Fall/Winter 2003

Incident Analysis: Finding Facts, Not Faults
By David Wylie

Every gardener knows that you haven’t pulled a weed until you’ve pulled it out by its root. The same logic applies to analyzing workplace accidents and near misses: You must discover the root cause of the incident before you can correct it.

For workplace safety purposes, we describe accidents and near misses under one umbrella term: incidents. Whenever an incident occurs at your workplace, you should conduct a four-step incident analysis to discover and correct its root cause.

Step 1. Gather facts
Start by making it clear that your objective is to correct safety hazards, not assign blame. Don’t use the term “accident investigation.” It may sound like a witch-hunt to your employees. "Incident analysis" is less threatening and more accurately describes your mission.

Go to the scene of the incident as soon as possible. The longer you wait, the greater the chance that evidence will get tainted or the site itself will change.

Look for equipment, work conditions, and unsafe behaviors that may have contributed to the incident. Interview witnesses before they have time to influence each other’s version of what happened. Try to ask open-ended questions in a non-threatening way.

For your benefit, Texas Mutual_SM safety experts have created an incident analysis form you can use to document your findings.

Step 2. Analyze the facts
The key to this step is being able to tell the difference between root causes and symptoms. For example, if an employee slipped on a wet spot, don’t assume that the wet spot was the root cause of the incident. Before moving to step three in the process, ask why there was a wet spot on the floor.

Was it from a leaky air conditioner, perhaps? Maybe an employee spilled a glass of water and didn’t take the time to clean it. The root cause of an incident is the very beginning of the hazard. If you only correct the symptom, the air conditioner will continue to leak or the employee will continue to act carelessly. In short, you’re setting yourself up for another incident.

Step 3. Take corrective action
Corrective actions have three parts: what should be done, who should do it, and when it should be completed. Assign individuals to complete each action within a specific timeframe.

Begin by correcting all work environment factors as soon as possible to prevent similar incidents from recurring. For items that will take longer to complete, set a specific time line for corrective action.

Often, you will identify unsafe behaviors that contributed to incidents. A behavior-based safety program can help correct these behaviors. Visit the safety resource catalog to learn how to launch a behavior-based safety program.

Step 4. Follow up
Just because you assigned corrective action tasks doesn’t necessarily mean your staff completed them. Furthermore, it doesn’t mean the corrective actions were effective. Follow up to make sure all corrective actions are in place and that they eliminated the root cause.

Collect data on the costs of the incident. You may be able to use this information to evaluate whether the cost of the incident justifies the purchase of new equipment or changes in production methods.

Make it all-inclusive
If your staffing allows, consider forming a team of employees to investigate all incidents. Hourly and salary employees, managers, supervisors, and safety personnel should be represented. Include employees who work in areas where incidents have been a problem. Use the loss run and claim detail feature to analyze your accident trends and help uncover high-hazard areas.

The team will gather and analyze facts, communicate findings, and supervise corrective actions. The team should share their findings and recommendations for corrective actions with all employees.

Make sure the team approaches every investigation as a fact-finding mission, not a faultfinding mission. When employees understand your goal is to make the workplace safer for everyone, they are more likely to participate in the process.

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