Incident Investigations – An Integral Component of a Safety Culture

Incident Investigations: An Integral Component of a Safety Culture

When any type of safety incident, accident, near-miss, or hazard is identified, it is important that the proper reporting procedures are followed in a timely manner.

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It is the responsibility of all managers to ensure their employees understand the importance of reporting all safety incidents or hazards immediately. As managers, we should make employees feel comfortable about reporting; if employees fear they will be punished in any way for reporting an incident, then no doubt many incidents will go unreported. It is the reporting of these incidents that will permit us to take steps in prevention of an injury in the future.

Definitions
– Incident: Any unplanned event resulting in or having the potential for injury, ill health, damage or loss.
– Accident: Commonly used to describe an incident which has resulted in an injury or damage.
– Near-miss: Any incident which could have resulted in injury, serious illness, or equipment damage. Reporting and sharing near-miss incidents is a key to improving safety.
– Hazard: A source or a situation with the potential for harm in terms of human injury or ill health.
– Accident investigation: The determination of the facts of an accident by inquiry, observation, and examination and an analysis of these facts to establish the causes of the accident and the measures that must be adopted to prevent its recurrence.

Key Points
– Investigations of incidents, injuries or hazards are not to be used as a means to assign BLAME. Any suggestion that assignment of blame or finding a “scapegoat” is intended would jeopardize the credibility of the investigation and reduce the quality and accuracy of information supplied.
– The investigation should occur as soon as possible. The less time between an incident and the investigation, the more accurate the information obtained. While concern for an injured person shall take precedence over everything else, when incidents involving injury or illness occur, early investigation is essential.
– The purpose of investigating incidents is to:
o Prevent similar incidents recurring in the future.
o Identify any new hazards.
o Implement suitable controls.
An Incident Investigation Process should be designed to uncover the facts of an incident, analyze those facts, determine the root cause, determine any contributing causes, and recommend & implement corrective actions aimed at preventing future occurrences.
The process below is is an example for investigation of safety incidents, accidents, near-misses and hazards.

Note that everything starts with the affected employee. If the employee decides to not report an incident, the entire process fails and an opportunity to prevent an injury is missed.

• By following the above process, we can determine the cause of an incident, implement actions to prevent future occurrences, and avoid the “blame game”.
• While unsafe human behaviour may end up as a cause in an incident, it is often the failure of safety management systems that led to or permitted the unsafe behavior.
• Yes, employees are responsible for their safety behavior; and management is responsible for having in place a safety management system that leads employees to want to use safe behavior at all times.
• An effective safety management system is an important part of developing a Culture of Safety; that point where safety becomes a core value that affects everything we do.