Workplace incidents can occur in any organization, regardless of how well-prepared or safety-conscious the organization is!
Conducting a thorough incident investigation is crucial to understanding what went wrong, identifying the root cause, and implementing corrective actions to prevent future incidents.
Companies need to have a team in place that is equipped to carry out such investigations effectively.
According to the Association of Workers' Compensation Boards of Canada, 227,271 workers reported lost time due to workplace injury from 2000 to 2021, indicating the extent of workplace accidents.
In this blog, we will explore how to conduct a workplace incident investigation, the importance of conducting a workplace incident investigation and the key steps to take when choosing and training a team for the task.
By implementing these best practices and online safety training, organisations can improve their safety culture and lower the risk of workplace incidents.
Procedural Stages Involved in Conducting an Incident Investigation
Conducting a workplace incident investigation involves multiple steps that must be followed carefully to ensure a thorough and accurate investigation.
The process includes the following steps:
-
Securing the Scene
-
Planning the Investigation
-
Collecting Relevant Information
-
Analyzing Collected Data to Find the Cause
-
Implementing Corrective Actions
-
Documenting and Sharing the Results
Organizations can improve their incident investigation process by understanding and following these procedural stages, ultimately promoting a safer work environment.
1. Securing the Scene
When an incident occurs, the top priority is to provide necessary assistance, including first aid or medical help, to any injured workers on site. Only after attending to the injured should you begin the investigation process.
The first step in the investigation is to secure the incident scene and preserve any physical evidence.
Use cones or other barriers to protect sensitive areas. If the investigation team must travel a significant distance to reach the site, on-site management should be instructed to perform this task.
The investigation team should also adhere to site-specific safety guidelines, wearing personal protective equipment (PPE) as necessary.
Once the scene is secured, start documenting the scene by taking photographs or videos and collecting any perishable physical evidence, such as CCTV footage and samples.
Depending on the nature of the incident, it may be helpful to record details such as the equipment in use at the time of the incident, weather conditions, the positions and use of machine guards, controls, and safety devices, as well as any other relevant information.
2. Planning the Investigation
Once you have secured the scene and recorded immediate information and evidence, it's time to plan the investigation.
A systematic investigation plan ensures that the process is comprehensive. In this step, you need to decide who to involve in the investigation, estimate how long it will take, and determine the required resources.
Additionally, preparing a kit with all the relevant documents and equipment is recommended to make the investigation smooth and efficient.
Depending on the circumstances, the kit could include items such as:
-
Cones and barricade markers
-
Warning tags or padlocks for susceptible areas
-
PPE (personal protective equipment)
-
Measuring tape
-
Interview forms
-
Investigation forms
-
Sample containers
When securing the area, it may be prudent to bring some of these items, like sample containers and cones, to the incident scene.
This preparation ensures that you have everything needed to proceed efficiently and effectively once you begin the detailed investigation.
3. Collecting Relevant Information
The next step is to gather all relevant information related to the incident.
This information can come from various sources, including the individuals involved, witnesses (whom you should interview), equipment at the scene, and documents such as maintenance logs, inspection reports, and training histories.
Interviewing those involved and any witnesses is crucial to gathering the necessary information, as they can provide detailed accounts of what happened. The information collected through these interviews might include:
-
Details about the worker(s)
-
Details about any injuries or property damage
-
A narrative description of the events that took place, including the location of the incident, the sequence of events leading up to the accident or near miss, equipment or objects involved, conditions under which the incident occurred, the task being performed at the time, and other pertinent details
-
Information about supervision at the time of the incident
-
Causal factors related to the incident
To ensure effective interviews, it is essential to alleviate any fears or anxieties the employees might have and make them feel comfortable. Assure them that the investigation aims to determine the cause, not assign blame. Inform them that they are welcome to have a labor representative present.
For the best possible data collection, follow best practices such as asking open-ended questions, listening to the interviewees without interrupting, asking clarifying questions, and resolving inconsistencies.
Conduct interviews at the incident location to help jog the witnesses' memories, take thorough notes, and, if possible, record the interviews.
Additionally, enrich your data by asking workers for their opinions on how they believe the incident could have been prevented.
Once all the required data is collected, it is essential to summarize and document it by completing an incident investigation form.
4. Analyzing Collected Data to Find the Cause
After gathering all the relevant data, the next crucial step is to analyze it. The primary objective here is to identify the incident's root cause, enabling the prevention of similar incidents in the future.
