No environment, health, and safety (EHS) professional wants to experience an incident at a job site, but the resulting investigation is an opportunity to uncover safety problems and correct them. You must take the right steps to get the right result, however, and the right result is the prevention of incident recurrence. Here are six steps to success.
A proper investigation must:
- Gather information.
- Search for and establish facts.
- Isolate essential contributing factors.
- Find root causes.
- Determine corrective actions.
- Implement corrective actions.
Let’s take a closer look at each of these steps.
1. Gather Information
Get a brief overview of the situation from witnesses and employees directly involved in the incident. At this point, a detailed report is not required—you just need enough information to understand the basics of what happened. Interview victims and witnesses as soon as possible after the incident, but do not interrupt medical care to interview. Interview each person separately and do not allow witnesses to confer prior to the interview.
During the interview, put the person at ease. People may be reluctant to discuss the incident, particularly if they think someone will get in trouble. Reassure them that this is a fact-finding process only. Remind them that these facts will be used to prevent a recurrence of the incident. Get a written, signed statement from the witness. It is best if the witness writes his or her own statement, but interview notes signed by the witness may be used.
2. Establish Facts
Examine the scene of the incident, looking for things that will help you understand what happened. This includes looking for dents, cracks, or scrapes in equipment; tire tracks or footprints; spills or leaks; scattered or broken parts; and other factual evidence. Also take photographs. Photograph any items or scenes that may provide an understanding of what happened to anyone who was not there. Photograph any items that will not remain or that will be cleaned up (e.g., spills, tire tracks, or footprints).
In addition, review records. Check training records to determine if appropriate training was provided and when training was provided. Check equipment maintenance records to find out if regular maintenance or service was provided or if there is a recurring type of failure. Check accident records to find out if there have been similar incidents or injuries involving other employees.
3. Isolate Contributing Factors
Contributing factors include the environment, design, systems and procedures, and human behavior.
- Environmental factors include noise, light, heat, and vapors, fumes, and dust.
- Design factors include workplace layout, design of tools and equipment, and maintenance.
- Systems and procedures factors include lack of systems and procedures, inappropriate systems and procedures, training in procedures, and housekeeping.
- Human behavior is a common factor in incidents and includes carelessness, rushing, fatigue, and so on.
4. Find Root Causes
Employees can face many hazards on the job, and there are almost always multiple causes that contribute to an incident. Try not to settle on a single cause theory—rather, try to identify all of the underlying causes as well as the primary cause. For example, in the case of a fall, in addition to obvious causes, such as a trip hazard, also consider possible causes such as inadequate lighting, whether the injured worker was carrying a large object that blocked his or her forward vision, or the trip hazard was left by a another employee who did not pick up after his task was complete.
5. Determine Corrective Actions
Once you know what happened and why it happened, you are ready to determine how to fix the problem so that you avoid repeat incidents. Think about not only what is the most expedient action but also about which actions will permanently solve the problems that led to the incident. A quick, cheap fix might not be the best answer in the long run.
6. Implement Corrective Actions
As soon as possible after the incident, take corrective action. Review the incident root causes and corrective actions with employees to make sure they understand what happened and how to avoid a repeat incident. Monitor your corrective action to make sure that it is effectively preventing recurrence of incidents—and also not inadvertently creating other hazards in the process.