OSHA incident investigation procedures may be more complicated than one might think. Investigating an incident in the workplace entails looking beyond the immediately available or perceptible information. This means that if someone gets hurt at work because they slipped on a puddle, for example, the incident report should reflect far more than the immediate facts of the incident.
Thorough incident investigations involve approaches that allow employers and employees to address any shortcomings and gaps in safety measures. By aiming to find the root causes of an incident, employers and employees will be able to prevent future incidents and make the workplace safer for all involved.
Contents
- Case Study
- Part 1: Incident Investigation Basics
- Part 2: Incident Investigation Principles
- Part 3: The 4-Step Systems Approach
- Part 4: Final Steps
Importance of OSHA Incident Investigation
Incident investigations are essential for identifying the root causes of workplace accidents and preventing their recurrence. OSHA regulations strongly encourage conducting these investigations, not only for compliance but also to foster a culture of safety.
Conducting thorough investigations helps organizations learn from incidents, implement corrective actions, and ultimately create a safer working environment.
Investigation Methodologies
Effective incident investigations utilize various methodologies to uncover the root causes of workplace accidents and develop preventive measures. Key methodologies include:
- Root Cause Analysis (RCA): Under RCA, the investigation occurs first, where all relevant facts are gathered, including data collection, witness interviews, and evidence analysis. These facts are then used to support the root cause analysis findings.
- Failure Modes and Effects Analysis (FMEA): FMEA is a proactive tool used to identify potential failure modes and their effects on system performance. By analyzing the likelihood and impact of different failures, organizations can prioritize risks and implement preventive measures.
- Casual Factors Classification: Derived by the National Safety Council (NSC), this methodology involves analyzing human error, equipment failure, environmental conditions, procedural deficiencies, and organizational issues. Safety committee members identify causal factors through thorough data collection, interviews, and analysis.
- Human Factors Analysis and Classification System (HFACS): HFACS focuses on human error and its contribution to incidents. By categorizing different types of human errors, this method helps organizations understand how human factors influence safety and develop strategies to reduce errors.
- TapRooT®: TapRooT® is a structured approach to incident investigation that uses root cause analysis to identify underlying problems. It involves a series of steps, including data collection, timeline creation, and root cause identification, to develop effective corrective actions.
Case Study
For this article, we’ll work with a case study involving an incident in the workplace.
We have a manufacturing facility with machines that need to be periodically cleaned. Per the employer’s established procedures and practices, the machines are not shut down during cleaning, exposing employees to moving machine parts.
According to the employer, the OSHA Standard 29 CFR 1910.147, or the Control Of Hazardous Energy (Lockout/Tagout), does not apply. The employer reasons that the cleaning takes place during normal operations.
An employee begins cleaning the machines without turning them off and performing lockout tagout, which is consistent with the employer’s prescribed practices. While cleaning, a large moving part on one of the machines strikes the employee’s shoulder and causes an injury.
Part 1: Incident Investigation Basics
What are worksite incidents?
According to OSHA, a worksite incident is “a fatality, injury, illness, or close call.” Incidents are events in which someone gets hurt on the job.
You’ll notice that the term also encompasses close calls or near misses–these are events in which someone was close to getting hurt but did not. This means that all incidents have to be investigated, regardless of the severity of the injury, and regardless of whether or not an injury occurred. If someone could have gotten injured in a certain situation, it counts as an incident.
Who conducts incident investigations?
While employees have a vital role to play in incident investigations, supervisors and management are ultimately the ones responsible for conducting investigations. Management and employees have to work together during the course of incident investigations.
Supervisors and managers have to facilitate the following things:
- Securing the area in which the incident occurred
- Ensuring that the injured person receives proper medical care
- Beginning the investigation soon after the incident
- Notifying the right personnel, institutions, agencies, and the like
- Identifying physical evidence, witnesses, and other possible sources of information about the incident
- Gathering information
- Ensuring that the investigation correctly identifies the root cause of the incident
- Meeting regulatory and company requirements regarding worksite incidents
- Analyzing past incidents and identifying possible trends
- Identifying hazards and how to prevent them
Employers need to have a clear process in place where employees are trained on how to report incidents. This process should emphasize that all injuries and incidents, no matter how minor, must be reported. Additionally, employees should be assured that they can report incidents without fear of reprimand or repercussion, fostering a culture of transparency and safety in the workplace.
