All organisations strive to avoid incidents (accidents, near misses & ill-health), yet they still occur. These occurrences
provide an invaluable opportunity to both identify shortcomings in organizational systems and ultimately end off with a
safer workplace. Although we wouldn’t welcome these incidents, they test the management system and allow it to be
tweaked and improved. Yet some will conduct superficial investigations and miss valuable information and the opportunity
to improve. Perhaps this is part due to a reluctance to be self-critical of one’s own creation, that is, these investigations
often find flaws within internal systems and procedures.
No one is perfect and we’ll all make mistakes and miss things. So taking this on board, investigations should be free to dig
as deep as needed and welcome the critical lens that allows the situation to be rectified. Give investigations the time they
deserve (within proportion of course) and you will be rewarded with a cheap and effective means of improving your health
and safety culture.
I KEEP six honest serving-men (They taught me all I knew); Their names are What and Why and When And How and Where and Who. Rudyard Kipling
Step 1 – Immediate Action
Make sure the area is safe or made safe and ensure injured persons are given the treatment they need before accessing the area and preserving the scene.
Step 2 -Plan the Investigation
How serious (or potentially serious) was the incident. This should drive the appropriate level of investigation and the resources and time afforded to it.
Step 3 – Gathering Information
The information needed to conduct the investigation falls into three basic categories: Physical -This may be a broken component, a pool of oil or a footprint. These may need to be photographed or sampled. Human – This information will commonly be gathered by interviewing witnesses who can provide key details about the incident. This can be recorded on a witness statement. Documents – There can be live documents to review such as inspection checklists and historic documents like old accident reports. A substantial amount of documentary evidence may need to be gathered.
Step 4 – Analyse the Findings
Having gathered all the information, its now time to make sense of it. This is useful to do in a team setting, as alternative conclusions and ideas can be discussed. This should lead to the identification of immediate, underlying and root causes.
Step 5 – Corrective Actions
Its time to do something about it. An action plan should deal with all causes and allocate responsibilities, resource implications and timescales. This stage is highly important for a number of reasons; it rectifies the flaws that caused the incident, hopefully, prevents its reoccurrence and demonstrates the value of the investigation process.
Step 6 – Reporting the Findings
The key findings of the investigation and outcomes should be shared. This could be anything from a detailed report to senior managers or a one-sheet overview for a staff notice board. Regardless, this demonstrates to all that incident investigation can elicit real changes that benefit everyone. Ultimately, improving the safety culture within the organization.
Protecting People can help your company with incident investigation training.
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