What went wrong? That’s the first question that comes to mind when any incident occurs. If an incident happens in your facility, learning what went wrong is just the first step in preventing future accidents. Using best practices for incident investigation paired with root-cause analysis can provide a solid foundation for fine tuning your serious-injury prevention strategy.
It’s not just a best practice to consider, in fact, OSHA urges food companies to investigate every single incident that results in an injury no matter how small. Companies should also review and document their “near misses” where someone might have been hurt if the circumstances were slightly different.
How to structure your investigation:
Make a plan: Effective incident investigation starts before an accident occurs with a step-by-step procedure
Designate your investigation team: The incident investigation team should be organized before an accident happens so team members can be trained in investigation procedures
Train your investigation team: The team needs to understand the 5 W’s of incident investigation – Who? What? When? Where? Why?
When to Investigate
Doing a little detective work following a worksite incident— a fatality, injury, illness, or close call— provides an opportunity for your staff to identify hazards in their daily activities and share what shortcomings a company may have in safety and health programs. Most importantly, it enables workers to take ownership of safety standards on the frontline.
What you need to cover in your investigation
1. Get the facts
Gather objective evidence - pictures/video, interviews, re-enactments, witness statements, training records, maintenance and PM records, prior incident history, etc.
2. Determine all the contributing factors
- Environmental – Light, vapors, dust, heat, and weather
- Design – Work station layout, tools used, and equipment
- Systems and Procedures – Evaluate whether SOP’s are appropriate and effective
- Human behavior – Safe or at-risk habits, proper training, and prior incidents
3. Determine root cause
Isolate the top factor that contributed to the incident and formulate a plan for change.
4. Establish and implement corrective actions
Once root cause is determined, formulate a plan to change the status quo for the better. Schedule and complete all actions needed to correct any shortcomings you find.
5. Communicate findings and key lessons learned
Determine what methods you’ll use to raise awareness of safety standards throughout the company and be sure everyone understands their role. Some things to consider:
- Do you need to update your training materials?
- Is re-training required?
- How will supervisors conduct on-the-job observations to ensure behavior change?
Incident investigations are key to preventing reoccurring incidents. Take the time to conduct a thorough investigation, then quickly implement changes. You’ll improve the work environment, increase productivity, and sustain a culture of safety in your operation.