Effective Incident Investigations

Thousands of incidents occur every day in workplaces. The failure of people, equipment, the environment, and management to behave or react as expected causes most of these incidents. Investigating incidents is important because it determines how and why failures in the management system may have occurred [6]. 

In addition, incident investigations help to identify hazards that either may have been missed earlier or may have slipped out of control during the normal process. It is useful only when conducted with the aim of identifying contributing factors to the incident, condition, and/or activity and preventing future occurrences [5]. 

This chapter will help you look at incidents in a different way. The bottom line if you do not capture near misses and small incidents that do not result in an injury, you will never stop injuries. 

In industry, we use many definitions to describe an incident or an accident. Frequently both terms are used interchangeably. We use the term loss-producing events to describe incidents. As we stated previously, sometimes the journey is more important than the destination. The following are some of the more common definitions  

Accident. An unexpected, undesirable event an unforeseen incident lack of intention [8]. 

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Employees in the process area where the incident occurred should be consulted, interviewed, or made members of the team. Their knowledge of the events represents a significant set of facts about the incident that occurred. The report, its findings, and recommendations should be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigative process should clearly deal with all involved individuals in a fair, open, and consistent manner. 

Three key components of the overall methodology that need to be selected to ensure effective incident investigation and identification of root causes are ... 

ABS Consulting. Root Cause Analysis Handbook A guide to effective Incident Investigation. Knoxville, TN ABS Group Inc., 1999. 

Effective incident investigation, reporting, and follow-up are necessary to achieve improvement in health, safety, and environmental performance. They provide the opportunity to learn from reported incidents and to use the information to take corrective action and prevent recurrence. 

While this study cannot be considered conclusive, it is probable that a further and more scientific study would establish that effective incident investigation reaps many benefits — as a productive means of eliminating or controlling hazards and achieving fewer injuries and illnesses, as an augmenting factor in attaining reduced workers compensation costs, and as a supporting element within a sound safety culture. 

Root Cause Analysis Handbook A Guide to Effective Incident Investigation. (No author). Rockville, MD Government Institutes, Inc., 1999. 

Vanden Heuvel, Lee N., Lorenzo, Donald K., Montgomery, Randal L., and- Hanson, Walter E., Root Cause Analysis Handbook A Guide to Efficient and Effective Incident Investigation, 3rd ed., Rothstein Associates Inc., 2008. 

Assume that the safety culture does not require effective incident investigation. Consider the following examples, limited to seven, of statements that could be made legitimately in investigation reports, but may be perceived as self-incriminating or accusatory of management levels above the first-line supervisor ... 

Before we get started, we want to discuss your journey. Let s revisit the accident pyramid. You need a good understanding of what it takes to reduce incidents. This model will provide some useful information. We will discuss this concept again in Chapter 12, Conducting Effective Incident Investigations. ... 

Evaluate and rebuild the incident investigation system as necessary to make sure that investigations are timely, complete, and effective. They should get to the root causes and avoid blaming workers. We will discuss this in more detail in Chapter 12, Conducting Effective Incident Investigations. [4]... 

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