Effective incident investigations
Experts offer advice
When an injury, incident or near miss occurs, finding out why is an important first step. That’s where a robust investigation process can make a big difference.
“Investigating a worksite incident – a fatality, injury, illness or close call – provides employers and workers with the opportunity to identify hazards in their operations and shortcomings in their safety and health programs,” OSHA says. “Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents.”
Timing is everything
One important element of any investigation is timeliness. That’s, in part, because memories fade, or evidence may get discarded or moved.
The National Safety Council recommends securing the area where an incident or injury occurred and preserving the work area “as it is.” Another helpful step is documenting the scene of an incident with videos and photos.
“You want to understand the circumstances at that time, so you want to preserve things as best you can,” said Kevin Donohue, senior safety consultant at Indianapolis-based consulting firm Safety Resources.
Part of understanding what was happening involves trying to recreate the scene. Larry Pearlman, a managing director at JMJ, a consulting company headquartered in Austin, TX, once investigated an incident that involved a worker death at a pipeline project. Because a vehicle was involved, Pearlman needed to determine what the driver was seeing at the time of the incident to consider factors such as weather and visibility, which were recorded by the vehicle’s camera.
The sooner you can find potential hazards, the sooner they can be fixed.
“As long as that risk is present and unmitigated,” Pearlman said, “it represents a realistic threat to the safety of people, property and equipment.”
The interview process
Interviewing workers involved in an incident, or getting their written statements, is another crucial step in investigations.
“The purpose of interviews is to get the facts and find out what happened,” said JoAnn Dankert, senior safety consultant at NSC.
Still, it’s important to set parameters for what information is needed, Pearlman said. For example, interviewees should be instructed to give an account of what they saw and did, not their opinion or speculation on potential causes.
Key people to interview include the employee(s) involved in the incident, co-workers, witnesses, the supervisor in the area where the incident occurred, other workers who have done the same task as the injured employee and anyone from other relevant departments, such as maintenance or sanitation.
Interviews can be conducted in several places. For example, near the scene of the incident “in case you need to go out and reference information, people, tools or equipment,” Dankert said. If a more quiet setting is preferred, a conference room or private room is an option.
Donohue recommends interviewing workers individually “because sometimes people will fill in blanks with somebody else’s story that they just overheard” about the incident.
Associate Editor Alan Ferguson discusses this article in the August 2022 episode of Safety+Health's “On the Safe Side” podcast.
Although OSHA doesn’t explicitly require employers to investigate all incidents and near misses, the agency strongly encourages it.
JoAnn Dankert, senior safety consultant at the National Safety Council, points out that establishments are required to record certain types of injuries and illnesses (detailed in 1904.7) on an OSHA 300 log, as well as complete a Form 301 incident report (or equivalent) for each recordable injury or illness.
Form 301 includes questions that employers need to answer, such as, “What was the employee doing just before the incident occurred?” and “What happened? Tell us how the injury occurred.” The requirements to complete Forms 300, 301 and 300A are outlined in 1904.29 and apply to employers with more than 10 employees during a calendar year. That number applies to an entire company and includes part-time, contract or temporary employees.
Along with some small employers, OSHA provides partial exemptions for individual establishments based on North American Industry Classification System codes. The agency advises contacting its nearest office or State Plan office, or searching census.gov/naics, to find the NAICS code for your industry.
California and Washington are two State Plan states that require incident investigations, so checking your state’s regulations is recommended.
Dankert said the interviews and other information gathered during the investigation should help answer the five W’s: who, what, where, when and why?
- Who: Who was injured? Who witnessed the incident? Who responded first after the incident occurred? Who supervised the victim? Who trained the victim on the job? Who installed the equipment (if the incident involved a piece of equipment)?
- What: What happened? What was the victim doing at the time of the incident? What was the victim doing immediately before the incident? If this wasn’t the victim’s regular job, what’s their regular job?
- When: What time did the incident occur? What day of the week did the incident occur? When was the equipment last inspected and/or maintained?
- Where: Where did the incident occur? Where was the victim at the time of the incident? Where were the witnesses? Where was the supervisor?
- Why: Was the victim working in crowded conditions (for example, too close to another worker)? Was anything different or abnormal on the day of the incident, with respect to working conditions or the work being done? Was the job understaffed on the day of the incident or at the time of the incident (for example, if three people are needed to do the job safely, were all three people working and present)?
Dankert said other important questions to ask are:
- Has anyone been injured performing the same task, or while using the same tool or piece of equipment?
- Have any near misses occurred that involved the same task, tool or equipment?
- Were any concerns about the safety of the task, equipment or environmental conditions, etc., brought to management before the incident occurred?
OSHA advises looking beyond the “immediate causes” of an incident when conducting an investigation or analyzing the information gathered.
“It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone was the cause of an incident,” the agency says. “To do so fails to discover the underlying or root causes of the incident, and therefore fails to identify the systemic changes and measures needed to prevent future incidents.
“When a shortcoming is identified, it is important to ask why it existed and why it was not previously addressed.”
Pearlman gave the example of an incident at an auto parts factory. Nine of the 10 machines on the factory floor rotated clockwise. A maintenance employee working on the machine that rotated counterclock-wise stuck his hand inside and expected it to move clockwise.
“It moves counterclockwise and he gets an amputation,” Pearlman said. “You could say that, ‘Yeah, he shouldn’t have had his finger in there.’ True. But why did the employer have 10 pieces of equipment, nine working one way and one working the other way? The employer didn’t foresee that sort of risk.”
Another example: an incident that involved a backover fatality at a construction site. The ensuing investigation found that because of scheduling needs, the employer pushed trucks into service without rear-facing cameras or other technologies to detect a person behind the vehicle.
This case speaks to safety culture issues within an organization, rather than simply driver or pedestrian errors, Pearlman said.
“What was the equipment and what was the ordering process, and how did those all fit together to create the scenario that got that person killed that day? And that, to me, is all about the culture of the organization.”
What comes after
When an investigation is concluding, NSC says, it’s time to implement corrective actions and track them.
Information sharing is key. Pearlman said it’s a potentially overlooked part of the post-investigation process and has a cascading effect that includes standard operating procedures, training and other areas.
“You have an incident,” he said. “You have the corrective action, then you have to codify that corrective action. That means you have to go back and do policy and procedure updates, normally.
And if you do policy and procedure updates, you have to do training updates.”
Those updates can extend to orientation and audit practices, among others, Pearlman added. “There are a lot of areas that have to be addressed,” Donohue said. “The biggest mistake is, ‘We found all this and we didn’t do anything with it or about it.’”
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