Running any business is not without risks. Even if you've accounted for potential problems with a good risk management plan, accidents do happen. It's a good idea to properly investigate accidents or even near misses (which together can be called "incidents").
Incident investigation (also called accident investigation) is a structured process used to report, track, and find the cause of incidents, involving a formal strategy to investigate the incident, document the investigation, track progress, and analyze investigation data to identify and control for repeat incidents. An effective incident investigation strategy is designed not to assign blame, but to develop strategies to deal with the underlying causes of accidents and near misses.
In this article, we'll cover why an effective incident investigation process is necessary. We will also discuss the steps involved in conducting the investigation and how to use an incident management system to maximize your efficiency.
Why Conduct Incident Investigations?
Occupational Safety and Health Administration (OSHA) regulations require all businesses to conduct incident investigations for all accidents that occur. But compliance is not the only reason why you should investigate all incidents that happen during your business operations.
Here are some other reasons why an incident investigation might benefit your business and protect you from risks in the future:
- It helps you find the root cause of incidents, which helps you create an action plan to prevent the same and similar incidents from happening again.
- It helps you find gaps in any measures you have already taken to control risks to your business.
- It would also bring out any flaws in your health and safety compliance that you may have not known about, enabling you to fix them.
- In case of workers' compensation or any other insurance claim, insurers might require you to present the findings of your investigation.
- In case of any legal liabilities or claims, an incident investigation would demonstrate that you have been proactive in exploring why an incident may have occurred and in taking steps to prevent future incidents. This shows a positive attitude towards occupational safety and health, which would benefit you in any court hearings.
Apart from these important reasons, conducting a thorough investigation into incidents and even near misses also shows your employees and clients that you're committed to ensuring health and safety in your worksite, increasing employee morale.
Logistics of an Incident Investigation
When and Where Are They Conducted?
Incident investigations are conducted at the location where the incident has occurred because remote investigations are rarely effective. Make sure to conduct them as soon as possible after it has happened so that any evidence that would help you find the root cause and act on it is not lost. The investigation team should head to the incident scene so that they can collect data that would help them with their work quickly and effectively.
Who Is Responsible for Conducting the Investigation?
Ideally, incident investigation teams should be led by people with formal training in such procedures. People with sound knowledge of legal and organizational requirements, basics of occupational health and safety, and the specific work processes related to the particular incident would also be assets to the investigation team. For incidents that have far-reaching consequences, a multi-disciplinary team consisting of both stakeholders and trained personnel may be necessary.
If the incident involves significant injuries or legal consequences, the company's legal team may manage the investigation while taking help from other people throughout the company. For smaller incidents with lower consequences and risks, a single investigator or a two-person team might be enough.
Deciding who would be on the team may also depend on the regulations for your state because some jurisdictions provide guidance such as requiring both management and labor (e.g., a workers' union) to be represented.
6 Steps of an Incident Investigation Process
An effective incident investigation involves six main steps, which are described in detail below:
1. Secure the Scene
When an incident occurs, the most important thing to do is provide the necessary help in the form of first aid or other medical assistance to any injured workers on site. Only after this should you look at starting your investigation.
The first step in the investigation is to secure the incident scene and preserve any physical evidence using cones or other barriers to protect sensitive areas. If the investigation team has to travel a long distance to reach the scene, on-site management should be instructed to carry out this step. The investigation team should also make sure to follow any safety guidelines required by the site, wearing personal protective equipment (PPE) if necessary.
Once the scene is secured, start documenting the scene by taking photos or videos of the scene, and collecting any perishable physical evidence including CCTV tapes and samples. Depending on the nature of the incident, it might be useful to record what equipment was being used when the incident occurred, weather conditions at the time of the incident, positions and use of machine guards, controls, and safety devices, and other relevant information.
2. Plan the Investigation
Once you have secured the scene and recorded immediate information and evidence, it is time to plan the investigation. A systematic investigation plan helps ensure that it is comprehensive and thorough. In this step, you need to decide whom to involve in the investigation, gauge how long it will take, and estimate what resources will be required.
In addition, it is recommended to prepare a kit with all the relevant documents and equipment so that the actual investigation is smooth and efficient. Depending on the circumstances, possible inclusions in the kit could be:
- Cones and barricade markers
- Warning tags or padlocks for really sensitive areas
- Measuring tape
- Interview forms
- Investigation forms
- Sample containers
It might be prudent to carry some of these, like the sample containers, cones, etc. to the incident scene when you are going to secure the scene as well.
