All incidents, regardless of size or impact, need to be investigated. The incident investigation process helps employers look beyond ‘what’ happened to discover ‘why’ it happened. The purpose of any incident investigation program is to identify the conditions, behaviors, hazards, and root causes of an incident. This information can then be used to implement effective corrective actions that will prevent an incident from happening again. It is important to remember that an incident investigations need to focus on identifying and correcting root causes, not establishing fault. In order to identify root causes, a formal systematic approach to an incident investigation must be used.
The framework of any formal incident investigation program should follow these basic steps:
- Preserve and document the scene after an incident
- Collect information related to the incident, interview those involved
- Analyze the facts and determine the root cause(s)
- Implement corrective actions to prevent a recurrence
- Educate employees by sharing the findings from the incident
In order to have an effective incident investigation program, personnel who will be conducting the investigations need to be trained on the techniques and methods. Remember, the primary reason for conducting an incident investigation is to learn from the incident and prevent it from happening again. Untrained employees are likely to make mistakes and miss critical information making it difficult to identify the true root cause, and prevent a recurrence.
There are a number of methods that can be used to conduct an incident investigation and root cause analysis, all come with varying degrees of complexity. A relatively simple method that can be used is the 5-Why method. The 5-Why is a method of exploring cause-and-effect relationships. This technique can be used as part of a root-cause analysis to uncover ways to avoid future incidents. For additional information on the 5-Why method, refer to the 5-Why tip sheet.
An effective incident investigation program is a key element of a successful safety program. Without it, employers are missing an opportunity to identify the root causes of incidents, and prevent them from happening again. If you need assistance with your incident investigation program, contact your local Marsh & McLennan Agency safety representative.