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Incident Investigation - An Opportunity

Originally created by the Minnesota Safety Council for publication in the Minnesota Counties Insurance Trust publication The Wellspring. Used with permission.

Organizations put a great deal of effort into safety and health initiatives. The reality is that regardless of the effort, injuries do occur. A strong incident program will have a positive effect on the frequency of future occurrences and the severity of the injuries. A safety program should be proactive, but an incident investigation is reactive. The purpose of the investigation is to use the information we gather to reduce future incidents.

What are the purposes and benefits of incident investigation?

The purpose of conducting an investigation is to identify the causes of the incident and eliminate them in order to prevent them from reoccurrences. Minor injuries that are promptly investigated and corrected may prevent more serious injuries and incidences form happening. A critical component to an effective investigation is documentation. The reasons for documenting include:
  • OSHA requires certain incidents and injuries to be reported on the OSHA 300 Log on an annual basis.
  • Employees/employers are required to submit First Reports of Injury to the department of Labor and Industry for workers' compensation claims.
  • The need for information in the event litigation occurs.
  • To track and identify injury patterns to help the employer prioritize safety efforts.
Quality incident investigations have other benefits that include:
  • Increased efficiency and productivity of affected positions.
  • Heightened level of safety awareness.
  • Reaffirms the employers commitment to safety and the well being of employees.
Should we have a written policy?

A written investigation policy/procedure can inform all employees about what is expected of them in response to an incident. The organization should determine in advance who will conduct investigations, when they will be done, and how they will be accomplished.

Employers should designate person, such as the injured employee's supervisor, perform the initial investigation and, if the injury is serious, have a team perform an in-depth, formal investigation. Written criteria can state when such a formal investigation is required, e.g., when an OSHA-recordable injury or serious near-miss occurs. The incident investigation policy should be included in the employer's Minnesota AWAIR program.

Who should investigate?

Persons that might be included on the investigation committee are:
  • injured employee's supervisor
  • safety coordinator
  • safety committee representative
  • management representative
  • collective bargaining representative or
  • outside consultant.
Persons who conduct investigations should be known for fairness and impartiality, and should receive training on investigation and interviewing techniques.

How do we perform effective investigations?

An investigation in intended to identify the causes of an incident. Unsafe acts and conditions that result in injury generally have an underlying reason. Reasons for the incident may be confusion about policies, insufficient training, and failure of the organization to enforce safety protocols, deficient prevention maintenance and inspections regiments. For example, an employee injury using a power tool may be the result of lack of training of personal protective gear.

An investigator or investigation committee is most effective when it identifies the basic or root causes for the incident and takes corrective action. For example: An investigation of an eye injury discloses that the supervisor does not enforce rules requiring wearing safety glasses when performing safety sensitive work. The supervisor and the injured employee may need to be disciplined for failing to abide by safety rules and employees may require additional personal protection awareness.

An investigation should always be documented. The written report can be shared with the safety committee to prevent further incidents of a similar nature. A Workplace Accident and Injury Reduction (AWAIR) Act requires the findings of an investigation be documented.

1. Choose a problem to solve based on:
a. Degree of risk.
b. Seriousness of potential outcomes.
2. Gather information.
3. Clarify the problem. What are the direct, indirect, and root causes?
4. Brainstorm potential solutions.
5. Select the best solution.
6. Devise a plan.
7. Follow the plan.
8. Get feedback on the effectiveness of the solution.
9. Modify the plan.
10. Follow up.

A Practical Tip

Some employers find it helpful to maintain an incident investigation kit, which keeps all the items needed for an investigation conveniently available. Some items that might be included are:
  • reporting forms
  • pencils, pens
  • paper, notebook
  • written investigation procedure
  • camera, film, extra batteries
  • tape recorder, tapes, batteries
  • measuring tape
  • flashlight, batteries
  • personal protective equipment
  • barrier tape, signs
Strive to avoid injuries. If one does occur, see it as an opportunity to investigate, find root causes, and initiate positive changes.
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