Serious injury prevention incident investigation

In Chapter 3, Serious Injury Prevention, I commented on studies made of over 1200 incident investigation reports to assess the effectiveness of the incident investigation systems in place. I said that on a scale of 10, with 10 being best, some companies scored a 2, that causal factor determination was poor, and that opportunities to re-adjust the focus of preventive efforts to the benefit of workers and employers were lost. Observations were not made in that chapter on a rationale that may explain why incident investigations are often superficial. 

Fabricators/manufacturers do not plan for their products to fail or to cause harm to people. But if an incident should occur that results in serious injury or death, the problem must be investigated immediately to prevent... 

Incidents and accidents, whether they cause damage to property or more seriously injury and/or ill-health to people, should be properly and thoroughly investigated to allow an organization to take the appropriate action to prevent a recurrence. Good investigation is a key element to making improvements in health and safety performance. 

All of these studies clearly show the futility of investigating only the few serious or disabling injuries when there are hundreds of near miss incidents which, if investigated and their causes corrected, would have prevented the occurrence of the more serious injury-causing accidents. 

The philosophy behind these various accident ratios is that by investigating and taking action to prevent near misses, the more serious accidents and incidents would be prevented. This approach could be said to be far too simplistic, in that not all near misses involve risks which might have caused fatal or serious injury. However, these ratios are of great value in comparing categories of accidents in order to identify those categories which are most likely to cause serious harm. 

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