"How to Conduct an Incident Investigation - National Safety Council"

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How to Conduct
BLUE - Pantone 288
GREEN - Pantone 356
an Incident Investigation
Your company has just experienced an incident resulting in an
unintentional injury to a worker. Now what? Reacting quickly to the
incident with a prescribed procedure and actions can demonstrate
your company’s commitment to safety and ensure the proper
information is collected to fulfill an incident investigation’s ultimate
purpose – to prevent future incidents.
Steps in an Investigation Process
The investigation process should begin after arranging for first aid or medical treatment for
the injured person(s). In getting started, remind everyone involved—especially workers—
the investigation is to learn and prevent, not find fault. Steps of the investigation process
include:
1. Call or gather the necessary person(s) to conduct the investigation and obtain
the investigation kit.
2. Secure the area where the injury occurred and preserve the work area as it is.
3. Identify and gather witnesses to the injury event.
4. Interview the involved worker.
5. Interview all witnesses.
6. Document the scene of the injury through photos or videos.
7. Complete the investigation report, including determination of what caused the incident and
what corrective actions will prevent recurrences.
8. Use results to improve the injury and illness prevention program to better identify and
control hazards before they result in incidents.
9. Ensure follow-up on completion of corrective actions.
What to Include in the Documented
Investigation Process
As with many processes, preparation and documentation are crucial. As part of the injury and
illness prevention program, the investigation procedure should detail:
• Who should conduct and participate in the investigation
• Incidents to be investigated
• Information to be collected
• Identification of causal factors (often referred to as root causes)
• Determination of corrective actions
• Tracking completion of corrective actions
How to Conduct
BLUE - Pantone 288
GREEN - Pantone 356
an Incident Investigation
Your company has just experienced an incident resulting in an
unintentional injury to a worker. Now what? Reacting quickly to the
incident with a prescribed procedure and actions can demonstrate
your company’s commitment to safety and ensure the proper
information is collected to fulfill an incident investigation’s ultimate
purpose – to prevent future incidents.
Steps in an Investigation Process
The investigation process should begin after arranging for first aid or medical treatment for
the injured person(s). In getting started, remind everyone involved—especially workers—
the investigation is to learn and prevent, not find fault. Steps of the investigation process
include:
1. Call or gather the necessary person(s) to conduct the investigation and obtain
the investigation kit.
2. Secure the area where the injury occurred and preserve the work area as it is.
3. Identify and gather witnesses to the injury event.
4. Interview the involved worker.
5. Interview all witnesses.
6. Document the scene of the injury through photos or videos.
7. Complete the investigation report, including determination of what caused the incident and
what corrective actions will prevent recurrences.
8. Use results to improve the injury and illness prevention program to better identify and
control hazards before they result in incidents.
9. Ensure follow-up on completion of corrective actions.
What to Include in the Documented
Investigation Process
As with many processes, preparation and documentation are crucial. As part of the injury and
illness prevention program, the investigation procedure should detail:
• Who should conduct and participate in the investigation
• Incidents to be investigated
• Information to be collected
• Identification of causal factors (often referred to as root causes)
• Determination of corrective actions
• Tracking completion of corrective actions
Who is involved
- Normally, the investigation is conducted by the injured worker’s
immediate supervisor. However, assistance can also be provided by the safety practitioner,
or team members from an investigative or review committee or safety committee if such
teams exist. In cases involving a fatality, senior management personnel, engineering staff
or legal counsel may also be involved. Those participating in the investigation would
include the injured worker, witnesses to the incident or events preceding it, and the injured
worker’s immediate supervisor if some other person is conducting the investigation. The
injured employee may also request the presence of an employee representative during the
interview if contractual agreements are in place.
What gets investigated
- Any incident resulting in a fatality or serious injury should be
thoroughly investigated. To obtain the best possible data to aid in predicting and preventing
future incidents, it is also recommended that all recordable, first aid and near miss/close call
incidents be investigated.
