Incident Investigation

In the past, the term "accident" was often used when referring to an unplanned, unwanted event. To many, "accident" suggests an event that was random, and could not have been prevented. Since nearly all worksite fatalities, injuries and illnesses are preventable, the Occupational Safety and Health Administration (OSHA) suggests using the term "incident" investigation.

Root causes of incidents are broken down into three levels: direct cause, indirect cause and basic cause. A direct cause is the result of physical contact with an object or hazardous substance and is usually the result of one or more unsafe acts, unsafe conditions or both. These unsafe acts and/or conditions are indirect causes, or symptoms. Unsafe acts and conditions are typically traceable to poor management policies and decisions or to environmental factors, which are known as basic causes. By eliminating one or more of the causes, many incidents are preventable.

Regardless of the cause, a follow-up incident investigation can assist in preventing future accidents in the workplace. OSHA strongly encourages employers to investigate all incidents in which a worker was hurt, as well as close calls (sometimes called "near misses"), in which a worker might have been hurt if the circumstances had been slightly different. Prompt reporting and recording of all injuries is essential for preserving the incident site and conducting a timely incident investigation.

An incident investigation form should be created to fit your company's specific needs. Your company's workers’ compensation insurance carrier may be able to provide you with an incident investigation form or you can create your own form to meet your company needs. At a minimum starting with the OSHA 301 form (Injury and Illness Incident Report) is suggested.

Incident investigation forms should consist of the following elements:

• Date and time: Identify incident date/year and the exact time the incident occurred.
• Location: Pinpoint the exact location of the incident including department and specific location within that department, and create a reference map direction/location identifier if necessary.
• Description of operations: Describe job activity performed by the injured employee and what led to the incident. Explain equipment/tool use and identify how this equipment may have been involved. If more than one of the same categories of equipment/tool is used for a certain job duty, identify the specific make, model and serial number of equipment/tool used when the incident occurred.
• Description of incident: Describe and review the chain of events that led to the incident, describe the actual incident and what occurred immediately after. Let the employee explain the sequence of events that led to the incident in his or her own words. Document the employee’s explanation of how and why the incident happened.
• Photographs taken: If need be, take photos of the incident location, equipment failure and process where the incident occurred.
• Interview the employee directly involved with the incident: Respond positively to the incident victim.
• Interview of witnesses: Interview employees working with and around the incident victim to review what they saw and how they interpret how the incident occurred.
• Measurements: If necessary, measure specific equipment and employee proximity to equipment where the incident occurred, e.g. machine guard location, etc.
• Supervisor/management acknowledgement: Confirm that direct supervisors have acknowledged that an incident occurred by having them complete an incident investigation form promptly when the incident occurs. Fulfill management acknowledgement by having the person in charge of safety investigate the incident and ensure that the investigative report is processed/routed to the appropriate management chain.
• Medical attention given: Identify if and what type of medical attention has been given following an incident. Confirm who completed the medical treatment and the type of treatment given, e.g. in-house first aid performed, first responders required, outside emergency help required.
• Follow-up recommendations: A summarization of the incident/near-miss identifying suggestions, recommendations and/or mandatory changes to be made per safety director and management should be completed promptly and forwarded to the supervisor where the incident occurred. Document an expected completion date and notify employee’s direct supervisor of this date to ensure that safety recommendations and/or changes are made to prevent future incidents. Depending upon the incident, such changes can include operations/job function changes and the way a job activity is performed, providing personnel protective safety equipment, repair and/or replacement of equipment/tools, developing a written policy or procedure, training or retraining of employees and/or supervisors, providing safety protective devices on or around machinery or equipment, etc.

Investigating a worksite incident—a fatality, injury, illness or close call—provides you the opportunity to identify not only the potential hazards, but also the shortcomings in your safety and health program. Most importantly, it enables your business to identify and implement the corrective actions necessary to prevent future incidents. Addressing root causes is necessary to truly understand why an incident occurred, to develop truly effective corrective actions, and to minimize or eliminate serious consequences from similar future incidents.

The procedures used for incident investigation provide an important function for preventing incidents from reoccurring. However, a comprehensive safety management system encompassing all areas of safety, including incident prevention, should be developed.

Sources

OSHA 1960.29

Accident Investigation Summaries OSHA 170 Form

Safety and Health Topics, Incident Investigation, Occupational Safety and Health Administration

The information contained in this article is intended for general information purposes only and is based on information available as of the initial date of publication. No representation is made that the information or references are complete or remain current. This article is not a substitute for review of current applicable government regulations, industry standards, or other standards specific to your business and/or activities and should not be construed as legal advice or opinion. Readers with specific questions should refer to the applicable standards or consult with an attorney.