Incident Investigation Technical Bulletin

You know that saying, “Accidents happen”?

Well, it just so happens that incidents happen too. However, when an incident occurs, it’s not enough to simply say, “Incidents happen!” By following the proper procedures, you can prevent workplace incidents from happening again in the future!

Dust off your magnifying glass and dig out your old trench coat…

Because investigation is required whenever there is an injury, an illness, an environmental release, or a near miss.

Why investigate?

As if the opportunity to channel your inner Sherlock Holmes wasn’t enough of an incentive to perform incident investigations, I dug up some other important reasons. Incident investigations can help you to:

• Prevent future incidents
• Evaluate and improve internal programs
• Comply with federal regulations
• Reduce workers’ compensation costs

Incidents are COSTLY!  There are direct costs and indirect costs of every incident.

Direct costs include:

• Compensation payments
• Medical costs
• Insurance costs

Indirect costs include:

• Time lost from job
• Lost efficiency of co-workers
• Manager’s lost time
• Training new replacements
• Negative press

“You know my methods, Watson.”

Every good detective knows that no two cases are identical, which means that there is no single method that works best for all cases. It’s best to be familiar with several different techniques; that way you can use whichever one best suits your needs for any given incident!

Some techniques include:

• 5 ‘Why’s
• Failure Mode and Effect
• 3 ‘E’s (Education, Enforcement, Engineering)
• MORT—Management Oversight and Risk Tree
• Fishbone Diagrams
• 4 ‘M’s (Man, Machine, Media, and Management)

Don’t let anything slip through the cracks.

The most important steps to remember are:

1. Go to the incident site and perform a walkthrough
2. Conduct interviews from the “center” out
3. Ask for suggestions to prevent a reoccurrence
4. Document corrective actions, responsible parties, and target dates
5. Track implementation until corrective action is completed
6. Document the completion date
7. SHARE THE RESULTS WITH OTHERS

Tips and Tricks

• Choose a location away from the public in a private room/area (Depending on the nature of the incident, the interview may be conducted at the incident scene.)
• Conduct interviews one at a time
• Do not refer to anything that another witness said
• Take notes and be an active listener (listen more than talk)
• State the objectives of the investigation
• Remind the person that management is not trying to fix blame
• Eliminate outside influences (press, associates, visitors, etc.)
• Ask the witness to re-enact what he/she saw
• Make sure the interview answers: who, what, where, when, and how.
• Ask for suggestions on ways to prevent a reoccurrence

CASE CLOSED

The evidence is undeniable: Incident investigations are the best way to prevent future incidents, decrease incident-related costs, and—most importantly—keep your workers safe!

This is Smart Alex, exclaiming: “It was Scarlet! In the Study! With the Candlestick!

—Oh, wait… wrong type of investigation…