How to Conduct an Incident Investigation and Root Cause Analysis

Incident Investigation and Root Cause Analysis

Accident and incident investigation and root cause analysis are important regardless of the industry, whether manufacturing, construction, or office work. Accidents and incidents impact all organizations. The goal is to provide a safe and zero-accident workplace and safety culture where employees feel free to report all incidences to help identify root causes and eliminate the possibility of a recurrence.

Let’s start with some definitions:

Incident is a term used to promote the idea that you can target, identify and prevent accidents from happening.

The outcome will be to define and implement corrective actions to prevent an incident from reoccurring and reduce worker’s compensation costs.

Root cause: root cause is defined as a factor that causes a nonconformance and should be permanently eliminated through process improvement. The root cause is the core issue—the highest-level cause—that sets in motion the entire cause-and-effect reaction that ultimately leads to the problem (s)

What are the costs of injury in the workplace?

Costs of injury are twofold, encompassing direct and indirect costs. Direct costs of injuries account for only about 1/3 of total costs. The remaining 2/3 are indirect costs, including:

  • A seasoned employee with specific skills may not be easily replaced, and productivity will suffer until their return.
  • Training costs for replacement workers
  • Loss of employee morale impacts the injured worker and their coworkers
  • Machine downtime/productivity loss due to loss of a skilled worker
  • Cost to customers in terms of late shipments due to loss of productivity impacting customer retention and future sales

The importance of a Safety and Health Management System

Implementing a Safety and Health Management System is the best way to be proactive. Implementing a program to track and monitor accidents and incidents demonstrates to your employees that you care about their well-being and the safety of their work environment.

Start with a well-defined Accident/Incident Investigation Process as the first component of a Safety and Health Management System.

Your Accident/Incident Investigation Program should include:

  • Identifying Accident/Investigation Team Members- make sure they are trained and understand the protocol
  • Having a designated written procedure
  • Hazard Correction Tracking from onset to correction
  • Process to communicate findings and corrective actions to all employees

How do you organize an incident investigation?

It is critical to building a cross-functional team to identify the root causes of an incident and define corrective action to prevent similar reoccurrence. The safety department spearheads the investigation but should include the (hourly) employees involved in the incident.

All occurrences require investigating, including:

  • Injuries
  • Illnesses
  • Incidents
  • Near Misses (critical when corrected can affect future incidents)
  • Property Damage and Fires
  • Environmental Releases

Incident Investigation and Root Cause Analysis

How to conduct a good incident investigation

The investigation team is cross-functional. It is essential to have input from each member, including supervisors, safety committee members, and employees, because:

  • They are familiar with the jobs, working conditions, and employees
  • They need to know the causes to prevent a repeat occurrence
  • They can improve hazard recognition skills

Gathering accurate and complete information is critical. Remember – you are not looking for fault.

The elements of a good investigation include:

  • Identification of contributing factors to the accident
  • Documentation of corrective actions already taken
  • Clear definition of the root causes
  • Identification of additional corrective actions to address the root causes

It is best to obtain facts and determine the correct (open-ended) questions to ask in advance. Organization is critical to the investigation.

A good quality investigation should include the following steps:

  • Visit the scene of the accident before physical evidence is disturbed
  • Make visual records such as sketches, photos, notes, and the condition of the area where the incident occurred
  • Determine if and what accident-related items should be preserved
  • Identify witnesses and map out the sequence of events leading to the accident
  • Interview witnesses as soon as possible
  • Document & review sources of information such as policies and procedures.
  • Reenact the accident if possible; “Show me what happened.”

Separate facts from opinion and direct evidence from circumstantial. When speaking with a witness, ensure the information is first-hand, not hearsay.

How to effectively interview witnesses

The rule of thumb is to interview witnesses as soon after the event as possible. Interview each witness separately and in a location that puts them at ease. Explain the purpose of the investigation and ask them to tell their version. Avoid placing any blame on them or their coworker. Try not to ask leading questions and use open-ended questions to spark conversation.

Events and Causal Factor Charting

A picture is worth a thousand words and can help recreate the accident scene.  Events & Causal Factor Charting provides a graphical depiction of events leading up to an incident or injury. This allows incident investigation teams to analyze events and root causes without assigning blame.

Events and causal Factor charting

Events and Causal Factor Charting (E&CF) was developed by the National Transportation Safety Board (NTSB) to aid investigators in organizing and communicating information gathered during the investigation.

What is root cause analysis?

Root Cause Analysis is a deeper investigation of all potential causes of an incident.  Root cause analysis asks, “What is the one step in a sequence of events that, if removed, the accident would not have occurred.” The process involves gathering data about each potential cause and evaluating that data to determine which cause would have prevented the incident from occurring.

There are many ways to go about the analysis. We focus on:

  • The 5-Why- Keep asking why until you get to the root cause.
  • Fishbone Diagram- Same approach as the 5- why, but more visual.
  • Cause and Effect Diagrams

To view the process and workflow for the 5-Why Process and Fishbone Diagram, please view our webinar for details and instructions.

What are the uses of cause-and-effect diagrams? The idea is to discover all potential causes that led to his incident:

  • To Discover All Potential Causes.
  • To Visualize Possible Relationships Between Causes.
  • To Provide Focus for Discussion.
  • To Aid in the Development of Incident Prevention Plans.

Once the process is complete, the findings can be presented to the safety committee or leadership team. At that point, the root cause, corrective actions, and persons responsible are identified.

The entire process should be documented from start to finish to ensure compliance with safety standards for your industry and to utilize as safety training in the future.  Do you have a solid Safety and Health Management Program? We can help.

Catamount Consulting delivers world-class safety tools and tips.

Catamount Consulting provides experienced, high-quality construction and mining safety professionals for short or long-term onsite safety service assignments. Contact us to schedule a time to discuss your organization and how Catamount Consulting can help you implement successful accident and incident investigations and root cause analysis. To view the webinar, click here for the meeting recording.

Special thanks to our presenter, Joe Keenan, MBA, CSP from Catamount Consulting.