Incident investigation method

Incident investigation method: Incidents should be investigated for several reasons, perhaps the most important of which is to find out the causes of incidents, so that, corrective action can be taken to prevent similar incidents from happening again. Incidents can be categorized in terms of their outcome: near miss, accident (injuries and damage), dangerous Occurrence and ill health. 

Arrangements must be made for internal reporting of all work-related incidents, and workers must be encouraged to do so. Records of work-related injuries must be maintained such as fatalities, serious injuries, occupational illnesses, and some dangerous Occurrences – have to be reported to outside agencies. The basic incident investigation procedure HSE,  INCIDENT INVESTIGATION OSHA

What is incident investigation method and reporting?

Unfortunately, despite an organization’s best efforts, accidents happen. When they happen, the incident must be reported, recorded and investigated in an appropriate and timely manner. There are many reasons to conduct an investigation, but one of the most important things is that an incident cannot happen again. 

The place where a worker trips and falls, one day may be that place where another worker will trip, fall and break the arm. So, all incidents must be examined to determine the possibility of serious injury, damage or loss. It is also likely that if near misses are rigorously reported, there will be a much larger number of events to consider.

This is not to say that all incidents need to be thoroughly investigated in great depth and detail which would be a waste of time and effort in many cases, but that all incidents must be examined for potential so that a decision can be made as to whether an investigation is required. 

The purpose to investigate incidents in the workplace

• To identify immediate and root causes – Incidents are generally caused by unsafe acts and unsafe conditions in the workplace, but they often arise from underlying or root causes. 
• Identify corrective actions to prevent recurrence – a key motivation behind incident investigations. 
• To record the facts of the incident: people do not have a perfect memory, so keep the investigation of the accident records documents as factual evidence for the future.
• For claims management: If a compensation claim is filed against the employer, the insurance company will review the accident investigation report to help determine liability. 
• For staff morale: failure to investigate accidents has a detrimental effect on morale and safety culture because workers will assume that the organization does not value their safety. 
• To allow risk assessments to be reviewed and updated: an incident suggests a deficiency with the risk assessment, which needs to be addressed.
• For disciplinary purposes. 
• For data collection purposes: accident statistics can be used to identify trends and patterns. 

Incident investigation procedure

1. Step: Gather factual information about the event.
2. Step: Analyze that information and conclude the immediate and root causes.
3. Step: Identify suitable control measures. 
4. Step: Plan corrective actions.

When investigating an accident or other type of incident, some basic principles and procedures can be to be used. However, before the investigation can begin, two important issues need to be considered:

1. Secure the Scene: is it safe to approach the area? Is immediate action needed to eliminate the hazard even before downfalls come? 
2. Casualty Care: Any injured person will require first aid treatment and may require hospitalization. This is of course a priority.

Step 1: Information Gathering

The first step is to find out what happened. The accident site must be visited as soon as possible, observe the working conditions, as well as the work methods and the characteristics of the employee (qualification, training, etc.). It is essential to take photographs and describe how the damage occurred. Incident investigation method

Once the immediate danger has been eliminated and casualties have been cared for, a decision must be made about the type or level of investigation as described above. It may be useful for an organization to develop a checklist. Items that could be included in an accident investigation checklist are:

• Personal data of the person involved. 
• Time and place of the accident. 
• Type and severity of injury sustained.
• If the injured person had received first aid, they had either returned to work or been sent to the hospital. 
• The underlying medical condition of the injured person. 
• A task that was being carried out at the time of the accident.
• The work environment in terms of climate, lighting level and visibility.
• The type and condition of personal protective equipment being used.
• Details of the training and information received.
• Details of relevant risk assessments that have been carried out for the task.
• Details of a permit-to-work system. 
• Details of supervision. 

 How do you record incidents?

Gather factual information from the scene and record it. This could be made using:

• Photographs
• Sketches
• Measurement
• Video
• Physical evidence such as samples or equipment that has failed.
• Marking of existing site/location plans

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What is the method of interviewing witnesses?

Once the scene has been thoroughly examined, move on to the second source of information, the witnesses. Witnesses often provide crucial evidence about what happened before, during, and after incidents. They should be carefully interviewed to ensure good quality evidence is collected. Good witness interview technique requires that the interviewer:

• Interview in a quiet room or area, free from distractions and interruptions.
• Introduce yourself and try to establish a relationship with the witness using appropriate verbal and corporal expressions.
• Use open-ended questions (such as those beginning with what, why, where, when, who, how, etc.) that don’t put words in the witness’s mouth and don’t let them answer with a ‘yes’ or ‘no’.
• Keep an open mind.
• Take notes so that facts under discussion are not forgotten.
• Thank the witness for their help

Once the witnesses have been interviewed, move on to the second step:

Step 2: Analysis of the information

After data collection, an assessment of the collected information should be made. All these data must be recorded for later analysis. It is the most important stage to find out the causes of the accident. From this point, preventive measures can be initiated to eliminate or reduce the risk of another accident occurring.

