The Seven Steps of a Thorough Accident Investigation
By Safety Management Group
There’s a tremendous difference between investigating a workplace incident and finding someone to blame for it. Unfortunately, it’s all too common for companies to confuse the two concepts. When something goes wrong, they work hard to identify they believe to be at fault, and that’s where the investigation stops.
However, most workplace incidents are not that clear-cut. Yes, an individual worker may bear at least some of the blame, but there are usually extenuating factors. Perhaps the worker wasn’t completely aware of the potential hazards. Maybe the right kind of safety equipment was unavailable. Or it may be that nobody had ever considered that type of incident to be a possibility.
A more productive accident investigation approach goes far beyond placing blame. Instead, it focuses on identifying flaws in the process leading up to the incident and the safety procedures that were supposed to prevent it from happening. The ultimate goal is not only to ensure that the accident isn’t repeated; it’s to use what you learn to head off other types of accidents. Another purpose is to prepare for the possibility of litigation, especially in incidents that result in severe injuries or fatalities.
It’s important to properly investigate all incidents, even those that may be appear to be inconsequential, for two reasons. First, the lessons learned in investigating even small incidents can be valuable in preventing larger incidents in the future. Second, investigating all incidents sends a message to employees and outside regulators that the company takes its commitment to safety seriously and pursues it consistently.
The investigator’s role is to gather and organize information in an effort to uncover the truth behind the incident. Because details aren’t always clearly defined, and because witnesses can offer widely disparate views of the same situation, the investigator should have enough experience and competency to perform the process with management’s complete confidence and cooperation.
The process and paperwork formats for the investigation should be in place long before they’re ever needed. While the severity of the incident will play a central role in determining the scope of the investigation, the overall process should be same. Without a defined process, whoever is assigned to investigate will be forced to develop a process as he or she proceeds. In addition, that process might differ from investigation to investigation, so the resulting value of any conclusions may be inconsistent. In any case, a thorough, effective investigation should include the following seven points.
1. Respond immediately
The most immediate task is to coordinate the company’s emergency response. In addition to notifying emergency responders and attending to injuries and damage, this also includes notification of all appropriate personnel (and workers’ family members), and securing the site to ensure that a proper investigation can take place. This may mean shutting down any work in progress and blocking access to materials and equipment that may have been involved in the incident. The goal is to prevent tampering with evidence and exposing workers to additional hazards. Finally, management must determine the depth of investigation the particular incident warrants.
2. Gather information
Once the accident site has been secured, the investigator’s focus shifts to gathering as much data about the incident as possible. It’s critical that this process begin immediately, before witnesses begin to forget details and before regular work compromises any evidence.
The information-gathering process involves questioning witnesses and asking them to complete and sign statements about what they saw. These findings should be documented, even if a worker says that he or she didn’t see the incident, because that information will be helpful if stories change down the road. The purpose of questioning is not to determine who deserves any blame; it’s to collect as much information as possible about exactly what took place.
Investigators should also gather any documentation that would be helpful, from equipment logs to photos and diagrams of the accident scene. As the investigator looks over what he or she has been able to collect, it’s important to identify any gaps in the information and attempt to fill those gaps through additional investigation.
3. Release the scene
While it would be ideal to keep the site of the incident secure while the investigation proceeds, in most cases, that just isn’t practical. That’s especially true when incidents occur on construction sites, where unnecessary delays can be costly. One the investigator believes that he or she has obtained all of the information that’s available (and has taken steps to preserve any evidence items), they site can be cleared for work to resume, after any necessary remediation.
4. Perform the analysis
At this stage, the investigator has access to all of the available data and is ready to determine what happened and how. The most effective way to analyze is to organize all of the events in two formats. First, they should be listed chronological order, providing a step-by-step recounting of the incident. Then they should also be organized logically, to show how specific aspects related to others. Once those steps have been taken, it becomes easier to determine everything that the investigator knows, along with any unknown aspects, so he or she can determine a probable cause.
5. Develop a report
Documentation is a key part of any safety program, and is particularly important when investigating accidents. A clear, comprehensive report collects all the facts so that everyone is working from the same information and can refer back to it (instead of trusting our imperfect memories). A report will also be helpful if litigation becomes necessary, since that typically takes place many months or even years after the actual incident. In addition to including a summary of what happened and the investigator’s conclusions, the report should include all of the backup documentation, from photos to witness statements and more.
6. Share the findings
Much of the value of an accident investigation rests in its ability to prevent future incidents. That’s why it’s so important to share the report’s findings and any recommendations with everyone from the management team through workers. The better everyone understands the conditions and any shortcomings that contributed to the incident, the less likely those situations will be repeated. Sharing what happens when something goes wrong also provides powerful motivation to encourage workers to make the right choices in the future. (However, if litigation is pending and there’s a possibility that sharing details might create additional exposure, it would be wise to have legal counsel review any information before it’s released.)
7. Make changes
Finally, it’s time to implement the investigator’s recommendations and make any necessary changes to processes and procedures to ensure that there won’t be a repeat of the incident. Part of making that change is regular follow-up to ensure that the correct steps are being taken. That way, the time and energy that have been invested into the accident investigation will have been worthwhile.