Incidents are typically the result of a chain of events rather than a single event, so understanding this sequence is key to identifying the root cause.
A root cause analysis is essential for uncovering underlying or systemic issues rather than just addressing surface causes like human error.
The "Five Whys" technique is an effective method for this, as outlined in OSHA's root cause analysis fact sheet.
It's important to remember that addressing only the immediate cause might correct the symptom of the problem (the specific incident) but not the underlying issue.
Additionally, the root cause is rarely as simple as human error. It often involves multiple contributing factors, such as equipment, environment, organizational management systems, and the mental or physical abilities of the worker(s) involved.
Identifying all contributing factors is crucial for effectively preventing future incidents.
By thoroughly analyzing the incident data and employing root cause analysis techniques, you can uncover the actual reasons behind the incident.
This comprehensive understanding allows you to implement effective measures to address the immediate cause and the broader systemic issues, thereby enhancing overall workplace safety and preventing the recurrence of similar incidents.
5. Implementing Corrective Actions
Identifying the root cause of an incident is just the beginning. To ensure that the investigation leads to meaningful improvements and isn't merely a formality, it's essential to implement corrective actions.
Develop an action plan that addresses the incident's immediate and underlying causes. Assign specific tasks to appropriate individuals and ensure the plan is diligently executed.
Monitoring the progress of the corrective action plan is crucial; without tracking, the necessary actions might never be completed.
Managing such a plan can be challenging, mainly when multiple corrective actions involve different people or when addressing several incidents simultaneously. An incident management platform can simplify this process.
It offers an easy-to-access dashboard and automates tracking, making monitoring the implementation of corrective actions effortless.
By effectively managing the corrective action plan, you can ensure that all necessary steps are taken to address the causes of the incident, thereby improving workplace safety and preventing future occurrences.
6. Documenting and Sharing the Results
The investigation is complete once all issues have been addressed and the findings have been thoroughly documented and communicated to the relevant stakeholders.
The documentation to be shared typically includes incident investigation reports, fact sheets, alerts, presentations, and more.
Keeping meticulous records of each incident builds a comprehensive database of risks and incidents, which can significantly enhance the efficiency of dealing with future occurrences.
After preparing the report, it's crucial to have it reviewed and signed off by all relevant parties. This includes the supervisor on duty during the incident, the witnesses and workers involved (if applicable), safety officers, and other pertinent individuals.
Ensuring that these parties verify the accuracy of the details and endorse the report is essential for maintaining credibility and thoroughness.
Share the key findings with management and workers once the report is verified and signed off. This transparency ensures everyone is informed about the incident and the steps to prevent future occurrences.
Evaluating the investigation process can help identify areas for improvement. This can include identifying gaps in policies or procedures, improving the team's accident incident investigation training, or changing the root cause analysis tool or technique used.
Frequently Asked Questions
What should be included in the initial incident report?
The initial incident report should include the date, time, location, description of the incident, and names of those involved.
How should witnesses be interviewed and statements collected?
Witnesses should be interviewed individually in a private location, using open-ended questions to gather their account of the incident. If possible, their statements should be documented in writing or recorded.
What documents and records should be reviewed during the investigation?
Documents and records to be reviewed during the investigation include relevant policies and procedures, training records, incident reports, and prior incident history.
Who should do the investigating?
An incident investigation typically involves a team of individuals with the right expertise and authority.
Here are the key roles involved in an effective investigation:
-
Safety Officer
-
Supervisor
-
Employees Involved
-
Union Representatives
-
Maintenance Personnel
-
Management
-
External Experts
How are the facts collected?
Facts are collected by securing the incident scene, documenting it with photos and videos, gathering physical evidence, reviewing relevant documents, and conducting detailed interviews with involved parties and witnesses.
Environmental conditions, equipment inspections, and communication records are also analyzed to ensure a comprehensive investigation.
Final Words
Understanding how to conduct a workplace incident investigation offers numerous benefits to employers and employees.
By following the procedural stages involved in an incident investigation, organisations can identify the root causes of incidents and develop effective recommendations and corrective actions to prevent them from recurring.
A thorough investigation can also help improve the safety culture within the organization and demonstrate a commitment to the well-being of employees.
By implementing recommendations and corrective actions and continuously evaluating and improving the investigation process, organizations can create a safer and more productive work environment for all.