It is important that all work-related near misses in a workplace be investigated along with those that involve injuries, illnesses, and fatalities. Near misses are those that could have caused harm if there were different circumstances surrounding the incident.
Defining the causes of those incidents and how to prevent them were explored in a recent Facilities Management Advisor webinar “Best Practices for Incident Investigations.” It was sponsored by Avetta, ABM Industries, and TMA Systems.
The webinar featured Brandy Bossle, CEO and Principal Consultant for Triangle Safety Consulting, LLC, a safety consulting firm, who provided her recommendations.
The who, what, where, when, why, and how of investigating workplace incidents
While investigations sometimes are conducted solely by the injured or ill worker’s supervisor, more effective investigations often include a team of managers and workers, a safety professional, the injured worker, and any witnesses.
Incidents involving temporary workers should be investigated by the staffing agency and the host employer.
“In cases involving a fatality, senior management personnel, engineering staff, or legal counsel, may also be involved. They might have more oversight than a minor incident,” Bossle said.
What and Why
Effective incident investigations concentrate on the facts and not assigning blame. About 74 percent of those watching the live webinar stated in a poll that they were involved in investigations where the worker was blamed.
Instead, investigate whether there was a failure in a program that manages safety and health in the workplace such as equipment, procedures, and training.
Improving safety and health will prevent future incidents, increase morale among workers, increase productivity, provide cost savings through lower workers’ compensation insurance premiums, and increase profits.
“In 2020, the National Safety Council estimated that on average the cost of a medically consulted injury was $44,000 while the cost per death was $1.3 million,” Bossle said.
Where And When
Investigations should begin immediately after the incident occurs to get the most accurate information from the affected employee and witnesses.
They should begin at the scene of the incident and can move to other areas where witnesses can be interviewed individually and separately. This is critical because people may forget details over time which could hinder the investigation.
Investigators should follow these 10 steps when performing an incident investigation:
Step 1: Isolate the incident scene.
Control the situation, care for the injured or ill workers, secure the area, and isolate it with barriers, cones, or guards so investigators can do their job safely. Collect information before the scene is changed.
Step 2: Document all evidence and photograph the scene.
While investigators could write notes and draw sketches and diagrams, they should consider taking photos and videos with cell phones, instead. When photographing objects, use a ruler for perspective. Take close-up and far-away shots of large machines.
Step 3: Identify and interview witnesses at the scene.
Compile a witness list and interview immediately with open-ended questions. Ask them to explain their version of what happened without interrupting, what could have prevented the incident based on the conditions leading up to it, and any clarifying questions. Take notes or video responses. Confirm accuracy.
Step 4: Collect on-scene information.
Before leaving the scene, get specifics about the worker’s position as well as their injuries or illnesses, description and timeline of events, characteristics of equipment associated with the incident, and characteristics of the task being performed when the incident occurred.
Step 5: Reporting incidents.
Contact Occupational Safety and Health Administration (OSHA) within 8 hours to report deaths and within 24 hours to report the loss of an eye, hospitalizations, and amputations. Investigators can call or visit their local OSHA office or, better yet, report incidents on the OSHA website.
Step 6: Collect the necessary documents.
Get manuals of associated equipment, industry guidance documents, maintenance information, training records, company policies and records, and previous corrective action recommendations against the worker.
Step 7: Identify hazards.
Investigators should determine how the incident highlights hazards and shortcomings with the company’s safety and health program. Learn more about identifying hazards by reading “Recommended Practices for Safety and Health Programs.”
Step 8: Create an incident report.
Be sure the incident report identifies the root cause which is a system-related reason why the incident happened. Determine management, design, planning, organizational, and operational failures. It should identify corrective actions including program-level improvements.
Step 9: Implement corrective actions.
Senior management should implement corrective actions as specified in the report to help prevent future incidents. Common corrective actions include training, signage, increased ventilation, and additional or improved machine guarding.
Step 10: Follow-up.
There should be periodic follow-ups by investigators to ensure corrective actions are implemented and that the root cause has been fixed. Doing so can help increase employee morale, productivity, and the bottom line.
During the live webinar, 59% of respondents reported in a poll that they were involved in investigating an incident where corrective actions did not address the root cause and the incident occurred again. Bossle believes effective incident investigations can help prevent repeat occurrences.
“Effective incident investigations are the right thing to do not only because they help employers prevent future incidents but because they help employers identify hazards in their workplace,” Bossle said.
By conducting incident investigations thoroughly, employers can work toward having safer work environments that can provide cost savings from avoidable injuries, illnesses, and fatalities.
To watch the webinar, click here.