An in-depth guide (Part 1)
We often don’t realise how quickly our working environment can change. In just a matter of seconds, an accident can occur, and it comes as a shock to everyone. It’s in these brief moments that we find ourselves questioning how such an incident could have happened and worrying about the potential.
Organisations often promise to get to the root of the problem that caused it, but then complete an investigation that barely scrapes the surface. When this occurs it’s a lost opportunity and the potential for recurrence exists.
Accident investigations can be seen as time-consuming, technical or invasive. So how can we get the best out of the limited time and resources available to ensure our accident investigation process provides value? Here are some hints and tips to guide you.
What is the purpose of an accident investigation?
In short, the main goal must always be to prevent recurrence.
When we hear the term “accident investigation,” it often stirs up a sense of dread; we don’t have the time, there are other pressing priorities and people get defensive. Whilst an accident investigation can take time to complete (depending on the depth and complexity of an investigation) they are necessary in order to help us uncover the root cause of an issue. By investing this time, we prevent similar incidents from happening in the future.
There are likely to be some uncomfortable conversations when you start to ask questions about what happened. It’s important to remember that the goal is NOT to point fingers or assign blame. Instead, it’s about finding the problem. Accidents are unpredictable events that reveal weaknesses in your systems. The trick is to develop a culture that enables transparency and openness, this is a key feature of a good health & safety culture as this promotes positive behaviors.
So, rather than fearing an investigation, we should see it as a valuable tool for improvement and safety.
What accidents should we investigate?
Understanding the types of accidents and incidents to investigate is one of the first crucial steps. It is helpful to document your process for accident investigation and this should include guidance on what to investigate, how to investigate and the level of detail needed for different types of event.
Each organisation has its own definition of accident, incident etc. The important thing is to focus on the actual or potential consequence and not to get bogged down in terminology.
Here are the two main categories we focus on:
Near Miss: These are unintentional occurrences that could result in damage, injury, or harm. They happen without prior planning and can vary in severity. Serious near miss events, i.e., those where the consequences would have been significant, are sometimes investigated, but are often ignored. Remember that its often a case of good luck that a near miss occurred and not a serious accident so your accident investigation process should detail when near miss incidents are investigated further.
Accident: An accident is unexpected and unplanned. It typically results in damage to property or equipment, an injury, or even a fatality. The more serious the accident is (or potential), the deeper your investigation should be.
Top Tips when Starting an Accident Investigation
We have highlighted some common errors we experience when supporting clients or reviewing their processes. These tips will help you to get added value from your accident investigation process.
Witness or Bystander?
Once the area where the accident occurred has been made safe and the injured person has received attention, immediately identify who was there. People are often in shock immediately after an accident and everyone responds differently.
People in the area often state that they saw what happened and it is not until you start to interview them that you realise, they did not actually see the accident. Rather, they heard the noise and turned around – i.e., they saw the result of the accident, and not what caused it. These people are valuable when collating information for your accident investigation but are not witnesses – they are bystanders. Therefore, you need to establish who saw the whole thing (i.e., a witness) and who turned around when they heard the accident occur (i.e., bystander).
Interview your witnesses and bystanders as soon as possible.
This is should ideally be within the first 24 hours, even if the initial conversation was a casual and informal chat to establish who saw what (see above). According to research as far back as Hermann Ebbinghaus in 1880 we forget or distort up to 80% of what we see, hear, and learn within a very short period, sometimes as little as 24 hours. Ebbinghaus called his research the forgetting curve. Other studies have been completed since, and the results are similar. Therefore, time is critical and the longer an investigation is left, the more likely it is that key information will be partly or fully lost or distorted.
Who should investigate?
Often, the wrong person is allocated to complete the investigation. Sometimes this is because the organisation has a blanket policy that specifies a particular role holder, e.g., line manager, as the person responsible. This role holder is often not provided with any training in accident investigation and report writing, does not have the expertise, competence, or time.
Organisations who have their own health and safety specialist often allocate this role holder as their investigator This is a good starting point, but that person is likely to need additional expertise, e.g., in production, the process or the machinery. Therefore, an accident investigation process should have a key person to lead and to include other specialists, such as engineers, supervisors, and even external technical specialists.
Follow specialist guidance
The Health and Safety Executive has written practical and user-friendly guidance on how to complete a suitable and sufficient accident investigation. This document is HSG245. It provides comprehensive guidance and can be downloaded free of charge from the HSE website. Our own IOSH Approved training course “Accident Investigation and Report Writing” is based on the principles in this guidance.
Look out for further insight into accident investigation in our next newsletter when we explore some practical tips on how to undertake accident investigation. Meantime if you have an interest in health & safety including accident investigation join one of our expert tutors on our next ISO 45001:2018 training course or ask for details of our consultancy services.