What is the purpose of an incident investigation?
It’s important to remember that the purpose of an incident investigation is not to find and assign blame. Taking this approach can lend an antagonistic tone to the investigation, which will likely make employees less likely to cooperate and thus affect the investigation’s outcome.
Incident investigations aim to achieve the following:
- Identifying the root causes of the incident
- Identifying corrective measures to prevent future incidents
- Improving morale among employees
- Increasing productivity
- Demonstrating that the employer values workplace safety
The tone of an investigation must be constructive. Instead of framing the investigation as an effort to find out who or what is at fault, management should instead take a more neutral approach. The investigation must focus more on what exactly happened, which system failure occurred, and what the company can do to prevent the incident from happening again.
When should incident investigations occur?
Employees must report incidents very soon after they occur, and employers must conduct incident investigations on time.
The timeliness of reporting and investigating is crucial. If an employee reports an incident weeks after it occurred, it can have an impact on the investigation. Witnesses may forget crucial details after some time and physical evidence may already be tampered with. Not only can this prolong the investigation, but it can also affect the accuracy of the outcome.
Part 2: Incident Investigation Principles
Use the Correct Terms
Using the correct words and terms during an investigation can help ensure that employers, management, and employees are in the right frame of mind. These particular terms are important when conducting a workplace incident investigation:
Incident vs Accident
OSHA previously used the word “accident” to refer to fatalities, injuries, illnesses, and close calls that happen in the workplace. However, “incident” has since replaced “accident.” This is because describing an event as an “accident” makes it seem like the event is unpreventable. However, most of these events are preventable. Thus, the term “incident” is considered to be more accurate.
Close Call or Near Miss
A close call or a near miss is an event that almost caused an injury but did not. Going back to the case study, a close call is when the employee was able to dodge the machine’s moving parts. In this situation, the employee was just a few inches out of the reach of the moving parts and was therefore able to walk away unscathed.
Root Causes
Root causes are oftentimes not the immediately observable cause of an incident. If an employee is struck by a machine’s moving part and gets injured as a result, the root cause of the incident is not the machine’s moving part. The root cause is likely a system failure — managerial, organizational, or operational failings that led to the conditions that eventually caused the worker injury.
Surface Causes
Surface causes are specific hazards or behaviors. These include personnel errors, insufficient maintenance, hazardous environments, and the like. In the case study, the surface cause is the employee getting too close to the machine’s moving parts.
Direct Causes
Direct causes are the results of behaviors and/or physical contact with certain hazards. In the case study, the direct cause of the injury was the machine’s moving part, which then struck and injured the employee.
Follow the Systems Approach
One important principle to remember is that incident investigations focus on systems, not behaviors. Going back to the case study, it can be easy to conclude that the incident occurred because the employee got too close to the machine and was unable to avoid its moving parts.
By focusing on individual behaviors, the investigation will:
- Assign blame, which can be counterproductive and affect employees’ cooperation with the investigation
- Not be able to identify any measures that employers and employees can take to prevent future incidents
Using the systems approach is more productive and avoids the assignation of blame on specific individuals. With the case study, the systems approach will lead the investigation to identify actionable system failures that led to employee injuries. The possible system failures in this example can be defective equipment, lack of training, poor surface maintenance, or failure to eliminate identified hazards.
Focus on Root Causes
Incident investigation root cause analysis identifies 6 categories of system failures, also known as root causes. These are:
- Materials
- Machine/Equipment
- Environment
- Man
- Methods
- Management System
Dealing with the surface causes of an incident without getting to the root cause of the issue is a band-aid solution. Simply reminding employees to be careful when performing maintenance on machines, for example, deals with the issue on a surface level. Mistakes can still happen in the future, and the problem will continue.
The root cause of the problem in the case study is the absence of an effective lockout tagout program that will protect employees. The employer also needs to invest in durable lockout tagout devices, such as valve locks or circuit breaker locks. By recognizing this, the employer will be able to take the necessary steps to protect employees from injury in the future.
Identifying the root cause and focusing on it instead makes it more unlikely for the incident to happen again. This is a more constructive approach that improves workplace safety and employee morale all at once.
