An incident is an unplanned or undesired event that adversely affects a company’s work operations. Incidents include work-related injuries, occupational illnesses, property damage, spills, fires or near miss events that could have resulted in any of these.
All incidents should be investigated. An incident that results in a serious employee injury, considerable property damage, a major fire, or spill obviously warrants an extensive investigation. A minor incident or near incident also requires a thorough investigation and may reveal significant potential for a serious incident if the conditions are left uncorrected.
There are two major components that contribute to the cause of an incident. They are the “work element” and the “root cause”.
- The “work element” is the condition or act that directly caused the incident. An example of a work element might be a small spill of oil on the floor that someone slipped on.
- The “root cause” is the system failure that allowed the work element to become deficient or to occur. For example, a root cause may be a lack of preventive maintenance that resulted in the fork truck leaking oil on the floor.
A thorough investigation will reveal the root cause of the incident. The purpose of an incident investigation is to determine the work element and root causes of incident, and to assist in providing the company with a solution to prevent recurrence.
Companies should have an incident investigation process to ensure that:
- All incidents (including near misses) are investigated
- Corrective actions are determined that identify the root cause
- Corrective actions are tracked until they are completed
- Trends are reviewed, gaps are identified and improvement plans are developed to prevent future occurrences.
Proper training and a clear understanding of roles and responsibilities is essential to the investigation process. All employees and people that will be involved in an incident investigation should be aware of what their role is in the process and how to perform their assigned responsibilities during an investigation process.
Investigations must be constructive, credible and timely. Remember that the investigator is trying to figure out what happened and how to prevent similar situations, not trying to place blame on any individual or group. If the investigation is antagonistic, and takes a “what did you do wrong?” approach, then the process becomes much more difficult, as employees do not want to be blamed or cooperate in a blame-giving situation. A more constructive approach is “what happened, and what can we do to prevent this from happening again?”
Timing of an incident investigation could be crucial to the outcome. If an employee reports an incident that happened three weeks ago, all an investigator has to go on is what the persons involved can remember. People’s memories fade or evidence may be disturbed which could hamper the investigation process. With timely reporting, an investigation can take significantly less time to complete, and operations will be able to resume more quickly.
One of the most critical and complex parts of the investigation is the gathering of evidence. There are some basic rules that may help the process.
Interviewing involved employees:
- Put the individual at ease – make sure they know the primary purpose of the interview is to prevent a recurrence of the incident and that it can only be done with their help. Avoid finger-pointing and applying blame.
Treat people with tact and respect. Make them aware that they need to be thorough and truthful in their account of the incident and that you are not there to get anyone into trouble, only to find out what happened and why, so that it won’t happen again.
- Be aware that injured employees and witnesses to injuries may have some emotions involved that affect them. Especially if the incident was severe, there may be some trauma that occurs.
- Stress fact gathering. Let involved employees tell their story completely. Wait until they have finished their version of events before interrupting or clarifying what was said. Then go over what they stated with them, to assure that you have their account of the story accurately and that you understand what they meant, not just what they said. Do not make assumptions or state opinions during this process. If other people have said something different from what was stated in this interview, ask leading questions to discover more information, but do not contradict what was stated in either interview.
- Conduct the interviews at the scene, if possible. This may help people to explain and may help the interviewer understand what happened. Make the interviews as private as possible, so that other employees cannot take any offense or contradict what is said. Witnesses may be interviewed at a later time, if privacy is at issue.
- Ask any necessary questions to determine what happened, what was done, and how it was done. Try to avoid asking WHY questions that may make people defensive.
- Close the interview on a positive note. Discuss the actions taken, or that will be taken if you know them. That will reaffirm the purpose of the interview. Make sure you thank the interviewee for their help in the investigation process.
At the end of this session, participants will be able to: (not limited to)
- Identify what events warrant an investigation
- Identify why companies should have an investigation process
- Detail the basic rules of evidence gathering