Eight keys to a successful post incident investigation
An employers’ handling of a workplace injury affects not only
the injured employee, but also co-workers and the company as a whole.
It can forge a commitment to teamwork, safe work practices and confidence
in the employer or it can result in distrust, rumors and half-truths,
and low morale. The incident investigation conveys a strong message
to the injured employee and the workforce. A lax investigation suggests
the incident is not important, a low priority for the employer, reflecting
a disinterest in the workforce. On the other hand, an aggressive investigation
focusing on who is to “blame” for
the incident creates discomfort and fear. From beginning to end
the process should be fair, professional, thorough and non-intimidating.
Here are eight keys that will help make the investigation successful:
- Define the purpose of the investigation
In and of itself the word investigation triggers defensive
feelings. It’s important that the injured employee and the
witnesses be put at ease. The purpose of the investigation
is to determine the cause or causes of the incident, identify
unsafe conditions, acts or procedures that contributed to the incident
and to recommend corrective actions. Clearly communicate
that it is not to assign blame and that the priority is the injured
worker and maintaining a safe work environment.
- Act quickly. Have an established system in place for all incident investigations
Ideally, supervisors should carry on the investigation, as they
are most knowledgeable about the type of work involved. Supervisors need
to be fair, objective and impartial. If an adversarial relationship exists
between the supervisor and employee, the chances of a successful investigation
and return to work are slim.
An accident investigation report form should be completed individually
with the injured employee and all witnesses. This should
be completed within 24 hours after the incident, when memories are
fresh and witnesses’ opinions
have not had a chance to be influenced by others. A safety
coordinator should ensure that all accident investigation report forms
are filled out completely and that the recommendations are being addressed.
Sample of report
- Immediately address the incident scene
Analyze the situation and implement temporary control measures
to prevent any further injuries to employees. Review the equipment, operations
and processes to gain a further understanding. When appropriate take photographs,
make drawings or take measurements.
- Reach out to the injured employee
Suffering a workplace injury is a traumatic experience. In
addition to the pain and discomfort caused by the injury, an injured
employee often does not know what to do and becomes frightened.
that the employer communicate that they really do care, want the employee
to receive the proper medical treatment and be enrolled in a Return-To-Work
program as soon as medically possible, with the ultimate goal to get the
employee back on the job. Proper medical attention, as well as the employers’ empathy,
should be provided before the incident investigation begins.
- Interview procedures
The injured employee, all witnesses and relevant employees
should be interviewed as soon as possible, ideally within 24 hours
of the accident. Interviews should be conducted with anyone who
can give relevant information, such as a manager or trainer, even
if they were not present at the time of the incident. Interview
each person individually and separately. Reassure each person of
the investigation’s main purpose, put them at ease
and do not conduct the interview as if in a courtroom.
With witnesses, an effective approach can be to ask them to relate
their account of the incident, listen intently, but do not
ask questions or take notes. This gives the witnesses time
to collect their thoughts. Then have them relate the story
again while taking notes and asking questions, avoiding any
questions that lead the witness. Try to achieve a chronological accounting – what
happened first, next, etc. Stay focused on facts, not opinion.
Review your notes with the witness to be sure they agree
that you have recorded it accurately. Encourage the witness to contact
you if they think of something else. Remind interviewees that all
information is confidential.
- Identify root causes
In many cases, there is one obvious cause for the injury,
but it is a mistake to stop there. For example, an employee
slips on grease on the floor. The obvious cause is the
grease on the floor. Drilling down further with a series
of ‘why’ questions
will help identify how the grease got there, why it was
not cleaned up, etc. The ‘5
Whys’ is a technique used in the Analysis
phase of the Six Sigma DMAIC
methodology. Although this technique is called ‘5 Whys,’ you
may find that you will need to ask the question fewer or
more times than five before you find the issue related
to a problem.
- Evaluate the evidence
Objectivity is the most important factor in evaluating the
evidence. Investigate causal conditions and unsafe acts; make conclusions
based on existing facts. Be sure to consider all contributing factors
and determine what evidence is direct, circumstantial or hearsay.
- Report writing
A factual, concise, clearly written report is critical to
protecting the employer and providing direction for corrective
actions. Include a summary of the events leading up to
and including the incident. Be specific with dates, time,
people, conditions, equipment, acts, etc. Keep the events in chronological
order. Provide recommendations for corrective actions and
indicate the need for additional or remedial safety training.