Why investigate incidents

A later study of the pictures may reveal conditions or observations that were missed initially. Sketches of the scene based on measurements taken may also help in later analysis and will clarify any written reports. Broken equipment, debris, and samples of materials involved may be removed for further analysis by appropriate experts. Even if photographs are taken, written notes about the location of these items at the scene should be prepared.

Although there may be occasions when you are unable to do so, every effort should be made to interview witnesses. In some situations witnesses may be your primary source of information because you may be called upon to investigate an incident without being able to examine the scene immediately after the event. Because witnesses may be under severe emotional stress or afraid to be completely open for fear of recrimination, interviewing witnesses is probably the hardest task facing an investigator.

Witnesses should be kept apart and interviewed as soon as possible after the incident. If witnesses have an opportunity to discuss the event among themselves, individual perceptions may be lost in the normal process of accepting a consensus view where doubt exists about the facts.

Witnesses should be interviewed alone, rather than in a group. You may decide to interview a witness at the scene where it is easier to establish the positions of each person involved and to obtain a description of the events. On the other hand, it may be preferable to carry out interviews in a quiet office where there will be fewer distractions. The decision may depend in part on the nature of the incident and the mental state of the witnesses. The purpose of the interview is to establish an understanding with the witness and to obtain his or her own words describing the event:.

Ask open-ended questions that cannot be answered by simply "yes" or "no". The actual questions you ask the witness will naturally vary with each incident, but there are some general questions that should be asked each time:.

Asking questions is a straightforward approach to establishing what happened. But, care must be taken to assess the accuracy of any statements made in the interviews. Another technique sometimes used to determine the sequence of events is to re-enact or replay them as they happened. Care must be taken so that further injury or damage does not occur.

A witness usually the injured worker is asked to reenact in slow motion the actions that happened before the incident. Data can be found in documents such as technical data sheets, health and safety committee minutes, inspection reports, company policies, maintenance reports, past incident reports, safe-work procedures, and training reports.

Any relevant information should be studied to see what might have happened, and what changes might be recommended to prevent recurrence of similar incidents. At this stage of the investigation most of the facts about what happened and how it happened should be known. This data gathering has taken considerable effort to accomplish but it represents only the first half of the objective. Now comes the key question - why did it happen? Keep an open mind to all possibilities and look for all pertinent facts.

There may still be gaps in your understanding of the sequence of events that resulted in the incident. You may need to re-interview some witnesses or look for other data to fill these gaps in your knowledge. This is not extra work: it is a draft for part of the final report. Each conclusion should be checked to see if:. The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar incidents. Recommendations should:.

For example, you have determined that a blind corner contributed to an incident. Rather than just recommending "eliminate blind corners" it would be better to suggest:. Never make recommendations about disciplining a person or persons who may have been at fault. This action would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future investigations.

In the unlikely event that you have not been able to determine the causes of an incident with complete certainty, you probably still have uncovered weaknesses within the process, or management system. It is appropriate that recommendations be made to correct these deficiencies.

The prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of the incident that you have so include all relevant details, including photographs and diagrams.

If doubt exists about any particular part of the event, say so. The reasons for your conclusions should be stated and followed by your recommendations. Do not include extra material that is not required for a full understanding of the incident and its causes such as photographs that are not relevant and parts of the investigation that led you nowhere. The measure of a good report is quality, not quantity.

Always communicate your findings and recommendations with workers, supervisors and management. Present your information 'in context' so everyone understands how the incident occurred and the actions needed to put in place to prevent it from happening again.

Some organizations may use pre-determined forms or checklists. However, use these documents with caution as they may be limiting in some cases. Always provide all of the information needed to help others understand the causes of the event, and why the recommendations are important.

A difficulty that has bothered many investigators is the idea that one does not want to lay blame. However, when a thorough worksite investigation reveals that some person or persons among management, supervisor, and the workers were apparently at fault, then this fact should be pointed out.

The intention here is to remedy the situation, not to discipline an individual. Failing to point out human failings that contributed to an incident will not only downgrade the quality of the investigation, it will also allow future incidents to happen from similar causes because they have not been addressed.

However never make recommendations about disciplining anyone who may be at fault. Witness information leaflet - how we investigate incidents pdf Show more. Related links. Our approach to maintaining health and safety on Britain's railways. The investment framework Managing safety Authorising vehicles and infrastructure Securing access to the rail network Licensing Better Value Rail What other bodies might I need to engage with? One of the statutory functions of a safety and health representative is to be able to carry out an appropriate investigation following an incident.

Refer to s. A safety and health representative is an invaluable source of knowledge that can help those undertaking a site investigation. Representatives bring an understanding of workplace systems, health and safety, and experience in liaising with workers and supervisors. Representatives may also be requested by a mines inspector to assist in a departmental investigation.

For example: If a procedure or safety rule was not followed, why was the procedure or rule not followed? Did production pressures play a role, and, if so, why were production pressures permitted to jeopardize safety? Was the procedure out-of-date or safety training inadequate? If so, why had the problem not been previously identified, or, if it had been identified, why had it not been addressed?

Additional Resources To assist employers and workers in conducting effective incident investigations, and to develop corrective action plans, the following resources can help: OSHA Fact Sheet.

This guidance document provides employers with a systems approach to identifying and controlling the underlying or root causes of all incidents in order to prevent their recurrence. National Safety Council.