangle, is a theory of industrial accident prevention. It shows a relationship between serious accidents, minor accidents, and near misses and proposes that if the number of minor accidents is reduced then there will be a corresponding fall in the number of serious accidents.
Major incidents, more complex events or incidents with high potential, Investigated by a team:
- Safety specialist / H&S professionals
- Senior manager/ partners/ Directors
- Technical specialist.
- Worker representative/ Safety Representative/ Union Safety Rep.
- Witnesses / Workers
- Supervisor / Line Manager
- etc.
When accident investigation should start?
•Immediate -Urgency will depend on the magnitude and immediacy of risk
•Adverse events should be investigated and analysed as soon as possible.
•Memory is best and motivation greatest immediately after an adverse event.
•NB –Consider the state of those being interviewed –May be in shock
General Question- What does involve in investigation?
•Analysis of all information available
–Physical –scene of incident
–Verbal –accounts of witnesses
–Written –documents
•Process drawings (P&ID’s)
•Risk assessments
•Permits to work
•Procedures
•Instructions,
job guides etc.
What makes a good Investigation?
•“To get rid of weeds you must dig up the root. If you only cut off the foliage the root will grow again.”
•Investigations which identify root causes that organisations can learn from their past failures and prevent future failures.
•Is suitable for purpose –proportionate to risk
•Thorough systematic and structured
•Is carried out with prevention in mind NOT apportioning blame.
•It does not jump to conclusions
•Based on facts provided
•Follows the causal chain all the way up to Management level
•Explores all lines of enquiry
•Timely, objective and unbiased
•Identifies immediate, underlying and root causes
•Reviews existing risk control measures
•Action plan AND implementation
Group Discussion
Discuss the first thing you should do when arriving at an accident scene, and then the later steps.
PRE-ACCIDENT PLANNING
- Clearly defined roles and responsibilities
- Training of key staff members
- Communications established
- Standard procedures established
- Necessary equipment and forms on hand
Typical contains of investigation reports
- Investigators details( Team-who are doing? )
- Date, time & Location of the incident with description of the event ( Case number)
- Details of injured persons/ person involve (Victim details age, etc.).
- Details of the injury
- List of evidence including witness interview ( if applicable) (documents examined etc.)
- Assessment of breaches of the legislation. ( violations etc.)
- Causes of the incident. ( e.g. immediate , underlying & root cause etc.)
- Recommendations & conclusion
Typical contains of investigation reports
Investigation report format and structure
There is no specific investigative report writing format. All you need to know and stick to is a structure. Therefore, outlining is the first step in investigative report writing as it will help you understand what kind of information you need to gather and how to present it. Here is a basic example of the outline:
- General case information - includes the name of the reporting person, case number, and important dates.
- Brief summary - shortly overviews the incident, involved parties, causes, and outcomes.
- Recommendations – pieces of advice on the measures that have to be taken.
- The purpose of investigation - defines the objectives.
- Incident descriptions - provides a full chronological incident description.
- Interviews documentation - gives detailed information on the interviews, including notes of the interviewer.
- Interviews summary - reveals the most important data gathered during interviews.
- Evidence & other findings - show everything sufficient that has helped to understand the situation and find a necessary solution.
- Conclusion - presents a final decision on a case, includes summarized information about a certain violation and the policies that will be applied.
- Appendices - include necessary additional materials.
Group Discussion:
- What are the main reasons for investigating an incident?
- Who might investigate a minor injury to a worker, which had no real potential to be worse?
- Who might investigate a major incident?
- What are the four key steps in incident investigation?
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