Despite all of our best efforts to prevent an incident, they still occur. A thorough post-incident investigation is an effective way to prevent injuries and illnesses from recurring. The investigation must focus on finding the hazard(s) that existed that resulted in the incident and taking measures to correct or eliminate the hazard(s).
The investigation should start as soon as possible after the incident is reported. Getting to the scene of the incident quickly is critical. You want to see the incident scene before it gets disturbed, changed, or cleared up. Interviewing the victim(s) and witnesses before they forget what happened will help put together the complete picture of what occurred. An incident or near-miss cannot be investigated if it is not reported promptly. All incidents (including near misses) must be reported as soon as possible. Elements of an incident investigation include preparation, on-site investigation, and development of a report with recommendations for prevention.
Being prepared for an investigation before one occurs is essential. Any employees (management, workers, safety personnel, etc.) must be trained in investigation procedures. A process for notification for when an incident occurs must be in place so that all investigators can mobilize and arrive on-scene quickly. A system should be developed to ensure all information is gathered. Forms and checklists can be created ahead of time and used to train those investigating the incidents.
Once the investigators arrive on the scene, two main tasks must be the focus; collecting the evidence at the scene and conducting interviews. The first step in collecting the evidence at the scene is documentation. As you arrive and approach the scene, this task starts. Start taking pictures and videos as you approach the scene. Remember, you want to get the condition of the incident scene without disturbing it. A good practice is to write notes referencing the pictures taken. These written notes might include measurements, sizes, and other things that might not be clear in the photos. If you are taking a video of the scene, these notes can be spoken aloud to capture it in the video. Some of the information you should be collecting include:
- Equipment or machines involved (include manufacturer, model, and operator).
- Condition of the equipment.
- Tools used.
- Environmental conditions, including air temperature, noise, lighting, and anything else that may have contributed to the incident.
- Conditions of the surfaces.
- Physical obstacles.
All interviews should be conducted away from the scene of the incident. A conference room, a quiet area in a job site trailer, anywhere other than at the scene. You want to reduce any distractions. The purpose of the interviews is to get the facts and find out what happened according to the person’s point of view in the discussion. The questions aimed at getting the facts are the who, what, when, where, and why questions. Keep the questions open-ended; phrase the question to avoid a simple yes or no answer.
Based on the information collected in the investigation, the root cause(s) of the incident will be determined, and recommendations for prevention will address the root cause(s). Whenever a recommendation is presented, it should address:
- Issues related to the specific incident.
- Matters related to similar situations, conditions, and equipment.
- Management system deficiencies.
- Evaluation of the present controls and prevention actions.
- Any controls and prevention actions that need to be implemented.
Upon completion of the report, copies should be made available to all of the incident investigation participants. The report must be honest. It cannot hold back any recommendations or deficiencies. In conclusion to the incident investigation, any changes to policies and procedures will need to be made, and re-training on those changes will need to occur.