“Safety lessons” are usually “learned” as part of the accident investigation after an injury. The health and safety professional community refers to these investigations as incident investigations – following the logic that almost all worksite fatalities and injuries, along with illnesses, are not accidents – but rather they are preventable incidents.
We can define incidents, to include not only those events where a worker was injured, but also near misses. Near misses are those close calls where a worker might have been injured if the situation had been different.
What are we looking to learn from an incident investigation?
In an incident investigation, the main aspects that we are looking to learn from are the root causes of the incident. This includes identifying the hazards in an operation and determining shortcomings of the safety and health programs that affected the incident.
How is an investigation to learn the root cause of the incident different than just figuring out what happened?
The focus of the investigation should be beyond the immediate causes of an incident, not on finding fault or blame. It is misleading to conclude that carelessness or failure to follow a procedure alone was the cause of an incident. The investigators should look for the underlying causes of the incident. With this learning, the systemic changes can be made to prevent future incidents.
What type of questions should be included in a root cause investigation?
When a shortcoming is identified, ask why it happened?
- If a procedure or safety rule was not followed, ask why was the procedure or rule not followed? Does the procedure or safety rule need to be changed?
- If production pressures lead to safety procedure short cuts, and, if so, who authorized the short-cuts? Can equipment or staging or procedures be modified to allow for safe production at high demand levels?
- Was the procedure out-of-date for current operations or was the safety training inadequate? If so, why had the problem not been previously identified, or, if it had been identified, why had it not been addressed?
What is the goal?
The goal of an investigation is to address the underlying or root causes with effective corrective actions. This is necessary to truly understand why an incident occurred … managing – fixing - the actual reason for an incident will pull the burden off of the injured and change the conditions to minimize or eliminate serious consequences from similar future incidents.