Written by Daniel Aday, CompOne Administrators Safety & Loss Prevention Specialist
The only thing worse than an accident happening, is a previous accident happening again. Incidents and accidents that occur and go without a proper accident investigation are likely to occur again. It is your responsibility as an employer or owner of a company to ensure that your employees are provided a workplace that is free of hazards, and that includes conducting a proper investigation on accidents and incidents and doing what is feasible to prevent them from happening again. The purpose of an accident investigation is to determine the root cause (the real reason) of why the incident occurred, or to find the initial hazard that set off the series of events that led up to the accident. While there are many ways to determine a root cause, it is best not to “jump to a conclusion” and assume what happened based on very little investigation
Additionally, the purpose of an accident investigation is NOT to assign blame. It is common to see untrained investigators simply put the blame or the cause of the accident on someone “not paying attention” or similar. While these components of an accident may play a part in why the accident occurred, they are not the root cause of why the incident occurred.
Finding the root cause may be as simple as just asking “why” more than a couple times. This is known as the “5 Why Analysis” and it is one of the most common forms of incident investigation you see in the workplace. It is incredibly easy to use and understand and to find root causes without much training. For example: “Lizzy was working on siding the building when she fell off the ladder and sprained her wrist” and ask the first why: “Why did Lizzy fall off the ladder?” Then follow up with the second why: “The ladder started to shift on her when she was working.” Third why: “The ladder sunk into the ground.” Fourth why: “There were missing feet on the ladder.” Fifth why: “The ladder was missing feet because the ladder was not inspected prior to use.” While this may be common sense to replace feet on a ladder, or to avoid using a ladder if it is broken or missing parts, many people may not look to inspect a ladder prior to use. A poor corrective action for this incident would be to write up Lizzy for not inspecting the ladder prior to use. This does not solve the problem, but only creates a reactive action. This does not eliminate the problem and allows the problem to still exist for all others who use ladders in a similar manner. The obvious root cause of this incident is that the missing foot was not identified prior to use. A great corrective action for this incident example would be to not only fix or replace the ladder, but additionally to also create a ladder inspection program that requires individuals to fill out a complete ladder checklist prior to use. Yes, this will take additional time, but will save the employer and employees from any future related accidents.
In addition to finding the root cause via “5 Why Analysis,” pointing out contributing factors also aids in investigation. Additional questions for this example might include:
- Was the individual using the proper three points of contact?
- Should the individual have fall protection gear on?
- Was it windy or were there other weather hazards?
These are all questions that should be asked during an investigation to help aid in finding ALL the root causes. (Yes, there may be more than one root cause!) Lastly, it is unlikely that every incident will require exactly 5 questions every single time. The investigation may only require a few questions, or very well may require several more. It is your responsibility, as an investigator, to understand when you have discovered the root cause(s) and to find a adequate corrective action that will prevent the incident from occurring again.
If you need any assistance with investigating an incident or are interested in accident investigation training, please feel free to contact me at email@example.com or at 734-341-6620.