Many workplaces struggle with one of the most critical elements of any attempt to manage safety and health via a safety management system – Incident Investigations. From the struggles of getting personnel to REPORT incidents (including near misses) to management recognizing these reports are GIFTS handed to us! But what normally happens, is we get employees reporting and we lose a lot of credibility with those employees when the investigation into their reports fall well short of being professional. And once the employees lose TRUST and CREDIBILITY in our ability to professionally and fairly conduct the investigation, it can take years/decades to regain that trust.
With that said, our friends in safety from across the pond have re-issued their outstanding publication on investigating accidents and incidents. It is a FREE publication and I recommend it for beginners and experienced practitioners alike. Much of the publication follows the roots of James Reason’s approach to Human Failure. The incident investigation process is quite simple and follows four (4) basic steps:
Step one: Gathering the information
Step two: Analysing the information
Step three: Identifying risk control measures
Step four: The action plan and its implementation
One of my favorite things about this publication is how they use different language. For example, they use the phrase “adverse event” instead of “incident”, “accident”, etc. Sometimes, changing the language around incidents can help change the mindset around how these events are viewed.
Adverse events have many causes. What may appear to be bad luck (being in the wrong place at the wrong time) can, on analysis, be seen as a chain of failures and
errors that lead almost inevitably to the adverse event. (This is often known as the Domino effect.). These causes can be classified as:
- Immediate Causes: the agent of injury or ill health (the blade, the substance, the dust, etc.);
- Underlying Causes: unsafe acts and unsafe conditions (the guard removed, the ventilation switched off, etc.);
- Root Causes: the failure from which all other failings grow, often remote in time and space from the adverse event (eg failure to identify training needs and assess competence, low priority given to risk assessment, etc).
To prevent adverse events, you need to provide effective risk control measures that address the immediate, underlying, and root causes.
CLICK HERE for this FREE publication.