“We are reviewing our incident investigation procedure and want to make sure that we are following the current best practice. What are the key things I should look at?”
A thorough investigation process is crucial for any organisation; it’s not enough to simply look into what went wrong when an incident happens. To follow best practice you need to understand what led to the incident happening and how you can prevent it from reoccurring.
What is an incident?
An incident is an unexpected, unplanned event that results in physical harm to a person, damage to property, a near miss, a loss or any combination of these things. It’s vital that all incidents, regardless of perceived severity, are investigated – not just those in which someone is harmed. The lessons learnt will be essential for preventing a reoccurrence.
Incidents can be due to immediate, root and underlying causes. Immediate causes are substandard acts or conditions that lead directly to an incident; for example, removal of a machine guard or not using PPE. Root causes can be described as inadequacies in the management system that allow immediate causes to arise, resulting in an accident, such as inadequate training or incomplete risk assessments. Underlying causes are less obvious failings such as poor maintenance of machinery.
A really thorough incident investigation process will identify all causes. Incidents can have multiple causes; it’s rare that an incident is caused by just one thing.
The investigation process
Once the injured person (if applicable) has been helped and the area made safe, you need to carry out a thorough and productive investigation. The health and safety regulator for Great Britain, the Health and Safety Executive, recommends a four-step process in its publication HSG245 :
- Gather the information: The initial information gathering is a critical part of any investigation. Information missed at this stage will hinder later stages of the investigation process and may result in an incomplete investigation and incorrect conclusions on the actions needed. Investigators should make use of the full range of information sources available, which can be numerous; for example witness statements, maintenance records, CCTV footage etc. The person or persons should be competent in undertaking investigations of this sort.
- Analyse the information: Look at the sequence of events/conditions that led to the incident. You’ll need to consider the chronology and take a logical approach to see how they could be linked. You might find it useful to use an event tree analysis to capture all the contributory factors.
- Identify risk control measures: Highlight all the risk control measures that were inadequate, missing or misused. To do this, you’ll need to map the activities, conditions and practices as they actually were in the run-up to the incident. These should be compared to what should have been in place according to current best practice, legal requirements, codes of practice, guidance and standards. From these findings you should then map out the additional measures that are needed to eliminate all of the immediate and underlying causes.
- Implement the action plan: The final step is to create a clear action plan with SMARTT (specific, measurable, agreed, realistic, time-bound and trackable) objectives that will effectively deal with the incident causes. The plan should also include lessons learnt, which can be applied to prevent similar incidents happening again.
“to follow best practice you need to understand what led to the incident happening and how you can prevent it from reoccurring”
Finally, make sure that the results of the investigation are shared with all relevant staff in the organisation. To keep things positive, focus firmly on the resulting action plan, the timescales, responsibilities and accountabilities set out within it, and how it will be implemented and monitored. It’s also good practice to share the lessons learnt from the investigation with the wider workforce.
As a result of the investigation, work with your team to consider which risk assessments and systems of work need to be reviewed and updated. You may also find it helpful to use a cost-benefit analysis to put a figure on the overall cost of the incident (including both insured and uninsured factors) and compare these to the cost of the control measures you have recommended. This will demonstrate the value of implementing any new measures you have identified and help to get leadership team buy-in.
This article provides a short overview of incident investigation best practice. Complex incidents in particular will require investigators who are competent in the process. Incident investigations are covered in detail in the NEBOSH HSE Introduction to Incident Investigation; a new qualification designed specifically for those who need to carry out incident investigations either alone or as part of a team, and produce risk control plans.
For more information about NEBOSH qualifications visit www.nebosh.org.uk