One of the biggest challenges when you are investigating an incident is sorting out the irrelevant information from the relevant information. More specifically – determine what is relevant to what happened, how it happened, and especially why it happened.
One way to do this is by using a systematic approach to investigate all incidents that focuses on finding the root causes. Doing so, means you can implement relevant and meaningful corrective actions.
You can use this 4-step approach to guide you. It can also be used as a training tool for members of your investigation team.
Step 1 – Preserve and Document the Scene
After you have verified the scene is safe and victims are being care for, the first step in the investigation is to secure the incident site to prevent evidence from being moved, altered, or tampered with.
- If evidence goes missing or is messed with – you are going to miss out on important clues on what caused the event.
- Use cones, tape, or barriers to physically block off the scene.
- You can use photos or videos to preserve and document the scene.
Document the incident facts:
- Date and time of incident
- Name/s of the injured
- Injury description
- Date, time, and location of incident
Step 2 – Collect Information
Collecting information of events leading up to the incident, the incident itself, and other important information is necessary to establish a timeline, identify victims and witnesses, and begin to uncover the initial and root causes of the incident.
One of the primary ways to gather information is to interview witnesses and the victim/s. The sooner a witness or victim is interviewed, the more accurate and candid his/her statement will be.
Set the interviewee at ease:
- Clearly state the purpose of the investigation and interview – to learn how to prevent future incidents and not to blame any one person.
- Interview witnesses separately – as least initially. A witness might say more if they aren’t in the same room as their supervisor, co-worker, or the victim. The same is true for when you interview the victim.
- Let employee know they have a right to have employee representative (e.g., labor representative) present, if available/appropriate.
- Conduct interviews in a quiet space, although in some cases, it might make sense to interview someone at the scene of the incident. It might help them explain something better, jog their memory, or help you both put questions and responses in context.
Now you’re ready to begin the interview.
- Ask the individual to recount their version of what happened and don’t interrupt them.
- Take notes and/or record the responses; interviewee must give permission prior to being recorded.
- Have paper and pen/pencil available for interviewee.
- Ask clarifying questions to fill in missing information; repeat back to the interviewees the information obtained; and correct any inconsistencies.
- Ask the individual what they think could have prevented the incident.
In addition to interviews, other sources of helpful information include:
- Equipment manuals
- Industry guidance documents
- Company policies and records
- Maintenance schedules, records and logs
- Training records (including communication to employees)
- Audit and follow‐up reports
- Enforcement policies and records
- Previous corrective action recommendations
Step 3 – Determine the Root Causes
The root causes are the underlying reasons why the incident occurred. Root causes generally reflect management, design, planning, organizational and/or operational failings (e.g., employees were not trained adequately; a damaged guard had not been repaired).
If you truly want to prevent a repeat of an incident, you must go beyond the easy surface causes – “worker was careless” or “employee didn’t follow the SOP.” Focusing on the easy causes is a lazy way out and it won’t get you the answers you need to put meaningful corrective actions in place.
Remember: Investigations are not effective if they are focused on finding who to blame because they will stop at the initial incident and stop short of discovering the root causes.
Step 4 – Implement Corrective Actions
Your investigation isn’t done until all the underlying causes of the incident have been identified and corrective actions are in place.
Some of the corrective actions will be quick and easy fixes; others may take more time and planning. Some may be specific and address a root cause directly and others may be sweeping improvements to the safety program in general.
Regardless, it is important that you communicate the corrective actions throughout the workplace. Employees pay attention to what management pays attention to and what management ignores. If you ignore incidents or don’t follow through on corrective actions your employees will get the message loud and clear. Employee safety isn’t valued.
So, take time to develop appropriate corrective actions and manage them through to completion.