Part 3: The 4-Step Systems Approach
Preserve/Document the Scene
Once an incident has occurred, prevent access to the area. This will prevent physical evidence from being removed or tampered with. Once investigators preserve the scene, they will have to document the facts of the incident.
Investigators use a few tools to document a scene. These include:
- An incident investigation form
- An incident investigation kit
- Cameras for taking videos and photos
- Pencils and paper for sketching the scene
- A tape measure to accurately measure and document distances and dimensions
- Cameras are useful in documenting the scene of an incident.
Collect Information
Investigators should have an incident investigation checklist to ensure that they collect as much information as possible. This checklist should include ways to find details such as the identities of the persons involved in the incident, the location of the incident, the supervisor in charge at the time of the incident, and so on.
Interviews are often a highly effective way to collect information. The incident investigation interview questions should therefore be as detailed as possible and should be formulated to help the investigator arrive at the root cause of the incident.
However, the timing of interviews is crucial. This is why an incident investigation must happen within a certain time frame. Investigators need to conduct interviews while memories are still fresh. It’s best to conduct the interview very soon after an incident has occurred, ideally right after the area is deemed safe. This way, the information the witnesses provide during the interviews is more likely to be accurate and detailed.
Investigators can also peruse various documents for more information. These documents include:
- Manuals
- Company policies and records
- Reports
- Maintenance schedules
- Audits
- Recommendations for corrective actions
Determine the Root Causes
The previous discussion on root causes above was more about why it’s important to identify system failures in incident investigations. This discussion focuses more in detail on how to determine the root causes of an incident.
Determining the root cause of an incident entails pursuing a logical line of thought and repeatedly asking why things occurred the way they occurred.
Take again the circumstances in the case study. These are some questions that an investigator might ask in this situation:
- Was there a failure in following cleaning and maintenance procedures? If so, why?
- Was there any incentivizing deviation from established procedures, such as the faster completion of tasks? If so, why has this problem not been previously identified?
- Are there any alternative measures instead of a lockout tagout that can help safeguard workers against the machines’ moving parts? If so, were these alternative measures put in place?
- Are these alternative measures sufficient in protecting workers against injury? In what ways can they be improved?
- Was there a failure to properly identify and/or report issues with the established cleaning procedures? If so, why?
Answers like “the employee failed to take alternative protective measures,” or “the employee was standing in the way of the moving part” are insufficient. Thorough investigations involve digging more deeply into these answers to find the root cause of the problem.
This line of questioning will lead to the root cause, which can then lead to solutions that will prevent the problem from recurring.
Implement a Corrective Action
Once the root cause has been identified, the company has to take corrective actions. Corrective action plans have to directly address the root cause and should not be band-aid solutions.
For example, marking a spot on the floor where workers should stand when cleaning the machine can help them stay out of the way of moving parts. However, it does not address the root cause of the issue and it will not effectively prevent future injuries.
While corrective actions can directly address issues that contribute to the occurrence of worksite incidents, corrective actions can also be more general. Corrective actions like these can take the form of changes in policies, developing new safety programs, changing inspection procedures, and the like.
Part 4: Final Steps
Recommending Improvements and Corrective Actions
Recommending changes that a company has to make to improve workplace safety is an important part of an incident investigation procedure. These recommendations should be focused on the following:
Engineering Controls
Engineering controls are measures and solutions that protect workers from hazards by eliminating or reducing hazardous conditions. Some examples include ventilation systems, barriers, containment of hazardous materials, and the like.
Management Controls
Management controls seek to protect employees from hazards by regulating and modifying behaviors. One example of this is the use of lockout tagout devices, which can help prevent employees from operating machines that are under maintenance or servicing.
While these solutions are important in the workplace, it’s important to remember that management should not rely on management controls alone to maintain workplace safety.
Temporary Measures
Temporary measures are quick fixes that will suffice in the meantime, but not for long. These measures lend the company more time to develop more long-lasting solutions while keeping employees safe from hazards.
Incident Investigation Report
Who fills out the incident investigation report? Once the investigation is over, investigators will have to write a report on their findings. A complete workplace incident report includes the following parts:
Background
This section includes the name of the victim and the details of the witnesses to the incident, such as their names, addresses, contact details, job titles, and length of service. The background also includes the date and time of the incident, the date and time that the incident was reported, and where the incident occurred.
