Incident Investigation

Industrial incidents occur everyday.  Some are major, with injuries to workers as well as damage to property, but most are minor and do not involve time lost, medical care or repairs to property.  Incidents can be controlled and prevented.  One of the best ways to prevent incidents is to investigate the causes of each incident that occurs.  The degree of investigation depends on the potential severity of the incident.

Every incident consists of a cause and a result.  An incident involving a near miss (near hit), no injury, or a slight injury may reveal as many constructive conclusions as the investigation of an incident involving a fatality.  Once the cause is set in motion, little can be done to control the result.  The difference between a scraped shin and a fractured skull is often a matter of luck.  Many slight injuries or near hits might just as well have been fatalities.

Incident investigations must be prompt and thorough.  Nothing can be assumed or taken for granted. Every alleged fact must be challenged until the investigator is finally satisfied that he knows just exactly what happened which means understanding, “Who did or did not do something and why?”  We are not trying to fix blame but improve conditions and attitudes.

Always remember the purpose of an incident investigation is to find the cause(s) so that plans can be made to prevent the incident from happening again.  The invariable cause of an incident is that someone did something that he should not have done or that someone failed to do something that he should have done.  Do not be confused by such words as “machine failure,” “man failure” and “unsafe physical conditions.”  Behind all these phrases is an unsafe act or failure to act on the part of somebody.

The investigating team should have all the preliminary information available regarding the incident, the person injured and the injury itself.  Equipment age, maintenance records and records of who performed the maintenance of the equipment should be obtained.  Manufacturers’ manuals and recommended procedures are also pertinent to the investigation.

Strenuous efforts should be made in an attempt to find out all the contributing factors.  Effective investigation is, first of all, a fact-finding job, which requires among other things, personal sincerity and honesty.  Facts as they are found should be met and acknowledged face to face.  An investigation should not be looked upon as a necessary evil but rather in its true light, which is the opportunity to bring about better control of hazardous operating conditions.

All incidents including near-hits should be investigated in order to find the answers to the following four “W” questions.  With these answers we can the answer the final two “W” questions.

1. Exactly What happened that resulted in the injury, damage incurred or environmental incident? Under what accompanying or special circumstances did the incident occur?
2. Where did these actions take place?
3. Who was injured, who was involved, who might know something about the incident or who was on location but not involved or does not know anything about the incident?
4. When did it happen?

Interview witnesses and do not lose the opportunity of discussing with the injured person, when available, the details regarding the occurrence of the incident and obtaining his recommendations for correcting the hazard which caused his injuries.  He may know more and have better answers than anyone else.

Once the facts are found from the four “W” questions, the investigation team can determine the answers to the fifth “W”: Why the incident occurred.  Once we have reconstructed the details surrounding the occurrence of the incident, we should proceed to determine what should be done to eliminate or control the hazards that caused the incident.  Finally, a follow up plan should be developed to see that the necessary changes are carried out.