Occupational Health and Safety Management
What Are the Benefits of Investigating All Safety Incidents?
Safety incidents and accidents happen in most organizations from time to time, but reactions to their occurrence vary greatly. So why is it that some organizations take all incidents extremely seriously (whether or not they led to employee injury) and some don’t? In order to answer this question, we first need to make sure that the terms we are using here are well-understood.
What is an Accident?
An accident is an unplanned, unwanted event which not only disrupts the work process but clearly causes injury or harm to people or property. Unlike people’s perception of the term, an accident is rarely a random event but is often controllable or even predictable.
What is an Incident?
An incident is an unplanned and unwanted event which disrupts a person’s capacity to do his or her job (or the work process in some way) and has the potential of resulting in injury, harm, or damage to individual or property (but does not result in actual injury or damage).
An incident should therefore be viewed as a warning that similar situations could arise in the future and may lead to harm to people or property. It can therefore be considered as the first of a series of incidents which could lead to a situation in which harm or damage will occur, sooner or later.
Accidents or injuries are the tip of the so-called “iceberg of hazards” but in ideal circumstances we should investigate incidents rather than just accidents since they are potential “accidents in the making”.
So how should we go about investigating all incidents?
Incidents usually result from a combination of both unsafe acts and conditions. These unsafe acts and conditions often arise because of defects in the safety and health program that has been put in place (assuming that there is one of course). With a missing or poorly developed safety and health program employees and their leaders will be forced to evolve their own safety standards on the work they have to perform. Much is then dependent on an individual’s experience, training, knowledge and the extent to which they are happy to adhere to safety standards on a consistent basis.
In broad terms, incident causes are typically broken down into:
- The direct cause(s) What was the direct cause of the incident? (or what caused the injury?)
- The indirect cause(s) What were the root or hidden causes that led to the incident? (or what caused the incident to occur at a deeper level?)
Although the direct cause of an incident is often relatively straight-forward to determine (and may see any reporting and investigation stop at that point) a proper and thorough investigation will seek to reveal the more indirect and root cause(s) of any incident. After all, the purpose of an investigation is to give the enterprise the capacity to prevent a recurrence of the incident before it leads to injury or harm.
As a result of the above, all organizations should have an incident investigation process to ensure that:
- All incidents (including near misses or “near hit” as they are sometimes called) are investigated
- Corrective actions are determined that identify the root cause(s)
- Corrective actions are tracked until they are completed
- Trends are reviewed, gaps are identified and improvement plans are developed to prevent future occurrences.
In addition, the incident investigation process should seek to do the following:
- determine what actually happened in each case
- determine the cause or causes of the incident (both direct and indirect root causes),
- identify any unsafe conditions, acts or procedures,
- help management to identify practical corrective actions,
- determines whether due care was observed throughout the process leading up to the incident,
- openly show the commitment of the organization that an adequate investigation system is in place.
And don’t forget, the purpose of any good incident investigation process is not to find fault or lay blame, but rather to identify the real and underlying causes of incidents so that controls can be put in place to prevent further occurrences.
A final summary
Accidents occur at the tip (or above the water line) of what is often called the “safety or hazard iceberg”. Under the water in this analogy are thousands of incidents which can provide great data on what accidents are just waiting to happen, if things stay the same. By taking all safety or health threatening incidents seriously and by having a thorough investigation process, many accidents can be prevented. Such an approach should ideally implement the following steps:
- Emphasize that safety is a value, not just a priority and the reporting of incidents is key.
- Encourage employees to report incidents immediately, fully and honestly.
- Ensure a clear investigation process exists and quality forms and checklists are in place to guide your efforts and provide necessary reminders.
- Look for direct and indirect/root cause(s), and avoid apportioning blame.