In this article, we will take a look at some of the guiding principles used to determine a “workplace incident” and what measures may be taken to respond appropriately.
What is an incident?
ANSI Z10 defines an incident as “an event in which a work-related illness, injury (regardless of severity) or fatality that occurred or could have occurred”. The event is generally predicated by a breakdown or failure to adhere to control measures. An incident does not have to result in an injury or illness; a near miss can represent a condition where it’s better to be lucky than good. In a perfect world, all injuries and near misses are reported/investigated, but such a scenario is usually impractical and may tax limited resources. Therefore, high risk and severity events generally get the spotlight of an investigation.
What is the purpose of an incident investigation?
As mentioned earlier, an incident investigation is used to determine if (and how) a breakdown of controls occurred. If the controls failed, the policies and procedures for that specific activity are re-examined to confirm adequacy. If adequate, the approach can remain unchanged; however, it may be prudent to increase inspection frequency and/or targeted control training (such as administrative, engineering, and PPE). If the analysis determines the controls are inadequate, the entire policy needs to be reviewed and re-evaluated.
Types of Incident Investigations
The types of incident investigations related to safety can span the spectrum. As part of the ANSI Z10 Plan, Do, Check, Act cycle, major incidents are investigated in a measured and logical manner to ensure that a program is working effectively. A core tenet of the analysis involves safety professionals asking “why” until answers lead to the root cause.
The 5 Whys – to pursue for a ‘root cause’ determination, e.g.:
- The employee cut hand
- Improper use of circular saw
- Did not inspect equipment prior to use
- Guards not in place
- Improper maintenance of equipment
Ishikawa theory (use of fishbone or “fishikawa” diagram) is based on an evaluation of the contributing factors that lead to the breakdown of controls, specifically:
- Personnel
- Method
- Measurement
- Machine
- Environment
- Materials
Management Oversight and Risk Tree (MORT) is based on an evaluation of the managerial procedures in place, consisting of specific controls and management systems to determine where the breakdown occurred.
- Follow uncontrolled energy (potential, mechanical, pneumatic, electric, thermal, radioactive, stored, etc.) and the reasons why the controls either were not in use or removed.
The purpose of all incident investigations is not to lay blame but to probe the hierarchy of control failure points and identify what measures can be taken to prevent a similar incident from occurring in the future!
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