- The type of information that should be collected during the
Information to collect
investigation process includes:
• Worker characteristics (age, gender, department, job title, experience level, tenure in
company and job, training records, and whether they are full-time, part-time, seasonal,
temporary or contract)
• Injury characteristics (describe the injury or illness, part(s) of body affected
and degree of severity)
• Narrative description and sequencing of events (location of incident; complete sequence
of events leading up to the injury or near miss; objects or substances involved in event;
conditions such as temperature, light, noise, weather; how injury occurred; whether
preventive measure had been in place; what happened after injury or near miss occurred)
• Characteristics of equipment associated with incident (type, brand, size, distinguishing
features, condition, specific part involved)
• Characteristics of the task being performed when incident occurred (general task, specific
activity, posture and location of injured worker, working alone or with others)
• Time factors (time of day, hour in injured worker’s shift, type of shift, phase of worker’s day
such as performing work, break time, mealtime, overtime, or entering/leaving facility)
• Supervision information (at time of incident whether injured worker was being supervised
directly, indirectly, or not at all and whether supervision was feasible)
• Causal factors (specific events and conditions contributing to the incident)
• Corrective actions (immediate measures taken, interim or long-term actions necessary)
What to have on hand
- To be prepared to complete an investigation promptly following
an incident, it is best to have prepared a kit ahead of time that includes:
• Investigation forms
• Voice recorder
• Interview forms
• Measuring tape
• Barricade markers/tape
• Flashlight
• Warning tags or padlocks
• Sample containers
• Camera or video recorder
© 2014 National Safety Council
Interviewing people
- Interviewing injured workers and witnesses necessitates reducing their
possible fear and anxiety, and developing a good rapport. Interviews should follow these steps:
1. State the purpose of the investigation and interview is to do fact-finding,
not fault-finding.
2. Ask the individual to recount their version of what happened without interrupting.
Take notes or record their response.
3. Ask clarifying questions to fill in missing information.
4. Reflect back to the interviewee the factual information obtained. Correct any
inconsistencies.
5. Ask the individual what they think could have prevented the incident, focusing
on the conditions and events preceding the injury.
– The purpose of all this fact-finding is to determine all the
Determining causal factors
contributing factors to why the incident occurred. Statements such as “worker was careless”
or “employee did not follow safety procedures” don’t get at the root cause of the incident.
To avoid these incomplete and misleading conclusions in your investigative process,
continue to ask “Why?” as in “Why did the employee not follow safety procedures?”
Contributing factors may involve equipment, environment, people and management.
Questions that help reveal these may include:
1. Was a hazardous condition a contributing factor? (defects in equipment/tools/materials,
condition recognized, equipment inspections, correct equipment used or available,
substitute equipment used, design or quality of equipment)
2. Was the location of equipment/materials/worker(s) a contributing factor? (employee
supposed to be there, sufficient workspace, environmental conditions)
3. Was the job procedure a contributing factor? (written or known procedures, ability to
perform the job, difficult tasks within the job, anything encouraging deviation from job
procedures such as incentives or speed of completion)
4. Was lack of personal protective equipment or emergency equipment a contributing
factor? (PPE specified for job/task, adequacy of PPE, whether PPE used at all or
correctly, emergency equipment specified, available, properly used, function as intended)
5. Was a management system defect a contributing factor? (failure of supervisor to detect
or report hazardous condition or deviation from job procedure, supervisor accountability
understood, supervisor or worker adequately trained, failure to initiate corrective action)
Completing report and documenting corrective actions
- At this point, once you’ve
gathered information and interviewed the involved worker and any witnesses, you can prepare
the investigation report itself and formulate corrective actions. Your company should have
determined who the report is sent to, within what time frame and what information gets
communicated to workers, management, or gets filed or posted. Each corrective action listed
should have a person assigned ultimate responsibility for the action, a completion date set and
a place to mark completion of the item.
© 2014 National Safety Council
Incident Investigation Process Diagram
Prepare
Determine:
• Create investigation and
• Who conducts and participates
interview forms
in investigation
• Document investigation procedures
• What incidents to investigate
• Select and train investigators
• What information to collect
• Prepare investigation kit
Incident
Enact
• Arrange for first aid or medical
• Interview injured worker
treatment of injured person(s)
and witnesses
• Secure the scene
• Document scene with photos
• Identify and gather witnesses
or videos
• Retrieve investigation kit
• Collect information
Nearly 11 workers die
on the job each day
Analyze
and 5 million are injured
• Review documentation
• Determine corrective actions
in the U.S. annually.
• Identify causal factors (root causes)
• Prepare report
The National Safety
using the “Why” method
• Communicate report
Council has launched
the Journey to
Safety Excellence
®
Campaign, with national
Correct
sponsor Grainger, to
help keep your workers
• Implement corrective actions
• Share information with others
safe. The Journey
• Track completion of corrective
• Critique process for continuous
provides you with free
actions
improvement
tools and resources to
make workplaces of any
size or industry safer.
For more information
and to become a part
Through the OSHA and National Safety Council Alliance, NSC developed this fact sheet for information purposes
of a growing online
only. It does not necessarily reflect the official views of OSHA or the U.S. Department of Labor. December 2014
community of safety
Under the Occupational Safety and Health Act, employers are responsible for providing a safe and healthy
practitioners, visit
workplace and workers have rights. OSHA can help answer questions or concerns from employers and workers.
OSHA’s On-site Consultation Program offers free and confidential advice to small and medium-sized businesses,
nsc.org/journey
with priority given to high-hazard worksites. For more information, contact your regional or area OSHA office, call
and join today!
1-800-321-OSHA (6742), or visit www.osha.gov.
© 2014 National Safety Council