An employee just had a significant accident at your workplace. What you do next can either help prevent a similar repeat or make matters worse. To avoid the latter, let’s look at what to do, how to do it, and most important, what not to do.
Most workplace accidents have predictable root causes that you can identify and prevent. However, your priority is to administer first aid to the injured worker, treating for shock and seeking medical attention.
While attending to the victim, look for hazards that could injure the person further or harm you or other workers. Ask bystanders to help secure the area by setting up barriers – yellow or red tape or cones and rope – and have somebody keep other people out of the area. Ask them not to move anything that isn’t a hazard.
No finger pointing
Significant injuries are traumatic to all involved, so the next step is to offer counseling. As events unfold, the most important “don’t” is to avoid blaming and finger pointing. The worker already feels victimized, and co-workers are tense with heightened emotions. They are worried about consequences, if they or others will get in trouble or even fired for a perceived safety infraction. Watch your body language – and theirs.
Keeping records is vital. What else is important? Many things, but here’s a partial list to get started. You should probably save damaged equipment and tools, make a scale diagram or drawing, save pictures or video and other evidence, and provide a written report. U.S. courts allow digital imagery, but some Canadian courts have ruled it inadmissible. Always check with your attorney first.
To record the incident properly, you’ll need an investigation kit. A basic one has plastic bags, containers, camera, film, batteries, lighting, tape recorder, tapes, camcorder, videos, pencils, graph paper, scale, tape measure, barrier tape, Keep Out signs, personal protective equipment and other items.
Root cause analysis
Investigations mean asking questions, and a good place to start is the standard who, what, when, where, how and why, why, why? Why so many whys? By continuing to ask why, you usually uncover the root causes of the incident.
The procedure is labeled root cause analysis (RCA), and the Los Alamos National Laboratory (LANL) defines it as any systematic process that identifies why a loss occurred, including contributing factors. Its purpose is to identify fundamental causes and implement corrective actions that will prevent recurrence.
Root cause analysis is like dominoes. The last one to fall is the incident, and the first one to start the process is the root cause. Your goal is to work backward to identify the first domino. While incidents can have more than one root cause, don’t confuse them with contributing causes. Contributing causes add to the chain of events, but do not start it. If done properly, RCA can identify fundamental causes rather than just immediate symptoms, opening the door to broader investigation of system vulnerabilities.
Team players
Any investigation is a team effort. The LANL recommends building your RCA team with as many disinterested and objective members as possible – people with nothing to gain or lose from the outcome.
Include safety analysts and people on your safety committee. However, anyone directly involved in the incident should abstain. Your team leader should be an RCA expert who organizes and leads the investigation, describes the process to the subject matter experts (SMEs), creates the report, and submits it to the correct individuals and organizations.
Subject matter experts come from inside or outside your company. They are often co-workers who know the task or work well. Insiders and outsiders have their pros and cons as team members. Insiders know the facility but are more likely to be biased.
Outsiders may be unfamiliar with the operation, but are usually more objective. Consequently, they may probe harder by asking more questions that potentially reach the root cause.
Who should not be on the team? You, the boss or owner, supervisor, or anyone with a bias. For the best objectivity, those who have much to gain or lose by the outcome should remain uninvolved. If you must be involved, don’t be the team leader, be an ex officio member with no vote or say in the matter – more like an independent observer.
Corrective action
After analysis, the second basic phase of RCA is corrective action. In this process, you review conclusions, develop and implement corrective actions, and follow up. The two phases should be independent. Several specific models of RCA are available, but the basics are to keep asking why until you reach a point where continuing to ask is inappropriate or meaningless.
By its nature, RCA is a retrospective approach to safety. Risks include assuming the system has no other defects, not adopting the broadest scope, inviting misuse by potentially blaming the innocent, and protecting management. LANL recommends having one small team to find and another to fix.
How prepared is your company for a significant injury? LANL suggests using these review items as a checklist:
Evaluate your RCA team. Are the SMEs appropriate? Are the facilitator/analyst and team independent?
Review your company’s safety culture. Is production overemphasized? Are procedures followed? Are training and drills current?
Knowing the basics of incident investigation and RCA can help you objectively determine causes and prevent future incidents.
