Train the Trainer – Incident Investigations
10 Incident Investigation Pitfalls to Avoid
Investigating near misses and incidents resulting in injuries, property damage, or fatalities is a key part of a successful safety program. Having a team in place to conduct these investigations is key to the usefulness of the investigation and in the prevention of future incidents. Here are 10 investigation pitfalls your investigation team should avoid.
- Starting Too Late
A common mistake is not beginning the investigation until you find out how seriously a worker is hurt. But waiting even a couple of hours can compromise the integrity of the accident scene and the evidence it contains. So, have at least one member of your incident investigation team on the scene to begin documenting the events of the incident, securing evidence, and identifying possible witnesses as soon as possible.
- Starting Too Soon
For serious accidents involving fatalities, seriously injured or multiple injured victims, law enforcement and government agencies will likely be on site to conduct their own inspections and carry out any necessary legal and regulatory procedures. You don’t want to hinder their investigation or required procedures. It’s a good idea to check with your company’s lawyer in these cases.
- Not Securing the Incident Scene
Secure the scene immediately after the accident. Cordon off the area and don’t let people walk through it. If necessary, use tarps or other coverings to protect the physical evidence against weather or the elements.
- Disturbing the Incident Scene
When an incident occurs, there may be pressure on you to clean up and restore operations to normal as soon as possible. In addition to compromising the investigation, caving to this pressure can make you liable for destroying evidence and obstructing a government or police investigation. So, preserve the accident scene in its pristine state until a proper investigation is carried out.
Exception: Disturbing the scene is okay if:
- It’s necessary to prevent further injuries or serious property damage;
- It’s necessary to prevent disruption of a vital public service, e.g., a water main or power line; or
- A government or law enforcement official orders you to.
- Relying on Someone Else’s Investigation
Government safety officers, police, and other agencies will conduct their own investigation if an accident is serious. But remember, they’re not doing the investigation for you; they’re doing it to you.
So, while you should participate and shadow the government’s investigators (if allowed), you should also do your own investigation to ensure that it accomplishes your company’s goals, e.g., identifying and correcting problems to prevent a recurrence.
- Not Having Right Person Investigate
The person or persons who investigates an incident needs to be knowledgeable and competent to conduct investigation but impartial and capable of investigating objectively. These are two reasons why it’s a good idea to have a team of employees and supervisors trained in incident investigation and participating in investigations.
- Not Getting List of Witnesses
A witness list is a critical piece of information and one you have precious little time to capture. So immediately make a list of people present at the scene, including contact information of individuals you don’t know, who might serve as witnesses before they vanish.
- Not Interviewing Right People
Interview not only the eyewitnesses but also individuals who weren’t present at the incident but might still have critical insight into causal factors such as, who used the machinery involved in the event during the previous shift or repaired it before the incident occurred.
- Not Capturing Right Information
In addition to physical evidence and witness testimony, make sure your investigation draws on key materials such as:
a) Manuals, maintenance and inspection records of machinery, equipment or tools involved in accident;
b) Training and disciplinary records of victims and other workers involved; and
c) Reports of previous incidents involving the same machinery, equipment, tools, personnel, operation, work area, etc.
- Not Properly Documenting Investigation
For documentation and possible future legal purposes, it is critical to prepare a signed and dated report listing at least the following information:
a) The date of the accident;
b) The date(s) of the investigation;
c) A description of the event;
d) The factors that contributed to it; and
e) Recommended actions to correct the problems identified.
Don’t use a roof pipe or vent as an anchor point. They are not designed to support the required 5,000 pounds per worker. Instead, use an anchor point that has been engineered and installed for the job, or another approved anchor point.
