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Oct 2017

Incident Investigation: Are you learning from your mistakes?


hand holding card that says root cause

How does your company seek to remove workplace hazards from the lives of employees? Preemptive programs, thorough record keeping, and extensive research on policy and protocol are all crucial to creating a safe workplace. Still, there is another method that is often overlooked or neglected: Incident Investigation. The Occupational Safety and Health Administration, along with the Environmental Protection Agency, encourage employers to conduct Incident Investigations whenever an accident occurs.

Investigation Components

Incident Investigations are a critical component to the correction of underlying occupational hazards. The backbone of these investigations, called Root Cause Investigations, are concerned with not simply finding the immediate cause of an accident. Rather, Root Cause Investigations seek to identify a systematic or procedural factor that may create the hazard. For example, an employee may drop a piece of equipment on his or her foot. The immediate cause of the hazard is that the employee dropped the equipment. A Root Cause Investigation would dig deeper than that, and determine why the employee had to pick up that piece of equipment in the first place.

The Root Cause Investigation is really the heart and purpose of an incident investigation. Identifying the hazard that resulted in the accident – as well as the factor that created that hazard – serves to correct the true cause of the incident. Carrying out a Root Cause Investigation can be difficult. Employers need to seek the factor that lingers beneath the chain of events that unfolded to cause an incident. To find that factor employers must ask the right questions when evaluating an incident.

Conducting an Investigation

It is important to assess every step of the accident by examining the progression of every action that led to the incident. Next, employers need to ask variations of what, how, and why questions. For example -using the previous scenario- why would the employee lift the piece of equipment? How was the equipment dropped. Was it too heavy? Did the employee trip over something? What changes have been made recently to protocol that may have influenced this scenario? These are all questions that employers may wish to ask in order to identify the pathway that may lead to the root cause of the incident.

Employers may wish to assign a small, interdisciplinary team to the project investigation as well. Selecting a few members from the workforce from varying departments stimulates thought and creativity on issues that could be the root cause. Additionally, assigning employees with various backgrounds lends different perspectives and knowledge regarding the processes that may have contributed to the incident occurrence. The team should meet once or twice a week, and continue to meet until the root cause has been identified or until all avenues are exhausted.

An interdisciplinary team may wish to utilize a few tools when conducting a Root Cause investigation. The most effective tool is the ability to ask the proper questions, as discussed above. However, a team may use past Occupational Safety and Health incident data, sequence of events charts, and other diagrams displaying the events of a particular incident and how it played out. Additionally, comparing the incident at hand with other similar incidents may help determine any hidden hazards that led to those incidents occurring.

Ultimately, any team carrying out a Root Cause Investigation must be prepared to examine the event and all related material and events with intense scrutiny. Identifying the root cause of an issue means looking far beneath the surface to determine a fundamental or systematical error. Once this error is recognized, then the root has truly been dug up.

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