Description of the Accident
In this section, the investigator has to describe how the incident unfolded, including the details of relevant events that occurred before, during, and after the incident.
Findings and Justifications
The investigator has to describe the surface and root causes of the incident. In the case study, the investigator can write that the surface cause is the employee standing in the wrong place while cleaning the machine. The root cause, meanwhile, is the absence of a lockout tagout.
This section will also have to include justifications for the findings, in which the investigator presents their data or any proof of their findings.
Recommendations and Results
The investigator also has to include any corrective action taken by the company. These include corrective actions that address surface as well as root causes. Thus, the investigator will have to describe any actions that seek to eliminate hazards as well as any revisions or additions to programs and procedures.
Summary
This section details the estimated costs of the incident, as well as the amount that the company will have to invest in corrective actions.
Review
At the end of the report, the investigator has to describe corrective actions and system improvements taken by the company, as well as the individuals responsible for these measures. The investigator also has to identify any individuals responsible for following up on corrective actions and improvements.
OSHA incident investigation reports are often considered to be an open document until management takes all corrective actions to address the incident. However, even when the matter is closed, companies will still have to periodically assess and evaluate their incident investigation techniques and the effectiveness of the corrective actions they implemented.
Common Incident Investigation Mistakes
Mistakes in incident investigations do happen, often compromising their effectiveness and potentially leading to recurring workplace accidents:
- Insufficient evidence gathering can lead to an incomplete understanding of the incident.
- Allowing personal biases or assumptions to influence the investigation can skew findings.
- Emphasizing individual blame rather than identifying systemic issues hinders the development of effective solutions.
- Inadequate training for investigators can result in poor-quality investigations.
- Overlooking near misses means missing opportunities to identify and address potential hazards.
- Insufficient or unclear documentation creates confusion and hampers the implementation of corrective actions.
- Delaying the investigation can result in the loss of critical evidence.
- Focusing only on immediate causes without considering contributing factors leads to incomplete corrective actions.
- Identifying corrective actions but failing to implement them results in repeated incidents.
- Neglecting to monitor the implementation and effectiveness of corrective actions prevents verification of their success.
Incident Investigation Training
Incident investigation training is crucial for maintaining workplace safety and strict compliance with OSHA regulations. It is essential for various organization roles, including supervisors, managers, safety officers, EHS professionals, designated accident investigation teams, human resources personnel, safety committee members, and general employees.
This training equips them with necessary skills such as evidence collection, witness interviewing, and documentation. An incident investigation course covers root cause analysis, regulatory requirements, data analysis, reporting techniques, and the development and implementation of corrective actions.
Technology in Incident Investigation
Technology plays a vital role in enhancing the efficiency and effectiveness of incident investigations. Automated tools and modern software can streamline data collection, analysis, and reporting processes. For example, digital incident reporting systems allow for real-time data entry and access, improving the accuracy and speed of information gathering. Advanced data analysis tools can help identify patterns and root causes more effectively.
Additionally, technologies like video surveillance, mobile apps, and drones can provide valuable evidence and insights during investigations. By integrating these technologies, organizations can conduct more thorough and timely incident investigations, ultimately less injuries and leading to safer workplaces.
Incident Investigation FAQs
What are the information needed for incident investigation?
Incident investigation mandates detailed information, including the date, time, and location of the incident, a description of the events leading up to and during the incident, witness statements, physical evidence, and any relevant documentation such as safety records and equipment maintenance logs.
Why is it important to report all incidents?
Reporting all incidents is crucial for identifying hazards, preventing future occurrences, improving workplace safety, and ensuring compliance with regulatory requirements. It also helps in maintaining accurate records and fostering a culture of safety.
When should you begin an incident investigation?
An incident investigation should begin as soon as possible after the incident occurs to preserve evidence, gather accurate witness accounts, and quickly identify the causes to implement a corrective action.
What is an incident investigation plan?
An incident investigation plan outlines the procedures and steps involved during an investigation, including roles and responsibilities, methods for collecting and analyzing data, documentation requirements, and timelines for completing the investigation.
Who needs to be involved in incident investigation?
An incident investigation should involve supervisors or managers, safety officers or EHS professionals, safety committee members, human resources personnel, and, if necessary, external experts or consultants. It may also include employee representatives and witnesses.