“Those that don’t learn from the past are doomed to repeat it.” This quote will be around forever. Which leads me into this blog post on “why conduct incident investigations?” Simply put, so the same incidents are not repeated. Injuries are reported because OSHA requires it. However, many incidents stop at the report stage.
Incident investigations are designed to answer the question “why” so that that future incidents can be avoided. The investigative process turns a reactive process to a proactive tool. Digging deeper into the root cause of the incident gives your organization an opportunity to correct small problems before they become much larger. You would much rather address a minor issue with an employee than address the employee’s family in a tragic situation as to why a repeat hazard wasn’t corrected for example.
So why do organizations stop at the reporting stage? Three situations come to mind, however this is not an exhaustive list. The first situation is that it’s the easiest thing to do is to stop at the reporting stage. The accident happened, it’s been reported, time to move on and get back to work.
The second situation is that organizations don’t truly understand the benefits from finding the root cause. When supervisors and other leadership get involved, it sends a clear message to all employees that management is committed to safety and is willing to take action to prevent others from being injured. When employees and leadership truly understand the incident, a resolution can be developed to keep similar incidents from happening again. Businesses save money because incidents are far costlier than people reanalyze. There are the obvious direct costs such as workers’ compensation claims, however there are less obvious costs too. The cost can include lost production, schedule delays, increased administrative time invested, lower morale, training of temporary personnel and more.
The third situation is that organizations don’t have a process in place to investigate the incidents. A simple process can be adopted and implemented. It can be modified as needed to fit the needs and the culture of the company. As with any new procedure, once people go through the process it becomes less complicated and efficiency of conducting investigations increases as well. OSHA has an Incident Investigations guide to help you get started. The following is a sample process checklist for investigating incidents.
- Requirement in place for reporting to XX person within XX timeframe
- Eliminate punitive action (would discourage reporting)
- Need to be more than just filling out paper
- Interview person affected, their supervisor and any witnesses
- Collect all key information
- Consider impacts from: employee thought process, effects of training or procedures,
- Review all causes
- Create sustainable corrective actions to mitigate those causes
- Ensure accountability with person responsible & due dates
- Follow up on recurring basis (bi-weekly, monthly) until actions are complete
- Share learnings from incidents on recurring basis
- Engage leadership in communication
- Highlight KEY areas (1-3) for each location/department
- Make sure to emphasize THE WHY behind the process: the need for learning
When incidents are investigated, the emphasis should be concentrated on finding the root cause of the incident so you can prevent the event from happening again. The purpose is to find facts that can lead to corrective actions, not to find fault. Employers who use an investigative process may find more effective control over hazards, increased revenues, decreased production costs, lower insurance premiums and a stronger safety culture.