Do you have a robust and consistent process? Is the person making the decisions sufficiently trained and experienced?
An incident gets reported, triggering two separate processes in most organizations. There is a reporting process and an investigation process – or is there?
Some organizations automatically investigate every incident. Others have a decision to make.
Making a case
There are different approaches to deciding whether or not an incident needs to be investigated. In some cases, there are thresholds to be met. Was there an injury? Property damage over $5,000? Is regulatory action anticipated?
Some organizations rate the occurrence's risk, which triggers an appropriate organizational response. The problem with that is that someone has to do some investigation to determine the risk level. Risk is also somewhat subjective, so who decides the risk level for an incident?
Investigating to investigate
Some investigation has to be done to determine whether an incident should be investigated. Frankly, once that heavy lifting has been done, you are most of the way through an investigation, so why not continue?
Who makes the decision about investigating? Is there a robust and consistent process? Is that person sufficiently trained and experienced? This process is predicated on the belief that some incidents should not be investigated. That may be true.
Expectation to investigate
What other body within an organization asked for more input than the health and safety function? People are always asked to report hazards, near misses, and incidents. They are asked to provide reporting on various things, and the vast majority expect something to be done with that information.
If someone reports an incident and the decision is not to investigate, what message does that send to the employees? It probably doesn't encourage any sort of further reporting.
If we expect people to report everything, they logically expect some action - normally an investigation.
Are there situations where an investigation may not be appropriate? There certainly are. The purpose of investigations is to understand why things occurred. There are many theories that all point to the same thing. We need to understand why things occurred to find the gaps in the health and safety management system. The purpose of investigations is to define these gaps.
Once the gaps are identified, we formulate appropriate corrective actions to close these gaps. The logical output, and the most valuable one, are corrective actions that directly address the identified underlying causes of an incident.
There is only one way to find these underlying causes, regardless of your level of experience and training. An investigation needs to be conducted. There is often some initial investigation done as part of the reporting process. An investigation is needed to understand the circumstances of the incident.
Reporting versus investigation
There has long been some confusion among health and safety practitioners regarding an incident report and an investigation. When an incident occurs, that triggers a reporting process, and that is about what has occurred. There are timelines for reporting to ensure that the loss is communicated to those who need to know, and that appropriate action is undertaken.
When I say appropriate action, I mean, at least in part, an investigation. It is not possible, generally speaking, to complete an investigation within 24 hours. However, it is often required to provide reports within hours of the occurrence. These are two separate activities. Investigation takes a methodical approach. This approach is informed by experience and training.
I hear from some that minor incidents don't need to be investigated, and besides, those people are busy doing health and safety stuff.
So, where does the priority for investigating reports lie? When there is a serious loss, that question is easy to answer. For other occasions, it's not so obvious.
I would suggest that if someone's busy doing health and safety stuff, they have a misguided set of priorities. Supervisors and managers are supposed to be doing health and safety stuff. Health and safety practitioners should facilitate a safe workplace and ensure that the health and safety program or system works properly. An incident indicates it is not working as imagined and require some investigation.
People who report something have a real expectation of some action. Why wouldn't they? They have been told that these reports are valuable or required to help the company be safe. So why would they be ignored? Shouldn't this be a priority? Isn't feedback from front-line workers what health and safety is all about?
The problem with investigations is that you have to investigate before determining that no further investigation would be fruitful or that there wouldn't be anything learned from further investigation. That isn't always an easy call to make.
You need to practice
I read a lot of incident investigation reports, and most of them are woefully inadequate. If you work in a good organization, you don't have a lot of incidents. That is good news.
However, incident investigation is a perishable skill like any other. You have to put it to work from time to time to keep your skills sharp. That's important since health and safety practitioners are being relied upon to find the underlying causes of incidents occurring.
When you have a chain of serious incidents, and your CEO has resigned over it. One has to ask, did previous investigations find issues that would have played into these serious incidents?
One of the leading causes of incidents is poor incident investigations. That is correct. While hindsight is 20/20, foresight is severely lacking. Corrective actions about retraining workers, holding a briefing, and communicating the incident are empty platitudes and the hallmark of poor investigations.
Incident investigations where the health and safety practitioners really get to contribute to workplace safety. No system is impervious to change. Health and safety systems are like a sand castle on a beach. They constantly erode and develop gaps. Incident investigations are one of the critical tools used to find those gaps.
Incident investigations are about proactively addressing causal factors before they can become contributing factors for a serious incident. Is there something more important than that?
Dave Rebbitt is the CEO of Rarebit Consulting, providing services across Western Canada. With over 30 years in health and safety, he continues to be involved in the development of the profession. Dave is the most published author of health and safety in Canada.