Determining the True Root Cause(s)

of Accidents and Safety Incidents

Incident Investigation and Analysis

Training Goal

Participants will be able to develop an

incident investigation protocol at their

respective institutions.

Objectives

To meet the training goal, the following objectives will be covered:

• Incident investigation overview

• Desktop incident investigation exercise

• Incident investigation protocol

• Training investigation team

Purpose of Investigation

• Determine sequence of events that led to consequence

• Offer corrective action recommendations to prevent recurrence of the incident

• Never to assign blame or assess liability

What should be investigated?

• All incidents that cause– Injury– Illness– Lost time– Property damage

• All near-miss incidents

Where should the investigation be conducted?

The investigation must be conducted at the site of the incident

Who should conduct the investigation?

• Team– Supervisor of the

affected employee– Safety committee

representative for area– Safety officer– Affected employee(s)

When should the investigation be conducted?

Immediately after the incident occurred

• Memories are fresh

• Evidence is in place

• Immediate corrective actions can be initiated

How to Conduct an Investigation

Focus on finding factfact, not fault

• Investigate the facts

• Review the facts to find the cause

• Recommend corrective measures

• Document findings and actions

• Follow-up

Investigate the Facts

• Look at the situation

• Record general information

• Collect evidence

• Interview witnesses

• Review records

Investigate the Facts

Look at the situation

• Examine the big picture

• Think of the 5 W’s (who, what, why, when, where)

• Outline your approach

Investigate the Facts

Record General Information

• Time and exact location

• Injuries

• Medical treatment or first aid

• Anything unusual

Investigate the Facts

Collect Evidence

• Photographs of equipment

• Samples of chemicals

• Broken parts or pieces

Investigate the Facts

Interview Witnesses

• Individually

• At the scene of the incident

• Immediately after the incident, if possible

• With an open mind

Investigate the Facts

Review Records to Identify Trends

• Inspection records

• Previous incident reports

• Maintenance records

• Workers’ compensation insurance forms

Review the Facts to Find the Cause

• Review all information

• Clarify the facts

• Analyze information

• Examine contributing factors

• List possible causes

• Identify the cause

Do not jump to

conclusions

Examining Contributing FactorsEmploy a process called branching to find root causes

Person slips on oil on floor

Why?

Oil was spilled on floor Person stepped in oil

Examining Contributing Factors

Oil was spilled on floor Person stepped in oil

Why?

Machine was beingserviced and oil spilled

Person walked throughwork area

Why?

Machine was beingserviced and oil spilled

Person walked throughwork area

Examining Contributing Factors

Why?

Spill notprevented

Oil spillnot cleaned

Person worked indepartment

Why?

Recommend Corrective Actions

• Look at each step in the chain of events

• Suggest attainable actions

• Assign responsibility for implementation

• Coordinate a schedule for implementation

• Start with simple solutions; move on to those that will be more complex

Recommend Corrective Actions

Causes: Actions:

Spill was not prevented

Oil spill not cleaned

Person worked in department

?

?

?

Document Findings and Actions

Incident investigation reports usually contain• General information• Description of injury or illness• Description of the incident• Analysis• Corrective actions• Dates for completion

and follow-up

Reporting

According to the subsequent remedial measure rule, documented recommendations for corrective actions are not admissible as evidence in a court of law. Therefore, appropriate corrective actions can be documented and implemented without fear that they will be perceived as an admission of a previously unsafe condition.

Reporting

• Do not assign blame, assess liability, or offer opinions in any written documentation

• Forward report to university/agency administration

Follow-Up

Ensure that recommended corrective actions

• Have been implemented properly

• Are effective in eliminating or reducing future incidents

• Do not create an unforeseen hazard

Developing an incident investigation

protocol

Include the following elements:

• Incident investigation procedures

• Responsibilities for incident investigation

• Reporting and record keeping procedures

• Investigator training

Incident Investigation Procedures

• Priority of incidents to be investigated

• Notification of incident occurrence

• First aid response

• Securing the area

• Gathering evidence

• Interviewing witnesses

• How program will be evaluated and updated

Reporting and Record Keeping

• Who prepares the report

• What will the report contain

• To whom will the report be sent

• How long will the reports be kept

• Who keeps the reports

Investigator Training

• Components of training

• Training records

• Hand-on exercises

• Retention exercises

Training Topics

How to

• Conduct an incident investigation

• Find the facts and not place blame

• Find the cause of an incident

• Complete an incident investigation report

Training Records

Remember to complete a training record

• Employee name

• Job title

• Employee signature

• Date of training

• Signature of trainer

Hands-On Exercises

Suggestions

• Set up a mock incident scene

• Use experiences from your organization

True or False

Every incident should be investigated immediately so that we can determine who was to blame.

Retention Exercises

Commonly known as a QUIZ

• Focus on important concepts, for example:

Retention Exercises

True or False

A “near-miss” should be investigated in the same manner as an actual incident.

True or False

Most incidents have only one contributing factor.

Retention ExercisesTrue or False

The incident scene should be returned to normal as soon as the investigator

arrives.

True or False

Corrective measure should address whatever hazards are uncovered in

investigating the incident.

Resources

• “Accident Investigation,” Comprehensive Loss Management, Inc.

• “Investigating Accidents,” Business & Legal Reports

• “Incident Investigation,” Safety Solutions

• “Accident (Incident) Investigation,” National Safety Council

Responsibilities for Investigation

Team

• Supervisor

• Safety officer

• Safety committee representative for area

What We’ve Learned Today ...

• The reasons for conducting thorough incident investigations

• How to set up an incident investigation and analysis program

Conclusion

When an organization reacts swiftly and positively to incidents, its actions reaffirms its commitment to the safety and well-being of its employees.