Organizations that do not deal with workplace accidents and incidents by conducting effective investigations are failing to manage health and safety, loss, and in some cases failing to comply with legal requirements.
“Accident” can be defined as an unplanned event that results in loss to an organization. The loss is usually focused as injury or illness to employees but should also include losses related to equipment, materials, environment, productivity, customer service, etc.
“Incident” can be defined as an unplanned event that under different circumstances could have resulted in loss to an organization. These are commonly called “near misses” or “close calls”
The purpose of an effective accident/incident investigation is to prevent a reoccurrence. In the case of an incident investigation this is critical, since if the event occurs a second time it could then result in an accident.
Incidents that are reported and investigated to prevent a reoccurrence can be termed as a “free lesson learned”. Through incident investigation an organization gets to learn about and correct a hazard or situation that exists that could have resulted in a loss and it only costs the organization the time taken to conduct the investigation. By correcting the circumstances that caused the incident the organization has avoided the potential for what could have been a very costly accident resulting in loss.
Accidents that are investigated to prevent a reoccurrence are a costly way for an organization to learn about the hazards that exist which are causing loss. This is a reactive and costly way to learn about hazards and develop health and safety standards and procedures designed to control the hazards and prevent accidents and loss.
An effective investigation process must be able to identify obvious causes which are, in effect, symptoms that provide information that something is wrong. Accidents/Incidents should ALWAYS be further investigated, to determine the underlying or root causes. The obvious causes must be remedied to prevent accident/incidents from occurring and/or recurring. Without an analysis to sift through the information gathered during the investigation, only the obvious substandard actions and conditions will be targeted for corrective action. Analysis is required in order to organize facts and determine the underlying reasons for accidents/incidents. The process requires asking “why” the accident/incident occurred, why each obvious cause existed, what underlying causes contributed to each obvious cause and finally, what lack of control contributed to each cause. The underlying causes and the lack of controls (e.g., inadequate program, program standards and compliance to standards) need to be corrected in order to prevent accidents/incidents from occurring and/or recurring. Thus, analyzing causes is the most important part of the accident/incident investigation process. It involves looking at problems systematically to come up with the proper corrective actions.
The basic steps of a good accident/incident process should include:
- Taking immediate action and immediate notifications
- Conducting the investigation as soon as possible
- Analysing the information gathered to determine all the obvious and underlying causes
- Complete the investigation report and establish an action plan to correct all the identified causes
- Follow-up to ensure the action plan is carried out and the corrective actions are effective
Organizations are also encouraged to share all the lessons learned with any stakeholders both internally and externally that would benefit from the information and help them proactively take action to avoid an accident/incident.