The goal of an accurate and thorough incident investigation is not to place blame, but to determine the true cause of the incident and make changes that reduce the chances of similar incidents occurring in the future. Make sure your investigation includes each of the phases below to assure that your team has every opportunity to uncover root causes:
1. Responding to the Incident
- Check the scene for hazards to yourself and others.
- If you can do so safely, control hazards or remove people from the hazards.
- Respond to medical needs: if necessary, summon help by calling emergency medical services (EMS) and/or provide first aid to the level you are trained.
- Secure the area if necessary to prevent further injury or disruption of evidence.
- Contact the appropriate personnel, such as supervisors, management, or emergency responders, after injured parties are medically stable.
- Start preserving evidence that may be needed for the investigation, including photographing or isolating evidence that may not be able to be removed from the scene.
2. Gathering Information
- Include both management and employees in the investigation. Multiple perspectives are invaluable.
- Make sure that the investigation team includes or has access to technical expertise in safety, engineering, operations, or any other subjects that might be helpful.
- Focus on finding causes for the issue rather than assigning blame.
- Collect as much data as possible by interviewing personnel involved in the incident (including witnesses) and documenting the entire incident site (i.e., with photographs or video). The more information you have, the easier it will be to see the big picture.
3. Analyzing the Data
- Look for root causes. A root cause is a factor that underlies other contributing causes and that could eliminate recurrence of the problem if it is addressed.
- Rather than just focusing on the actions of the people involved in the incident, try to consider the organization as a whole and whether there are any weaknesses in the current procedures that may have contributed to the incident.
- Using multiple methods of data analysis, such as Ishikawa (fishbone) diagrams or the Why Method, can help uncover root causes that may have been missed using only one.
4. Determining/Implementing Corrective Actions
- Be specific in your instructions for what each action entails and how it should be implemented.
- Assign responsible parties to ensure that the corrective actions are completed and a time frame for completion.
- Keep your recommendations constructive and objective.
- Clearly point out instances where human error is a cause, but avoid recommending disciplinary actions, which should be handled by Human Resources.
- Outline a follow-up plan to assure that actions are implemented correctly and work as planned.