Incident investigations: What to investigate and why

Incident investigations are a critical part of your safety program and safety culture. When an incident occurs, when and how you address it is equally as important as what you address and why. If you “tell” employees that safety is important but fail to “show” your commitment through prompt and thorough investigations of incidents, you de-value your word and lose face with your people.

OSHA defines an incident as "an unplanned, undesired event that adversely affects completion of a task." In the past, the term "accident" was used to refer to an unplanned, unwanted event. To many, "accident" suggests an event was random and could not have been prevented. Since nearly all worksite fatalities, injuries, and illnesses are preventable, OSHA now suggests using the term "incident" ( a term I have used for 25 years) to address any event in which an unwanted outcome occurs. This includes injury, illness, property damage, or near-miss (I prefer, “near-hit”), otherwise known as a close-call.

When an incident occurs, it is an indication that something has gone wrong. Incidents do not just happen; they are caused. The basic cause(s) of an incident is from one or a series of unsafe acts and/or conditions that sets up circumstances leading to that undesired event. The primary purpose for conducting an investigation for every incident is to determine the cause and initiate corrective action(s) that prevent similar type incidents from recurring. Certainly, the level or depth of an investigation – the amount of detail and effort needed - will vary, depending on the incident. Bear in mind that what may initially appear to be an insignificant event on the surface may shed light on a serious condition or practice that needs immediate attention. What is important, then, is for each incident to get your attention and prompt evaluation.

So, we investigate all incidents, whether an injury or property damage has occurred or not, because the root cause and contributing factors that led to the incident could result in a similar incident leading to the ultimate undesired event - a fatality.

Let me be clear: the purpose of an incident investigation is to always identify, address, and correct actions and/or conditions that can lead to a fatal or serious injury. Your employees are most important. The point of the investigation should always be a reinforcement to your employees that it is about improving their safety – both performance and working conditions. The goal of investigating a property damage incident is not to focus on what was damaged or the cost of the damage; the goal is to identify the root cause of the damage to prevent someone from being killed or seriously injured. In other words, it is about improving your safety culture and safety performance at all levels within the organization.

Investigating a worksite incident provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents.

The focus is on identifying and correcting root causes, not finding fault or blame. I have never liked the term, “behavior-based safety.” Whether intended or not, the outcome to behavior-based safety investigations often ended in finding a scapegoat rather than the root cause. Throughout my career, I have addressed safety through integrated performance – including processes, procedures, and employee practices. Looking at the whole picture, from how the process(es) work, what procedures are currently in place and the accuracy of those procedures, to how and why employees practice or follow those procedures, will reveal what went wrong, what caused the undesired event, and how to address it, going forward.

To ensure a thorough investigation, you need multiple people involved. A cross-functional team works best by including the involved employees, the supervisor, the safety department, and may include human resources, maintenance, and engineering. Multiple perspectives and input should be sought to drill down to the actual root cause(s) and contributing factors that led to the incident and ensure findings lead to accurate and prompt correction(s). This may involve changing a procedure. The size of your team will depend on the incident.

There are numerous benefits to investigating all of your incidents. Mentioned earlier, it demonstrates to your employees that safety is a value rather than a changing priority of circumstances. It will also improve workplace morale, increase productivity, increase your employee engagement and participation, and the obvious – identify hazards, whether conditions or practice, processes or procedures – and allow you to eliminate or reduce the hazard while safeguarding your employees through process and procedure review and employee practices that may need to be adjusted.

Incident investigations are critical to your safety culture and benefit your employees and your reputation. Understanding that connection will ensure your investigations have value.