Incident investigation fact finding

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. 

The third step in incident investigation is to generate a report detailing facts, findings, and recommendations. Typically, recommendations are written to reduce risk by ... 

The investigation of incidents identifies the specific root causes and contributing causes for incidents. There is less emphasis on identifying the specific individuals responsible. Disciplinary actions are rare but likely if there is a history of repeated occurrences. There is usually a greater amount of explanatory detail in the incident report. There is greater tendency in a fact finding organization to report near-miss as well as minor incident events. 

Employers should have trained inhouse teams for investigation of unusual incidents. These include accidents and near misses that could have had harmful consequences. The objective of an incident investigation is to learn from experience, and this requires publication and dissemination of a clear report of the findings. Multidisciplinary teams are better able to gather and analyze the facts of an event. The knowledge of employees who work in the area where an incident occurred is a substantial asset. They should be consulted, interviewed, or made part of the investigating team. 

The major components of a compliance system are regular inspections, reporting, incident investigation, follow-up, enforcement, and recognition and reward. The system should emphasize fact finding, not fault finding. That applies to all the safety and security programs and policies described in Chapter 3. Initiation and maintenance of an effective compliance system are important to ... 

Incident investigation is concerned with fact-finding, not faultfinding. During the accident investigation, it is important to find out answers to the questions who, what, where, when, why, and how. Who questions include ... 

The gathering of evidence is a fact-finding process that provides the data to be analyzed, and prevention decisions can be based upon the findings. The investigator s evidence usually comes from four sources people, locations, equipment/parts/ accessories, and paper documentation. The evidence sought should identify what was normal, what occurred abnormally, what time it occurred, how it happened, and what the results of the incident were. 

Accident investigation routines have been improved particularly by the large contractors. The trends are towards more detailed fact-finding investigation as well as interviews to reveal the root causes of the incidents. The pressures from management and clients of the projects as to better safety concern have also improved the reporting of the near-accidents at constmction sites. The best constmction companies now report some thousands of near-accidents and at-risk situations, while only a few lost-time accidents have occurred at their sites. 

Accident and near miss incident investigation are fact-finding, not fault-finding. 

The golden rule of accident and near miss incident investigation is Accident and near miss incident investigation is fact-finding and not fault-finding. ... 

In other words, use accidents and near miss incident investigation systems and methodology to get to the facts, the root causes of the accident, and don t use it to find fault. Finding fault will not help in identifying and removing the cause of accidents and near miss incidents. 

Accident investigation should be fact-finding and not fault-finding and, if used effectively, can contribute greatly to the reduction of accidents and near miss incidents occurring in a workplace. Once the near miss incidents are identified and their causes corrected the probability of accidents occurring is reduced. 

If we search for culprits to blame using the finger-pointing method Ian Nimmo just described, the investigation process is very simple. As Nimmo just indicated, we identify specific individuals (in this case the chemical process operator) as accountable for the incident. It would be easy to say the operator failed to follow established procedures. Disciplinary actions could result to teach people that this is unacceptable behavior. [3] Using just the first layer approach would be a waste of effort. Such injustice could create an atmosphere encouraging sincere individuals to be less likely to report all the facts. It is probable that we would not find out all the underlying contributors and hence be unable to effectively prevent a repeat of an incident with a 5.5 million (1979) price tag. 

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