Objective:
To assure that employees are familiar with the basic guidelines and phases of a comprehensive incident investigation.
When an incident occurs, it is the organization’s responsibility to uncover its true cause and take steps to prevent a similar incident from occurring in the future.
Investigation Guidelines:
- 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 placing blame.
- Collect as much data as possible. The more information you have, the easier it will be to see the big picture.
Phases of the Investigation:
- Incident response: Immediately after an incident occurs, control or eliminate any hazards or threats, and arrange for medical attention to be provided as necessary. Secure the scene of the incident to assure that evidence is preserved for investigators.
- Data collection: Thoroughly document the incident scene using methods such as photographs, videos, diagrams, and collect any physical evidence that can easily be removed from the scene. Interview witnesses, victims, and other individuals to create a complete and objective account of the incident.
- Analysis: Analyze the collected data to determine all root causes of the incident. Use tools such as Ishikawa (fishbone) diagrams or the Why method to help interpret the data. Look at the system as a whole to identify issues that may have led to the incident.
- Corrective actions and follow-up: Recommend actions to correct any issues that may have led to the incident and create a follow-up plan to assure that the actions are properly implemented and effective. Point out human error if it is found to be a cause, but leave any disciplinary procedures for Human Resources to oversee.
