Industrial accidents, on the job injuries, begin with cause and end with effect; they are not, in any real sense, accidents. For this reason, any injury mandates investigation, correction, and forecasting.
What are the proper steps in investigation?
1. Reserve Judgment. Questioning employees can be tricky. Assure everyone knows the facts are important. You're trying to build a narrative about an incident, not to fire someone.
2. Begin with the physical location of the incident. Are guards in place, floors even, floors wet, proper equipment in place? Is the physical location in good working order?
3. Was personal protection equipment available and in use?
4. Gather any recordings of the incident, visual or audio.
5. You have your setting, now interview the characters. Interview the injured party, how did this incident occur? Interview co-workers who witnessed events leading up to the moment or the incident.
6. Find the Human Error. Always a factor, and here's why: either the employee erred in the execution of their job, or management erred in their design of the job.
7. Mentally walk through the incident after creating the narrative of events. Where could this incident have been prevented?
These steps should lead to a narrative which is specific about the incident from just before cause to effect, not just a description of an injury, but a detailed story describing what happened.
The investigation should state whether or not procedures were followed, and were those procedures adequate in protecting the employee. Why were they appropriate or ineffective?
Did the normal work conditions lead to injury, or did some unusual conditions play a part?
Define the unsafe elements: employee behavior, management process, workplace conditions, personal protection, time of day, time into the shift (weariness), any event or condition contributing to the injury.
Find the primary cause, secondary cause and tertiary cause of the incident.
Employee fell down and broke their wrist does not tell the story, and not much can be gleaned from that report to prevent future incidents.
Employee lost footing when stepping into a pothole in the parking lot and broke their wrist. The employee was carrying a load which blocked their view, and was too heavy. This narrative suggests:
- fix the parking lot to create a smooth surface
- teach employees about carrying loads
- use hand trucks for heavy or large loads.
This report can prevent future incidents. Who, what, why, when, where and how.
Step 8: Forecast incidents by applying these lessons learned from the investigation by inspecting similar components across company operations. Fix the potential problems before the incidents occur.