3. Collect All Relevant Information
The next step is to collect all the relevant information related to the incident. Such information is available from various sources, including the people involved, witnesses (whom you should interview), equipment on the scene, and documents such as maintenance logs, inspection reports, and training histories.
Interviewing the people involved and any witnesses to the incident is a crucial step in collecting the information you need, as they can let you know what exactly happened. The information collected through these interviews might include:
- Details about the worker
- Details about any injuries or property damage
- A narrative description of the events that took place (including 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 took place, the task being performed when the incident occurred, and other details)
- Information about supervision at the time of the incident
- Causal factors related to the incident
To ensure that the interviews are effective, reduce your employees' possible fears and anxieties and make them feel at ease by assuring them that the purpose of the investigation is to find the cause rather than point blame. Let them know that they can have a labor representative present if they wish.
For the best possible data collection, follow best practices like asking open-ended questions, listening to the interviewees without interrupting, asking clarifying questions and correcting inconsistencies, interviewing the witnesses in the place where the incident occurred to help jog their memories, taking notes and, if possible, recording the interview.
Another way to enrich your data is to ask the workers for their opinions on how they think the incident could have been prevented.
Once you have collected all the required data, it is essential to summarize and document it all by completing an incident investigation form. Online incident management systems like Pulpstream makes this documentation and data collection process easier than ever, as you can simply input the data online instead of bothering with tons of physical forms.
4. Analyze Collected Data to Find the Root Cause
After the data is collected, it must be analyzed. The goal here is to find the root cause of the incident so that this and similar incidents can be prevented in the future.
Incidents are usually caused by a chain of events rather than a single event, so understanding the sequence of events is crucial to find the root cause. This can be done by performing a root cause analysis, which helps you uncover underlying or systemic issues rather than surface causes of the incident (like human error). A simple but effective technique is the "Five Whys" method, outlined in OSHA's root cause analysis fact sheet.
It is important to remember here that while finding and rectifying the immediate cause might fix the symptom of the problem (that specific incident) but not the issue itself. Also keep in mind that the root cause is unlikely to be a simple human error. It's likely that there are numerous contributing factors including equipment, environment, organizational management systems, mental or physical abilities of the worker(s) involved, and more. Discovering every contributing factor related to the incident is the only thing that will help you prevent future incidents.
5. Implement Corrective Actions
Of course, identifying the root cause of the incident is not enough. To ensure that the incident investigation was useful and not a waste of time, corrective action must be implemented.
Create an action plan to resolve the causes of the incident, both immediate and underlying, assign people to implement the actions, and ensure that the plan is acted upon. Make sure you track the progress of the corrective action plan because if you don't, the actions might never get implemented.
It isn't easy to keep track of such a plan, especially if there are multiple corrective actions with varied people implementing them, or even worse, if there are multiple such incidents to act upon. A digital incident management platform can make it an effortless process, with an easy-to-access dashboard and automations to make tracking seamless.
6. Document and Share the Results
The investigation is finally complete when all issues have been dealt with and the results have been documented and communicated with stakeholders. The documents to be shared include incident investigation reports, fact sheets, alerts, presentations, etc. Meticulous documentation after every incident will eventually form a comprehensive database of risks and incidents that will help deal with any future incidents efficiently.
Once the report is ready, it is important to get it cross-checked and signed off by any parties involved, such as the supervisor who was on duty when the incident occurred, the witnesses and workers involved in the incident (if applicable), safety officers, and others. After they check the accuracy of the details and sign off on the report, you can share your key findings with management and workers.
Revitalize Your Incident Investigation With a Digital Solution
An effective incident investigation is important to prevent similar events from occurring again. It involves several steps, coordination between multiple stakeholders, and constant integration and analysis of different kinds of data. Doing all this manually can get quite cumbersome.
A digital solution such as Pulpstream's incident management platform can make your team's work much smoother, easier, and more efficient, saving you time and resources. The cloud-based platform allows you to gather, capture, and store all types of data, including investigation forms, digital signatures on reports, and even photographic and video evidence related to the incident. An intuitive dashboard allows you to access the documents any time, anywhere, collaborate with your team, and generate data-driven insights for corrective action.
Find out how you can make your incident investigation team's work easier, more efficient, and cost-effective with Pulpstream's no-code incident management system.