Who should investigate?
Investigations should be led by supervisors, line managers, or other people with sufficient status and knowledge to make recommendations that the organization will respect. The person to conduct many investigations will be the Department Manager or Supervisor of the person/ area involved because they:
- know about the situation;
- know most about the employees;
- have a personal interest in preventing further incidents/accidents affecting ‘ their ’ people, equipment, area, materials;
- can take immediate action to avoid a similar incident;
- can communicate most effectively with the other employees concerned;
- Can demonstrate practical concern for employees and control over the immediate work situation.
When should the investigation be conducted?
The investigation should be carried out as soon as possible after the incident to obtain the maximum information. There may be difficulties that should be considered in setting up the investigation quickly – if, for example, the victim is removed from the accident site or if there is a lack of a particular expert. An immediate investigation is advantageous because:
- factors are fresh in the minds of witnesses;
- witnesses have had less time to talk (there is an almost automatic tendency for people to adjust their story of the events to bring it into line with a consensus view);
- physical conditions have had less time to change;
- more people are likely to be available, for example, delivery drivers, contractors, and visitors, who will quickly disperse following an incident, making contact very difficult;
- there will probably be the opportunity to take immediate action to prevent a recurrence and to demonstrate management commitment to improvement;
- Immediate information from the person suffering the accident often proves to be most useful.
Consideration should be given to asking the person to return to the site for the accident investigation if they are physically able, rather than wait for them to return to work. Although not as valuable, a second option would be to visit the injured person at home or even in hospital (with their permission) to discuss the accident.
Accident Investigation Method
There are four basic elements to a proper investigation:
- Collect facts about what has occurred.
- Assemble and analyze the information obtained.
- Compare the information with acceptable industry and company standards and legal requirements to conclude.
- Implement the findings and monitor progress
Information should be gathered from all available sources, for example, witnesses, supervisors, physical conditions, hazard data sheets, written systems of work, and training records. However, the amount of time spent should not be disproportionate to the risk. The investigation should explore the situation for possible underlying factors and the immediately obvious causes of the accident. For example, it would not be sufficient to conclude that an accident occurred because a machine was inadequately guarded in a machinery accident. It is necessary to look into the possible underlying system failure that may have happened.
Investigations have three facets, which are particularly valuable and can be used to check against each other:
- direct observation of the scene, premises, workplace, the relationship of components, materials, and substances being used, possible reconstruction of events and injuries or condition of the person concerned;
- documents including written instructions, training records, procedures, safe operating systems, risk assessments, policies, records of inspections or tests and examinations carried out;
- Interviews (including written statements) with persons injured, witnesses, people who have carried out similar functions or examinations and tests on the equipment involved, and people with specialist knowledge.
A detailed investigation should look at the following factors as they can provide useful information about immediate causes that have been manifested in the incident/accident.
- the behavior of the people involved
- suitability of people doing the work
- Training and competence.
- workplace conditions and precautions or controls
- the actual method of work adopted at the time
- ergonomic factors
- normal working practice, either written or customary.
Underlying and root causes
A thorough investigation should also look at the following factors as they can provide useful information about underlying and root causes that have been manifested in the incident/accident:
Underlying causes are the less obvious system or organizational reasons for an accident or incident, such as:
- supervisors did not make pre-start-up machinery checks
- the hazard had not been considered in the risk assessment
- there was no suitable method statement
- pressures of production had been more important
- the employee was under a lot of personal pressure at the time
- have there been previous similar incidents?
- Was there adequate supervision, control, and coordination of the work involved?
Root causes involve an initiating event or failing from which all other causes or failings arise. Root causes are general management, planning, or organizational failings, including:
- quality of the health and safety policy and procedures;
- quality of consultation and cooperation of employees;
- the adequacy and quality of communications and information;
- deficiencies in risk assessments, plans, and control systems;
- deficiencies in monitoring and measurement of work activities;
- quality and frequency of reviews and audits.