No matter how committed an organization is to workplace safety, at some point an incident may occur. When that happens an incident investigation is conducted to get to the root cause and make corrective actions to ensure that incident doesn’t happen again.
While investigations are commonplace, organizations continue to struggle with executing them and are often displeased or discouraged with the results. That’s because incident investigations are riven with challenges that often present barriers to success. To have an effective process, organizations need to identify and understand these roadblocks and focus on improving their process for better outcomes. This article explores what causes incident investigations to fail and shares best practices to help move the process forward.
Safety professionals have been developing tools and systems to better evaluate a safety event and take appropriate action. The white paper, Re-framing Incident Investigation Using Visual Literacy explains that in recent years, increasing evidence shows that approaches are not yielding reliable data or driving suitable corrective actions. Something has gone wrong with incident investigations.
The white paper outlines the common barriers and problems organizations must overcome:
Incident investigations are critical to an organization’s safety culture. If there is lack of engagement in investigation activities and an organization isn’t seeing the desired results, then it’s time to consider the best practices below.
Develop a structured, consistent process.
A process isn’t set up for success when it lacks purpose, and role clarity, and when there are multiple exceptions and inconsistencies in execution. An organization must develop a structured process that is followed consistently in the event of an incident, no matter the level of the incident. The National Safety Council has a great process diagram that covers what to do before and after an incident happens.
Collect the right information. Many times, conclusions are drawn with limited data when it’s important to collect as much information up front as possible. Make sure to include the following data points when seeking and collecting information:
Ask the right questions to identify root causes.
From the information collected and interviews conducted, an organization can start getting to the root cause of why an incident happened. But, before getting there, more questions need to be asked to gather more details. What happened, how did it happen, and why did it happen are common questions to ask. OSHA digs even deeper.
Here is a sample:
Leverage safety management systems for preventive and corrective actions.
Trying to manage safety data in software applications such as Microsoft Word or Excel has its share of problems. There’s lack of version control, security, and accessibility, and the chance of data entry error runs high. That’s why every organization needs a reliable safety management system that collects, analyzes, and communicates incident data. A sophisticated system can help employees report incidents more easily especially if the system is readily accessible. It can also help managers generate custom performance reports and identify trends based on certain indicators like common root causes or incidents by day of the week, time of day, shift, and location.
Engage the entire team.
For a thorough investigation, an organization must engage the entire team. A cross-functional team includes the employees involved or closest to the incident, their team members, any witnesses, the supervisor, the safety department and may include human resources, maintenance and engineering. Having multiple perspectives helps identify the actual root cause(s) and contributing factors that led to the incident and can lead to accurate and prompt correction(s). Leadership must also play an active role in the investigation, so that the process runs as it should and so that the leader is aware of the entire situation and can properly communicate actions and solutions to the entire organization.
At the heart of an incident investigation is a desire to fully and properly understand how an incident/deviation unfolded. The best practices above help eliminate the biases and challenges that often surface when an incident happens and focus on developing an effective process. However, there is an element that is often not considered that adds another layer of clarity and value to the process. Visual literacy can be pivotal in both improving and elevating incident analysis.
The white paper discusses where and how visual literacy is beneficial:
An organization can have the best intentions when developing their incident investigation process, but too often it goes to the wayside when an incident occurs. Reactionary behaviors get the best of us all.
When an organization is able to address the factors blocking the intended path to incident prevention, and can properly collect and analyze the data needed for resolution, then it has the best chance for preventing future incidents and improving overall safety efforts. Organizations must make a shift in their approach and reframe the incident investigation process to create a new learning dynamic that effects change in both culture and safety performance.
Dive deeper into incident prevention and learn how visual literacy can help facilitate the investigation process when you download the white paper, Re-framing Incident Investigation Using Visual Literacy.