The purpose here is to find the immediate and root causes of the incident. These will be the things that are present at the time and place of the accident. For example, a piece of metal dropped from the scaffold platform and hit a worker’s head and injured due to the sharp edge of the metal piece. The immediate cause of injury is dropped objects, but there are many contributors to this cause. It is common to think of these in terms of unsafe acts and unsafe conditions.

So here, for example, poor housekeeping (unsafe condition) and the worker working without a safety helmet (hazardous act). The underlying or root causes are the things that lie behind the immediate causes.

What are examples of immediate causes?

• Lack of communication – information error or omission
• Failure to follow the rules or procedure
• Inadequate safety device
• Improper manual handling
• Inadequate PPE
• Influence of intoxicating substances
• Damage tools
• Misuse of tools and PPE
• Work environment
• Lack of housekeeping
• Improper access

What are examples of underlying causes?

• Inadequate supervision
• Inadequate policy and procedure
• Improper planning
• Inadequate motivation
• Workload
• Inadequate maintenance and inspection
• Deployment of an inexperienced worker

Direct Causes examples

They are of two types: Unsafe Action (human origin) and Unsafe Condition (origin of the work environment).

• Unsafe Action: It is defined as any action or lack of action of the person that works, which can lead to the occurrence of an accident.
• Unsafe Condition: It is defined as any condition of the work environment that can contribute to the occurrence of an accident.

Often the root causes will be failures in the management system, such as:

• Lack of adequate supervision of workers.
• Failure to provide the proper personal protective equipment.
• Lack of adequate training.
• Lack of maintenance.
• Inadequate checks or inspections.
• Failure to carry out adequate risk assessments.

Many of the accidents that occur in the workplace have an underlying or root cause. If that root cause is identified and treated, then the accident should not happen again. For example, if a worker is hit by a dropped object, the obvious solution is to maintain good housekeeping. It might also be worth asking how long the poor housekeeping had been there. If he had been there for a long time, why hadn’t he seen it before? And if he had seen himself, why hadn’t he fixed himself?

These questions can identify an underlying cause, such as inadequate supervision, or failure to assign housekeepers in the workplace. In contrast to this idea of a single cause, some accidents at work are complex and have multiple causes. There are several immediate causes of the accident and each of them has underlying or fundamental causes. For example, a worker could be hit by a moving vehicle. The immediate causes of such an accident could be:

• There is a lack of flag man.
• Bad positioning of the vehicle on the road near a pedestrian exit.
• Aggressive braking by the driver.
• A distracted pedestrian is walking out in front of the vehicle.

On investigation, each of these immediate causes could have its separate root causes, such as:

• There is no training for the driver, who is new to the workplace and does not know the necessary flag man.
• Lack of segregation of pedestrian and transit routes; without barriers or marks that separate them.
• Lack of proper induction of the driver in his new workplace, so they are unaware of the design and position of pedestrian exits, etc.
• There is no refresher training for a worker who walks only in the pedestrian root.

If there are multiple causes for the accident, then each of these causes must be identified during the investigation, otherwise, incomplete corrective action will be taken, and similar accidents may occur in the future.

Step 3: Identification of suitable control measures

Once the immediate and underlying causes of the accident are known, appropriate control measures can be taken. The correct control measures must be established. Otherwise, the time, money, and effort be wasted on inappropriate and unnecessary measures that will not prevent similar occurrences in the future.

Control measures must be identified to remedy both immediate and underlying causes. The immediate causes are usually easy to identify: if there is an oil spill on the floor, clean it up; if the machine guard is missing, put it back.

The underlying causes may be more difficult to determine because they reflect failures in the management system. The correct control measures that must be taken to remedy the failure of the management system are identified because this will help prevent similar accidents from occurring in similar circumstances throughout the organization.

The content of a typical incident investigation report may include the following:

• Date and time of the incident.
• Location of the incident.
• Details of the injured person/persons involved (name, job title, employment history).
• Details of the injury sustained.
• Description of the activity being carried out at that time.
• Drawings or photographs are used to convey information about the scene.
• Witness details and witness statements.
• Immediate and underlying/root causes of the incident.
• Evaluation of possible breaches of the legislation.
• Recommended corrective action, with suggested costs, responsibilities and timeframes.
• Estimation of the cost implications for the organization

Barriers to Reporting:

Reasons Workers Might Not Report Incidents: Unclear organizational policy on incident reporting. There is no reporting system.

