Incident Investigation & Analysis: A Practical Approach
Incident Investigation and Analysis
Incident
An undesired event that results or may result in losses. If the result is presented as personal injury and/or property damage (loss), it is called an accident.
Accident
An unwanted event that disrupts the normal process of labor and results in damage to persons and/or damage to property.
Near Miss
An unwanted event having the potential to cause injury or property damage that, on this occasion, did not occur.
Investigation of Incidents/Accidents
A set of activities that can establish how an incident happened, determining actions, substandard conditions, and their underlying causes. It seeks to understand what happened, how it happened, why it happened, and how to prevent the incident/accident from occurring again.
Note
The accident investigation can inquire in depth about the causes and origins without stopping at the first causal finding. It facilitates or supports arguments and discussions about the incident, locating and sensing elements that contribute to its occurrence, discarding those that have no objective validity consistent with the incident.
Causal Model
Lack of Control: (Inadequate programs, inadequate standards, breach of standards)
Basic Causes: (Personal and work factors)
Immediate Cause: (Action and substandard condition)
Incident: (Contact with energy)
Loss: (Person, property, process)
Incident-Accident Analysis
The use of statistical information on accidents and incidents to establish hot spots, prioritize control measures, and take corrective action, carried out to prevent injuries to workers or property damage.
Role of the Supervisor in Incidents/Accidents
Supervisors have a vested interest to protect workers, as they have been involved in the generation of objectives for their area and share in the planning process. Furthermore, incidents/accidents impair their results and indicate that they have not been able to control some aspects of their objectives.
Supervisors must inform upper management of all accidents that occur in their area, in compliance with operational objectives.
Supervisors possess greater knowledge of the people and working conditions in their area. They know better how to obtain information, apply the necessary corrective measures, and instruct their staff on them.
Benefits
- Demonstrate concern for the safety of their workers.
- Learn to detect substandard actions and conditions.
- Assess their control over risks.
- Take corrective measures to prevent recurrence.
- Improve their image as a supervisor.
Action Immediately After an Incident/Accident
- Rescue the injured or those in danger.
- Provide first aid.
- Communicate and move, remove, or control any potential for additional losses.
- Identify and preserve evidence at the scene of the accident for a more detailed review later.
Gathering Evidence
The most important sources of evidence are people, in addition to documents, the relative positions of people and objects, and parts and components.
Steps for Proper Investigation
- Interview the injured person or those directly involved in the incident.
- Interview eyewitnesses to obtain their version of what happened.
- Informally interview witnesses whose involvement is not clear to help elucidate the causes.
Site Inspection
- Check the place where the incident occurred and its surroundings, looking for causes that had direct or indirect involvement in the accident.
- Check the condition of materials (manufacturing defects, material fatigue, premature wear, etc.).
- Check the condition of machines (critical or moving parts without protection, etc.).
- Check the condition of facilities (creation of confined spaces, non-standard facilities).
- Check other conditions (poor lighting, poor hygiene, flammable environments, etc.).
Reconstitution of the Incident/Accident
This involves recreating the unsafe act or condition without putting the injured person at risk. It is performed when the version of events casts doubt on what happened. The goal is to determine whether the versions agree or not with the reconstitution and to identify procedural changes or changes in environmental conditions that could improve safety.
Injured Person Interview
Due to fear on the part of workers, it can be difficult to interview the injured person. This fear may stem from potential ridicule, fear of discipline and loss of employment, or concerns about replacement of damaged items. The interview must be performed as accurately as possible to get closer to the truth and identify better control measures.
Effective Interview
The goal is to identify the causes of the accident, not to assign blame. The injured person should be asked to describe what happened without interruption. The interviewer should not try to score points or make the interviewee feel uncomfortable. It is important to establish what happened with relative certainty and to acknowledge that the interviewee’s version of the facts may be contrary to other versions. The interviewer should provide feedback and recommendations to the affected person, as they are often the best source of information on how to prevent similar incidents in the future.
Compilation and Analysis of Incident/Accident Data
This depends on the following:
Sources of Information: Data on past accidents or experience external to the organization can be valuable. Accidents can be controlled based on severity assessment and using operations research methods. The data collected must be in writing and signed.
It is important to remember that the incident/accident is a consequence and results in losses. These losses must not be repeated.
Management Function
Timely action by management is crucial to avoid problems with employees. When employees see that management is taking timely control measures to prevent the recurrence of an incident/accident with the same or similar characteristics, it builds trust and confidence.
The management function can be divided into:
- Defining an Investigation Policy: Raise awareness of the importance of investigation and highlight the involvement of workers in reporting incidents and accidents.
- Reviewing Performance: Management must be regularly advised of the outcome of investigations into incidents, corrective actions taken, and pending issues.
- Assigning Responsibilities: Set criteria and assign responsibilities to various levels of company management to investigate events.
- Personal Involvement: Management must participate personally in the investigation of significant events, understand the gears of the research program, and be informed of the control actions taken.
Incident Report
An incident report allows for the orderly and unified tracking of data collected in relation to failures in work operations, enabling statistical analysis and providing valuable information on causes and other phases of established programs.
Preparation of a Report
A relatively simple document designed to be used in any accident investigation, it has the following items:
- Identification: (Date of accident, incident report number, name of the supervisor)
- Description of Incident: Describes step-by-step what happened, including what contributed to the occurrence of the incident.
- Analysis of the Causes of the Incident: This is the core of the report, which identifies the causes of the accident and determines the appropriate action to prevent or control them.
- Assessing the Problem: Indicates the potential for the problem to reoccur and the potential loss if it repeats.
- Recommendations: Based on a careful analysis of what happened, provides a technical opinion and determines the corrective action to follow.
- Remarks: Any additional information the investigator deems relevant.