Safety Leadership

Safety Leadership: It’s time to rethink incident investigations


Editor’s Note: Achieving and sustaining an injury-free workplace demands strong leadership. In this monthly column, experts from global consulting firm DEKRA share their point of view on what leaders need to know to guide their organizations to safety excellence.

Have we overly complicated incident investigation to the point that it’s nearly impossible for organizations to keep up with them effectively? Are incident investigations done to “please” the software? Would the time spent on incident investigations be better spent on prevention?

The answer to all three questions is yes. Investigations can be simplified, and organizations are better off spending time monitoring and responding to weaknesses in their risk management system.

We’re not suggesting that organizations abandon investigations. Instead, we’re challenging the paradigm that treats every incident as though it’s unique.

Identifying incidents with serious injury and fatality potential is a positive and important shift for the safety field. It allows organizations to drive investigation activities based on an incident’s potential. This approach works well for any incident, whether it involves process safety or personal safety.

However, if the existing investigations system is substandard and getting to the root causes is a challenge, the additional investment in investigative resources only results in more confusion about causation and ineffective corrective actions.

We also see many organizations stuck in a paradigm of looking at incidents individually without learning from previous, similar incidents. Although longitudinal analysis of incident data is helpful, it doesn’t typically identify fundamental deficiencies in exposure control management systems.

We have to ask ourselves: If we have three “fall from height” events, does it make sense to do three time-consuming root cause investigations? It’s doubtful the three incidents were independent.

Starting at the beginning

The purpose of an incident investigation is to understand two things:

  • Which factors existed that influenced people to make decisions contrary to controlling the exposure?
  • Which elements of the risk management process failed, leading to an exposure that remained unidentified and/or uncontrolled?

This means putting the exposure into context. An uncontrolled SIF exposure results from a breakdown in the risk management process. If the SIF exposure was scheduled (a planned working from height, etc.), then a failure to control the exposure is without a doubt a breakdown in management system controls – if they even exist. If the SIF exposure was unscheduled (a machine suddenly jams and a quick decision is made), understanding the context of decision-making is important. For example, decision-influencing factors such as urgency pressure, safety climate and fatigue can be greater in unscheduled exposures.

In the personal safety space, the exposures that create SIF potential are limited – usually fewer than 10. At the operational unit level, the list is often even smaller. Therefore, it’s feasible to have a targeted SIF prevention program for each SIF exposure.

In process safety, the number of exposures that can cause SIF incidents is larger but still manageable. The key is to prioritize the list and work from highest frequency of occurrence to lowest frequency of occurrence.

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