Investigate to Find Facts, Not Faults
September 2001

A cut hand, a fall, a sprained back, even a near-miss. No one likes it when an incident occurs on the job. But when something goes wrong, it’s in everyone’s best interest to determine exactly what happened and why.

Unless everyone keeps an open mind, however, the investigation may not reveal the incident’s true cause. A successful investigation must be objective, a skill that needs to be taught. Otherwise, people will concentrate on finding fault instead of facts, and the true cause, not just the immediately apparent one, may never be discovered.

The true cause of an injury may be more complicated than initially suspected. There are times when an employee performs an at risk behavior and gets hurt as a result, but the cause is often times a combination of employee, management, equipment or environment.

Let’s say an employee gets his hand caught in a machine. The easiest – and usually incorrect – assumption is that the incident is purely the employee’s fault. What if the employee used the machine yesterday and saw that it had no guard on it but didn’t report it? What if he did report it and the supervisor didn’t follow up on it? What if the supervisor saw for himself that the employee was working without the guard, but said nothing? What if the previous employee had removed the guard or the guard was being repaired? Management, employees, equipment and environment have all combined to create this incident.

What Supervisers Can Do
Supervisors play a key role in any investigation. That can mean something different at each company, of course, but there are general guidelines. Supervisors can ensure a good investigation by not jumping to conclusions, following written procedures, using proper forms, and training their employees to answer questions truthfully and completely.

Telling the real story can be a sensitive issue if employees feel that telling the truth could get a co-worker in trouble. One of the most important jobs is to take the ‘fear factor’ away from employees. A strict no-fault policy is crucial.

Incident Investigation Form
Based upon our many years of experience investigating incidents and working with all of our group members in their efforts to truly determine the "root" causes of injuries the Safety Department of Lovell has developed the "Supervisor’s Investigation & Report of Incident Form". This replaces the multi part form we formerly distributed.

We believe this new form provides a useful tool for you to use when performing your incident investigations. If you would like this form in electronic version, please let us know and we will gladly e-mail it to you.

Follow these steps
While many steps of an investigation are overseen by the supervisor, it’s important that employees understand the process, and that they are involved.

• Respond to the emergency. See that any injured person receives medical attention. Secure the area. Use barricades or tape to keep people from changing the scene in any way. Shut down involved equipment, including locking/tagging it out.
• Identify potential witnesses. Find out whether any employee saw, heard, or smelled anything that may help explain the incident.
• Collect evidence and record data. Supervisors and investigators should rely on a pre-assembled investigation kit that includes a camera, film, flashlights, sampling equipment, pad and paper. Know who is responsible for maintaining this at your company.
• Conduct interviews. Talk to each employee separately, focusing on the who, what, when, where, why and how of the incident. Ask open-ended questions and write down each response. Have employees review what you wrote down. Have them write their own statement.
• Review all the data. Study all relevant reports involving equipment maintenance, housekeeping, work permits and similar incidents.
• Prepare the investigation report. Record only facts, not your opinions.
  
• Implement corrective action. Follow your company’s protocol for making necessary changes to prevent future incidents.
  
• Follow up. Check back to make sure that appropriate remedies are in place and working as intended.

Finally, be prepared that you might not always like the investigation’s outcome. Management and employees must both face whatever the investigation shows. No one should let his/her ego get in the way of improving safety.

If you have any questions, on this or any other safety and health issue, please call your local area representative or the safety office of LSM at 212-709-8801.

Susan Geier Fahmy, CSP