All incidents – regardless of size or impact – need to be investigated, including near misses. The time spent, and the detail involved will vary depending on how complex the incident is.

Investigating every incident allows you to look beyond what happened and discover why it happened. It also allows you to identify and correct deficiencies in your safety and health programs, management shortcomings, and unsafe processes, conditions, and actions.

Finally, and most importantly, an investigation gives you the chance to:

• Fix a hazard before it can cause harm – in the case of a near miss; or
• Prevent additional harm – in the case of an incident with injuries, property damage, or fatalities.

It is estimated that, on the average, preventing a workplace injury can save almost $40,000, and preventing a fatality more than $1.4 million.

Investigating incidents helps you and your organization:

1. Prevent injuries and illnesses
2. Save lives
3. Save money
4. Show a commitment to health and safety
5. Boost workplace morale

Since the point of an incident investigation is to figure out WHY it happened – don’t waste time finding who’s at fault, who’s to blame, or who to point the finger at. Rarely will the cause be that straightforward and simple.

To help you get to the “why”, one common approach is a “systems approach” to incident investigation. A systems approach looks beyond the immediate causes of the incident – operator error, faulty equipment, unsafe conditions, and asks WHY. Here’s a simple example of how it works:

A worker suffers an injury from a piece of equipment or machinery, the investigator or incident investigation team must keep asking “why” until the root cause or causes (it’s often multiple causes) are identified.

• Was the machine adequately guarded?
  • If not, why not?
    • Was the guard damaged or non‐functional?
      • If yes, why hadn’t it been fixed?
        • Had the damage been reported?
          • If not, is there a reporting process in place?
          • If yes, where did the breakdown in the process occur?
        • Was a procedure or safety rule not followed?
          • If yes, why was it not followed?
            • Did production pressure play a role?
              • If yes, why were production goals allowed to be more important than safety?
            • Was the procedure out of date?
              • If yes, why had the issue not been identified before?
              • If it had been identified, why had it not been fixed?
            • Had the employee been trained properly in the procedures to do the job safely?
              • If yes, why wasn’t the training effective?
                • Had too much time has passed since training?
                • Was training too general?
              • If no, why not?
                • Is there an established training program?
                  • If no, why?
                  • If yes, go back to the previous questions and figure out why the training was not effective.

In a systems approach, investigations don’t focus on solely worker behaviors or “what the worker did wrong.” Instead it focuses on uncovering the root causes of the incident. This allows you to fully understand why an incident occurred and what corrective actions will be the most effective. Without getting down to the root of the problem, you’re just putting a band-aid on a problem that needs sutures.

Next month we will look at how to establish an effective incident investigation program.