An incident is never pleasant. But at least it provides an opportunity to learn and improve. However, it’s important to learn the right lessons by successfully identifying root causes.
An investigation is launched when an incident occurs. One immediate question that you should answer within your organization is: Which incidents get investigated?
Accidents should be investigated. What about near misses? Should they all be investigated without exception? Or maybe you want to investigate only near misses that had a potential for a serious injury or fatality (SIF). These are questions that you should answer based on your industry, the number of incidents, and the size of your EHS staff.
Next, you should determine if a root cause analysis is performed systematically as part of all incident investigations. You can, for example, have a “two-tier” approach: An investigation that includes a full root cause analysis (e.g. for accidents and near misses with SIF potential), and a “lighter” investigation that does not include it (e.g. for minor near misses).
A Set of Standard Questions
As part of your incident investigation process, be sure to have a set of standard questions used to determine root causes.
It’s important not to confuse questions about the incident itself with questions that help to identify root causes. For example, the following questions are not used to identify root causes, even though they’re required to be answered:
- Who was injured?
- What is the nature of the injury or damage?
- Where did the incident take place?
- When did the incident happen?
- What equipment or machinery was involved?
Here are questions that you can use to start building a set of standard questions to identify root causes, for your organization. These are based on a guide on incident and accident investigations from OSHA:
- Did written or well‐established safe work procedures exist for employees to follow?
- Were employees following safe work procedures?
- Was there any deviation from established safe work procedures?
- Did supervisors or workers recognize deviations from the normal job procedure?
- Were potential hazards properly identify (e.g. as part of a Job Safety Analysis)?
- Were employees trained to deal with any hazardous conditions that could arise?
- Were there any hazardous environmental conditions that may have contributed to the incident?
- Were any actions taken to eliminate hazards or control risks?
- Did controls perform as expected?
- Were the proper equipment and tools available and being used for the job?
- Did any mental or physical conditions prevent employees from properly performing their tasks? Were they distracted?
- Were there any tasks considered more demanding or difficult than usual (e.g. strenuous activities, excessive concentration required)?
- Was there anything different or unusual from normal operations (e.g. different parts, new or different chemicals, recent changes/maintenance/cleaning on equipment)?
- Was the proper personal protective equipment (PPE) specified for the job or task?
- Were employees trained in the proper use of any PPE?
- Did employees use the prescribed PPE?
- Was PPE damaged or not properly functioning?
- Was there any indication of misuse or abuse of equipment and/or materials at the incident site?
- Is there any history of equipment failure, were all safety alerts and safeguards operational and was the equipment functioning properly?
- Was there any shortage of personnel on the day of the incident?
- Did supervisors or workers detect, anticipate, or report an unsafe or hazardous condition?
- Did supervisors conduct regular safety meetings with their employees?
- Were the proper resources (e.g. equipment, tools, materials) required to perform the job or task readily available and in proper condition?
- Were employees properly trained and proficient before performing the work?
The list above gives you an idea of the type of questions that help to identify root causes. The list is not exhaustive. There can be additional questions that you may include based on your industry or other factors.
The key is to create, maintain, and use a list of standard questions as part of any incident investigation, to help you identify root causes. In addition, the use of EHS software can ensure that the same set of questions is used across all sites for all incidents, and that the answers are available for analysis to detect trends.