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Introduction to Workplace Incident Investigations
Welcome to this article on Incident Investigation. Investigating accidents and understanding the elements which contribute to workplace injuries or incidents is a vital part of an effective safety culture.
We will take a look at what is involved in carrying out an incident investigation at work.
Accident / Near Miss Causation
First let’s look at the causation of accidents and near misses. Technically an incident is accidents + near misses. An accident is where there is injury or damage.
It is important to note that the majority of accidents are due to poor risk management and control measures. In 75% of cases investigated, site management were considered to be wholly or partially responsible for failing to take the necessary precautions and safety measures to prevent the accident. This is why it is so important for employers to stay alert when it comes to risk management.
What is a Near Miss?
So what, exactly is a near miss? The technical definition is an unplanned or unwanted event which disrupts the work process and has the potential of resulting in injury, harm, or damage to persons or property. In practical terms, a near miss disrupts the works process, but it does not result in an injury or damage. It is a ‘wake up call’. Employers should still investigate near misses because they may give insight into existing or potential risks that could just as easily have caused injuries or damage.
Example of a Near Miss
If a 50 kilogram carton falls from a 2 metre high rack and lands near a worker, this is a near miss. It was unplanned, unwanted, and had the potential for injury, but nobody got hurt.
What is an Accident?
The difference between an accident and a near miss is that an accident results in injury or damage. An accident stops the normal course of events and causes property damage or personal injury whether it is minor, serious or fatal. It is an unplanned, unwanted, but controllable event which disrupts the work process and causes injury to people. The key here is the word ‘controllable’. While everyone can agree that accidents are unplanned and unwanted, the idea that they are controllable might be a new concept. They are predictable and preventable. They don’t have to happen.
Most workplace injuries and illnesses are not due to accidents, but rather predictable and foreseeable eventualities. And all accidents that occur must be reported to the Health and Safety executiv
Example of an Accident
Let’s go back to the example of the 50kg carton on the 2m high shelf. It falls for a second time but this time, it hits and injures an employee. Predictable? Yes. Preventable? Yes. Investigating why the carton fell will usually lead to a solution to prevent it from falling in the future.
Iceberg Illustration
Accidents are only the tip of the iceberg. Near misses give insights into what risks and hazards are at work below the surface. This is why near misses and accidents should both be investigated. Events having a HI-PO, or high potential for loss, should be investigated fully, regardless of how severe the loss was in reality.
Again, it is very important to report and investigate near misses to the Health and Safety Executive, not just accidents, because near misses are accidents that, luckily, took a slight diversion. So how do you investigate an near miss? First, you need to determine what the worst outcome would be. Could there have been equipment damage? Could workers have been injured? How severe would the outcome have been? If the near miss could have resulted in significant property loss or serious injury, it should be investigated as thoroughly as an actual accident.
Remember that there are many more near misses than accidents. You can learn lessons from near misses, and these lessons are free and without serious consequences. The causes of an accident and the potential for an accident are the same thing. If you eliminate the potential, you eliminate the future cause.
Bird Triangle
The Bird Triangle visually explains that for every one fatality, serious or major injury, there are 10 minor injuries, 30 property damage accidents, and 600 ‘close calls’, or near misses that give you a scare, but result in no visible injury or damage.
Why Investigate Incidents?
Incidents can force work to grind to a halt, forcing your operation to lose money. If you investigate incidents and make sure they do not become accidents, you ensure that your business continues to operate smoothly.
Rules require you to investigate serious accidents, but let’s recap why you should investigate near misses as well. First, you will be preventing future near misses that can lead to accidents. You do this by identifying and eliminating hazards and uncovering flaws in equipment or work processes. It is also important to note that you will be maintaining worker morale. When you investigate a near miss, it shows your staff that you care about their safety and wellbeing.
Accident / Near Miss Investigation
A number of personnel may be involved in accident investigation. You will start out with the injured person and witnesses. Then first-line supervisors, middle managers, and senior managers could be called in, as will safety specialists and safety representatives of the company. It is possible that external agencies and experts will be brought in to assist in the investigation as well, but only in extreme cases.
Developing a Plan
Your company’s Accident Investigation Plan should be developed before you have a near miss or accident. This should include the who, what, when, where, and how. It should also include accident investigation training, tools, policies, and procedures that are specific to your company, and specific to the nature of the investigation. Motor vehicle investigations will differ from warehouse investigations or off-site investigations.
Tips for Developing a Plan
Make sure you develop your action plan ahead of time so that you reduce the chance for evidence to be lost or witnesses to forget. List out, step by step, all procedures, forms and notifications, or create a flow chart to lay out processes visually. You might also want to include who in the workplace should be notified of a near miss or accident, how to notify outside agencies and who will conduct internal investigations.
In addition to that, you should clarify who will be trained, and what level of training he or she will need, who is responsible for the finished report and in what time frame, and who should receive copies of the report. Once you have that, you will outline who decides what corrections should be made, when they will be made, and who will be responsible for making those changes happen. Finally, you’ll need to decide who will go back and make sure the controls are in place and that the controls are effective.
How to Investigate Incidents at Work
Now that you have learned about developing a plan, you will learn how to conduct an investigation. It is crucial to collect evidence and interview witnesses as soon as possible because as you wait, evidence will begin to disappear, and people will forget what happened.
Investigate all near misses and accidents immediately. As you collect facts, you may find that you uncover a number of other near misses that were previously undiscovered.
