Why investigate

Accidents are a learning experience, albeit with a high price. If you can identify the reasons why an accident occurred, preventative actions put into place to correct failings should reduce the risk of the same or similar loss happening again. Most jurisdictions place a duty of care on the employer to provide a safe place of work, safe work equipment, personal protection equipment, etc.

Investigating accidents, especially after an injury or fatality, is part of that duty of care in order to prevent a re-occurrence.

Increasingly, it is becoming a legal requirement in many jurisdictions ensure you are aware of the legal requirements to investigate accidents in your operating location s.

Families can suffer serious long-term disruption to their lives where the main 'breadwinner' is permanently injured or killed at work.

Unfortunately, this is still a reality for many thousands of families every year across the industrialised world - for example, across Europe, over 5, [1] people are killed in workplace accidents every year. The physical and mental toll on families that can result from a serious workplace accident to a family member cannot always be measured simply in financial terms.

Accidents cost businesses money. In the event of an accident depending on the scenario , costs include:. The advantage is that this person is likely to know most about the work and persons involved and the current conditions.

Furthermore, the supervisor can usually take immediate remedial action. This situation should not arise if the incident is investigated by a team of people, and if the worker representative s and the investigation team members review all incident investigation findings and recommendations thoroughly. An investigator or team who believe that incidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes.

Therefore, it is necessary to examine all underlying factors in a chain of events that ends in an incident. The important point is that even in the most seemingly straightforward incidents, seldom, if ever, is there only a single cause. For example, an "investigation" which concludes that an incident was due to worker carelessness, and goes no further, fails to find answers to several important questions such as:.

An inquiry that answers these and related questions will probably reveal conditions that are more open to correction. As little time as possible should be lost between the moment of an incident and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses.

The tools that members of the investigating team may need pencil, paper, camera or recording device, tape measure, etc. The simple model shown in Figure 1 attempts to illustrate that the causes of any incident can be grouped into five categories - task, material, environment, personnel, and management. When this model is used, possible causes in each category should be investigated. Each category is examined more closely below.

Remember that these are sample questions only: no attempt has been made to develop a comprehensive checklist. Figure 1: Incident Categories. Here the actual work procedure being used at the time of the incident is explored.

Members of the investigation team will look for answers to questions such as:. To seek out possible causes resulting from the equipment and materials used, investigators might ask:. Again, each time the answer reveals an unsafe condition, the investigator must ask why this situation was allowed to exist. The physical work environment, and especially sudden changes to that environment, are factors that need to be identified.

The situation at the time of the incident is what is important, not what the "usual" conditions were. For example, investigators may want to know:. The physical and mental condition of those individuals directly involved in the event must be explored, as well as the psychosocial environment they were working within. The purpose for investigating the incident is not to establish blame against someone but the inquiry will not be complete unless personal characteristics or psychosocial factors are considered.

Some factors will remain essentially constant while others may vary from day to day:. Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management and the role or presence of management systems must always be considered in an incident investigation.

These factors may also be called organizational factors. Failures of management systems are often found to be direct or indirect causes. Ask questions such as:. This model of incident investigation provides a guide for uncovering all possible causes and reduces the likelihood of looking at facts in isolation. Some investigators may prefer to place some of the sample questions in different categories; however, the categories are not important, as long as each question is asked.

Obviously there is considerable overlap between categories; this overlap reflects the situation in real life. Again it should be emphasized that the above sample questions do not make up a complete checklist, but are examples only. The steps in the investigation are simple: the investigators gather data, analyze it, determine their findings, and make recommendations.

Although the procedures are seemingly straightforward, each step can have its pitfalls. As mentioned above, an open mind is necessary in an investigation: preconceived notions may result in some wrong paths being followed while leaving some significant facts uncovered. All possible causes should be considered. Making notes of ideas as they occur is a good practice but conclusions should not be made until all the data is gathered.

Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses. In some jurisdictions, an incident site must not be disturbed without approval from appropriate government officials such as the coroner, inspector, or police. Physical evidence is probably the most non-controversial information available. It is also subject to rapid change or obliteration; therefore, it should be the first to be recorded.

Based on your knowledge of the work process, you may want to check items such as:. You may want to take photographs before anything is moved, both of the general area and specific items. 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.

Metacognition has attracted considerable attention in recent psychological research. There has been extensive investigation, for example, of our metacognitive sense that information is present in … Expand. Metacognitive Development: Educational Implications. Metamemory, one subtype of metacognition that refers to knowledge about memory, has attracted particularly strong research … Expand.

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The study of metacognition can shed light on some fundamental issues about consciousness and its role in behavior. Incident investigations that focus on identifying and correcting root causes, not on finding fault or blame, also improve workplace morale and increase productivity, by demonstrating an employer's commitment to a safe and healthful workplace. Incident investigations are often conducted by a supervisor, but to be most effective, these investigations should include managers and employees working together, since each bring different knowledge, understanding and perspectives to the investigation.

In conducting an incident investigation, the team must look beyond the immediate causes of an incident. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone was the cause of an incident.

To do so fails to discover the underlying or root causes of the incident, and therefore fails to identify the systemic changes and measures needed to prevent future incidents. When a shortcoming is identified, it is important to ask why it existed and why it was not previously addressed. These examples illustrate that it is essential to discover and correct all the factors contributing to an incident, which nearly always involve equipment, procedural, training, and other safety and health program deficiencie.