Accident Investigations
I read this today and wanted to pass on these words of wisdom:
“The only up-side to an accident is to perform a thorough study of it with hopes of preventing any more like it”.
Wow, read that again and think about it. That is why an accident investigation process is so important!
A successful accident investigation must always focus on discovering the root causes.
Root causes exist in areas such as workplace design, cultural and organizational factors, equipment maintenance and other technical matters, operating systems and procedures, staffing, supervision, training, etc.
It’s been said that “Eliminating the immediate causes is like cutting weeds, while eliminating the root causes is equivalent to pulling out the roots so that the weed cannot grow back”.
Focus on the Root Causes, Not Blame or Fault!
If an investigation is focused on finding fault, it will always stop short of discovering the root causes. It is essential to discover and correct all the factors contributing to an incident or accident, which nearly always involve equipment, procedural, training, and other safety and health program deficiencies.
By addressing the underlying or root cause, you can understand why an incident occurred, develop truly effective corrective actions, and thereby minimize or eliminate serious consequences from similar future accidents.
Moreover, if an investigation is understood to be a search for “someone to blame,” both management and labor will be reluctant to participate in an open and forthright manner. Workers will be afraid of retaliation and management will be concerned about recognizing system flaws because of potential legal and financial liabilities.
Although a supervisor sometimes conducts incident investigations, to be most effective investigations should be conducted by a team in which managers and employees work together, since each brings different knowledge, understanding, and perspectives to an investigation. Working together will also encourage all parties to “own” the conclusions and recommendations and to jointly ensure that corrective actions are implemented in a timely manner.
Where the incident involves a temporary worker provided by a staffing agency, both the staffing agency and the host employer should conduct an incident investigation If a temporary worker is injured and the host employer knows about it, the staffing agency should be informed promptly, so the staffing agency knows about the hazards facing its workers. Equally, if a staffing agency learns of an injury, it should inform the host employer promptly so that future injuries might be prevented, and the case is recorded appropriately. Both the host employer and staffing agency should track and where possible, investigate the cause of workplace injuries.
But remember, investigations should focus on identifying root causes, not establishing fault. We suggest that ALL accidents should be investigated — no matter how “incidental”.
Our goal is to prevent accidents from occurring. Always Safety First!