• Information procedures that need to be simplified.
• Excessive paperwork.
• Takes too long.
• Culture of blame
• Believe that reports are not taken seriously by management.

Step 4: Plan corrective actions.

An accident investigation serves to determine the causes responsible for a said work accident, in addition to serving as preventive measures to reduce the probability that this or other accidents will occur again.

It is recommended to investigate all the events that have occurred, both those that generate damage to health, as well as those that have not caused injury to the person, but that could cause harm to them. An incident investigation should lead to corrective action. Remedial actions can be presented in an action plan:

Corrective action
Recommended action	Action	Responsible person	priority
Refresher Training for defensive driving for all new drivers	yes	Construction manager	Medium
Termination	no
One-day housekeeping	yes

Who investigates?

Accident Investigation: Systematic process of determining the causes, facts or situations that generated or favoured the occurrence of the accident, which is carried out to prevent its recurrence, by controlling the risks that produced it. Its main objective is to prevent the occurrence of new events, which leads to improving the quality of life of workers and the productivity of the organization.

The investigation will be carried out immediately after the accident once the situation is within a period not exceeding 72 hours.

1. Area Managers: Investigate the accidents that occurred in your area or section, and send the results of the investigation to the Directorate of Planning and Development / Specialist of Safety and Health at work.
2. Transportation Manager: Carry out investigations of traffic accidents involving vehicles in the area of transportation.
3. Occupational Health and Safety Specialist: Advise and assist in investigations whenever the personnel in charge do so.

Accident recording

Monthly statistics will be kept of all the accidents that have occurred and the rates of occupational accidents, the data to be recorded will be the following:

• Date of the accident
• Department to which the injured person belongs Form of the accident
• Nature of the accident (First aid, disabling, traffic or on the way)
• Nature of the injury: type of physical injury produced (if there was an injury)
• Location of injury: part of the body affected by the injury,
• Material agent: object, substance or facility that caused the accident
• Dangerous condition: technical cause of the accident
• Measures taken

Near miss incident reporting

An organization must pay attention to a near miss because it can have the potential for serious injuries and fatalities the worst realistic outcome is a life-threatening or life-altering injury. A near miss, sometimes also called a close call or near hit is an incident without property or personal injury, but which, with a slight change in timing or position, could easily have caused damage or injury. They are a warning sign that an incident is about to happen and should be reported and investigated immediately. Well, these incidents are common in most workplaces.

Near-miss incident events are often not reported to superiors. You mistakenly choose to say “Nothing has happened here”. The reporting of near misses is a work procedure that is part of the obligation to guarantee health and integrity in the workplace, which aims to eliminate occupational risks and adopt rapid prevention measures

OSHA does not legally require businesses to report near misses unless the incident resulted in injury or property damage. It is common practice for employers to make near-miss reports for safety management and incident recording.

Whenever a near miss occurs or is reported, it is critical not to blame the employee alone, as the root cause of a near miss is more likely to be a failure in the organization’s systems or processes. Another way to encourage near-miss reporting is to emphasize the benefits to employees by giving real-life examples of how an injury was prevented or life was saved

Near miss report format
Reporter name		Location
Date		Incident type	Near miss
Witness	1	2	3
Name
Description:

 

Has the safety procedure been breached? (describe):

 

Why an unsafe act was committed, or why was the hazardous condition present?

 

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Conclusion

Incident investigation is an important tool for preventing accidents and injuries. By following the steps outlined above, organizations can identify the root cause of incidents and make changes to prevent them from happening again. Here are some additional tips for conducting an effective incident investigation:

• Be objective and impartial. The goal of an incident investigation is to find the root cause, not to assign blame.
• Gather as much information as possible. The more information you have, the better equipped you will be to identify the root cause of the incident.
• Interview all relevant witnesses.
• Review all relevant documentation. Documentation, such as maintenance records and safety procedures, can provide valuable insights into the incident.
• Use a variety of analysis tools. There are a variety of tools that can be used to analyze incident data, such as root cause analysis, failure mode and effects analysis, and five whys.
• Make recommendations that are feasible and effective. The recommendations that you make should be feasible and effective in preventing similar incidents from happening in the future.
• Communicate the results of the investigation to all affected employees. It is important to communicate the results of the investigation to all employees so that they can understand what happened and how to prevent similar incidents from happening in the future.