Workplace Incident Investigation
The term Incident, is defined in the international standard for Occupational Safety and Health, ISO 45001:2018, as “occurrence arising out of, or in the course of, work that could or does result in injury and ill health”. The term Accident is also commonly used, and can be defined as an incident where injury and ill health take place. At the same time an incident where no injury and ill health occurs but has a potential to do so is referred as “near-miss”.
Incident investigations are intended to determine the cause of an incident, to identify unsafe conditions or acts and to recommend corrective actions so that similar incidents do not take place in the future. The purpose is prevention, not the blame. It is recommended to investigate not only accidents but also “near-misses”, where one might have been hurt if the circumstances had been slightly different.
Root cause identification
An investigation team who believe that the incident is caused by unsafe conditions, will likely to try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts, will attempt to find the human errors that are causes. But the fact is, there may be more than one factor which may lead, an accident to take place. Therefore, it is necessary to examine all underlying factors in a chain of events that ends in an incident.
Some of the investigations come up with the conclusion, that the incident took place due to the negligence or carelessness of the worker, by failing to identify some reasons behind his act such; distractions, not adhering safe working procedures, operational controls not in place, incompetent to perform the work, etc. An investigation, which look at the reasons behind someone’s act, will have the opportunity to prevent the future incidents.
To make the investigation more effective, every effort shall be made, to interview witnesses. This will be primary tool to gather information which are required to reveal the causes behind the incident. It is important to explain the real reason behind the investigation (that is to avoid similar incidents to take place in future and to make the workplace safest) to the interviewee, to get the fullest cooperation.
A simple model is shown below to illustrate that the causes of any incident can be grouped into five categories; task, material, environment, personnel, and management.
Using this model, possible causes under the each category are investigated, to come up with the causes which lead the incident to take place. Each category is examined more closely as shown below.
Here, the need for a safe work procedure, the availability of the work procedure, and up to what extent the procedure is in practice, is examined.)
Possible causes resulting from the equipment and materials used, equipment failures, poor design of the equipment, hazardous products, substandard materials, etc. associated with the incident are closely examined.
The nature of the environment as well as the changes in the working environment at the time of the incident, such as weather, workplace arrangement, conditions, poor housekeeping, temperature, noise, lighting, dusts, fumes, etc. are studied to reveal the causes.
Under this, adherence to safety instructions, following work procedures, experience on the work being performed, competency, gone through essential trainings, physical fitness, mental ability, tiredness, fatigue, stress, pressure to complete tasks under a deadline, etc. of the individuals who are directly involved in the event are examined.
This may also be referred as organizational factors. Here, it is examined that whether the management has taken appropriate actions to ensure the workplace is safe. Under this category, communication of safe work procedures to all employees, availability of written procedures, conduction of orientation, provision of adequate supervision, educating and training, establishment of mechanisms to identify hazards and assess risks, determination of control measures, ensuring pre-determined control measures are effectively practiced, correction of unsafe conditions, maintenance of equipment/ machinery, safety inspections, etc. , are examined.
Reporting the results and recommendations
The investigation report is compiled and communicated to the management, which includes what has happened, causes for the incident to take place, contributing factors, and recommended actions to avoid similar incidents in future.
Management is responsible for acting on the recommended actions, and the health and safety committee or representative, can monitor the progress of these actions.
There is no purpose of spending money, time and other resources for the incident investigation, if the lessons learn from the investigation are not applied, to avoid/ reduce future incidences.
In fact, incident investigations are reactionary. But effectively carried out investigation will provide the best opportunity to prevent similar incidents in the future by clearly communicating the findings and recommendations. Therefore, do not underestimate the value of communicating the results of an investigation. Better deliver a detailed report to the management and communicate the summary of your findings for employees to be proactive.
Therefore an ultimate objective of a company regarding health and safety, shall be establishment of an organization culture, where every mind is safety conscience.
Author : Fahim Mohamed