Techniques for investigating incidents and accidents

HSE LEVEL 1,2 AND 3 COURSE Techniques for investigating incidents and accidents

Investigating incidents and accidents in the workplace requires a systematic approach to uncover the root causes and contributing factors. Various techniques and methodologies can be used to conduct thorough investigations. Here are some common techniques for investigating incidents and accidents:

The 5 Whys Technique:
- This technique involves asking “why” multiple times (usually five) to drill down to the root cause of an issue. By repeatedly asking why, investigators can identify the underlying causes of an incident. For example:
  - Why did the machine malfunction? (The electrical circuit failed.)
  - Why did the electrical circuit fail? (The wiring was corroded.)
  - Why was the wiring corroded? (It was exposed to moisture.)
  - Why was it exposed to moisture? (The area was not properly sealed.)
  - Why was the area not properly sealed? (Insufficient maintenance procedures.)
Fishbone Diagram (Ishikawa Diagram):
- A fishbone diagram is a visual tool used to identify potential causes of an incident by categorizing them into different branches, resembling fishbones. The main categories typically include people, processes, equipment, materials, environment, and management. Teams brainstorm possible causes under each category and analyze their contributions to the incident.
Fault Tree Analysis (FTA):
- FTA is a systematic method used for complex incidents. It involves constructing a fault tree that shows the logical relationships between different factors contributing to an incident. The tree’s root represents the incident, while branches and nodes represent contributing factors. Analyzing the fault tree helps identify the key events or conditions that led to the incident.
Barrier Analysis:
- Barrier analysis focuses on identifying gaps or breakdowns in safety barriers that are supposed to prevent incidents. These barriers can include safety procedures, training, equipment safeguards, and more. Investigators examine how these barriers failed or were bypassed, leading to the incident.
Change Analysis:
- Investigate whether recent changes in processes, procedures, equipment, or personnel played a role in the incident. Changes can introduce new risks or affect established safety measures.
Event and Causal Factor Charting (ECFC):
- ECFC is a method for systematically organizing information about an incident. It involves charting events and causal factors in chronological order. This helps investigators understand the sequence of events leading up to the incident and identify contributing factors.
Human Factors Analysis:
- Investigate how human actions and behaviors contributed to the incident. This may include factors such as inadequate training, fatigue, distraction, or poor communication.
Safety Culture Assessment:
- Examine the organization’s safety culture to determine whether cultural factors, such as attitudes, values, and leadership, played a role in the incident. A poor safety culture can contribute to unsafe behaviors and conditions.
Witness Interviews:
- Interview individuals who were directly or indirectly involved in the incident. Gather their perspectives on what happened, what they observed, and any actions they took. Witness interviews help reconstruct the sequence of events.
Document Review:
- Examine relevant documents, such as safety procedures, work permits, training records, maintenance logs, and incident reports, to gather information about the incident’s context and contributing factors.
Reconstruction and Simulation:
- In some cases, incidents may be reconstructed or simulated to better understand the sequence of events and identify contributing factors. This is especially common for complex incidents.
Expert Consultation:
- Seek input from subject matter experts, safety professionals, or specialists in relevant fields to gain insights into complex or technical aspects of the incident.
Data Analysis:
- Analyze data from various sources, such as sensors, equipment logs, or health records, to identify trends, patterns, or anomalies that may have contributed to the incident.
Peer Review:
- Have a team of peers or experts review the investigative findings and conclusions to ensure objectivity and rigor in the investigation process.

It’s essential to adapt the investigation techniques to the specific incident’s complexity and nature. A comprehensive investigation should involve multiple techniques and thorough documentation to uncover the root causes and develop effective preventive measures. Additionally, maintaining a non-punitive approach to reporting and investigation can encourage open and honest reporting of incidents.

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