Interviewing a Witness
Interviewing a witness. It is important to interview victims and witnesses as soon as possible and it is especially important to listen to them. Be sympathetic. Interviewing a witness is not the time to point out mistakes or poor judgment. Verify that they received proper training and ask them if they know what happened to caused the accident, but again, be sure to do this sympathetically.
Conducting Investigation
An effective investigation requires proper planning, organizing and training. One of the most important parts of an investigator’s job is to be able to sift through all of the available information and concentrate on the most important pieces of evidence. There are four main types of evidence:
- People evidence
- Position evidence
- Parts evidence
- Paper evidence
People evidence involves interviewing witnesses. Details from witnesses inform the investigators about the symptoms of the problem. Interviews are the starting point that directs the investigator to the causes of the accident.
Position evidence helps everyone visualize and document what happened. This can be done through drawings and sketches. However photos and videos are preferable due to the fact that they are more accurate and time-saving. When photographing, photograph from all sides and use a long, medium, and close-up sequence of shots. This will allow you to capture details and context.
Parts evidence involves the tools, equipment, materials, and facilities involved in an accident. Often, faulty or improper equipment can affect people’s actions. For instance, a forklift could be overloaded or not work correctly, scaffolding could be constructed poorly, or a pipeline may have been inadequately serviced. These issues give clues that lead to the cause of an accident.
Paper evidence is rarely at the scene of an accident, so it is often overlooked, but it can be an important tool in uncovering root causes of accidents. This can include logs, schedules, personnel training records, and task procedures. Permits, licenses, certificates, meeting minutes, and statements can also provide important clues.
At the Scene
If you are on site when an accident happens, make sure you are safe by checking for dangerous situations that still exist. You do not want to become another victim. Then help anyone who is injured and secure the area and make sure the proper people gather and handle evidence. Identify physical evidence and witnesses an make sure witnesses are separated from each other for interviewing purposes. Each person will have his or her own perspective, and this should not be tainted by another person’s version of events. Once physical evidence is stabilised, then begin as soon as possible with interviews. Remember, be a good listener.
Fact Finding
Fact-finding is a key part of any investigation, and you will need to be able to recreate the scene from your documentation. When gathering facts, take notes on environmental conditions, housekeeping of the general working environment, and floor or surface conditions. Take lots of pictures and create a photo log where you note the date and time. Give a description of what is being photographed and from what angle so that you can link these to a sketch of the scene.
Some scenes are more delicate than others. If items of physical evidence are time sensitive, then address those first. You may need help if the volume of evidence is too large for one person to handle quickly and properly.
Conducting an Investigation
Conducting an investigation. When conducting and documenting an investigation, you need to answer the who, what, when, where and why questions. Who was present? What activities were occurring and what happened? Where and when did the accident take place? Why did it happen? You should be able to determine basic causes. For example, if an employee gets cut, it could be due to any number of root causes, and some of them may not be obvious immediately. Was there a broken tool that nobody reported or was it reported and never fixed? Did someone ignore a hazard because of lack of training or a policy that discouraged reporting? Was there horseplay going on or was personal protective equipment defective? Was signage inadequate or was the recognition plan missing? Some of these explanations may take a bit of time to uncover, but be persistent.
You will also need to find out if the root cause is a company or industry-wide hazard. Ask if the company has taken previous action to control the hazard, and if so, what were those actions? Is it a training issue?
Another useful method for your investigations is what’s known as the Why method. While you’re conducting investigations, keep asking “Why?” until you reach the real root of the problem. For example:
- An employee was injured. Why?
- He was running. Why?
- Because he was in a rush. Why?
- Because he was given too much work to do. Why?
And so on. This method often shows that there are several root causes for an accident.
Causes of Accidents
Write the Report
Write the report. Your report should include an accurate narrative of what happened by summarising sketches, notes, photographs, physical evidence, and witness statements. Make sure you answer the who, what, when, where, why, and how questions. For instance, when and where did the accident happen? What was the sequence of events? Who was involved? What were the damages? How were employees injured? Include a clear description of the unsafe act or condition, personal factors, or job factors. You will then recommend both immediate and long-term corrective action and suggest a follow-up and review to verify the corrections have been made and are effective.
Taking Remedial Action
Taking Remedial Action. Corrective, or remedial, actions come in two forms: temporary and permanent. Temporary actions mainly correct the immediate causes and only cover up the symptoms. The only way to cure the basic, core problems is through permanent action. Permanent action remedies the person
Notification of Accidents
Due to RIDDOR, or the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations, it means that companies are obliged by law to report on all accidents, injuries and near misses.
Once the report has been written, the proper authorities need to be notified of the accident. There are a few types of accidents that need to be reported. The first is a fatal accident of an employed or self-employed person. The second is injuries from the Specified Injuries List, which will be shown later. The third is an accident that prevents any employee from doing their work for more than seven consecutive days, not including the day of the accident, but including non-working days. The fourth is an accident to a non-working person which was caused by a work activity that required medical attention or triggered a loss of life. The last is any dangerous occurrence.
Now for some technical information: Accidents must be reported in the approved Form No. F2508. Records of any dangerous, notified occurrence need to be kept for 10 years, usually at the place of work.
Specified Injuries
Here is the list of the specified injuries that must be reported to the HSE should they occur during work:
- Any injury that requires an amputation
- Any injury that could lead to permanent damage to eyesight
- Any crush injury to the head or torso, causing damage to internal organs
- Any burn injury
- Fractures, other than finger or toe fractures
- Any degree of scalping that requires hospital treatment
- Any loss of consciousness caused by trauma to the head or asphyxia
- Any other injury arising from working in an enclosed space
If this accident investigation article has been useful you may wish to know that it is available as an eLearning course