The purpose of conducting an investigation is not to lay blame on anyone, but to determine the root cause(s) and prevent reoccurrence.
The principal investigator for most investigations will be the supervisor or instructor of the affected individual. As little time as possible should be lost between an accident/near miss and beginning the investigation, this way one is more likely to observe the conditions as they were at the time.
Steps in investigating an accident
- Gather information
- Observe the scene
- Discuss incident with affected individuals
- Identify causes
- Develop corrective actions for each identified cause
- Complete and observe effectiveness of corrective actions
Finding the root cause
The primary aim of the investigation is to identify the factors that resulted in the incident in order to identify what behaviours, actions, inactions, or conditions need to be changed to prevent recurrence of similar harmful outcomes and to identify the lessons learned.
In most situations there will be multiple root causes that need to be corrected.
An open mind is necessary during incident investigations, assumptions and preconceived notions can mask valid causes or highlight erroneous causes.
Corrective actions are assigned at the end of the investigation process, the intention is to rectify and improve any areas where improvement is required. Corrective actions have a direct relationship with the root causes of the incident. Usually there is at least one corrective action item linked to each of the causes/contributing factors.
By completing the corrective actions, not only are the areas that require improvement being corrected, but it allows the persons involved to take responsibility to prevent re-occurrence. Each corrective action item is assigned to a person with an expected completion date.
If you require additional assistance, please contact IZUNA Occupational Health and Safety.