Unlock the secrets of incident investigation: Avoiding one crucial mistake
When an incident occurs, busy supervisors must resist the temptation to treat the incident report as mere paperwork. Instead, they should approach it as a tool for preventing future injuries. The critical question to ask is, "What’s the hazard?" Identifying the hazard accurately is the cornerstone of effective investigation to eliminate the chance of future injury to workers.
The crucial question: What’s the hazard?
Picture this. It is an ordinary day at work, and you, as a supervisor, are focused on the routine tasks that keep the workplace running smoothly. However, in the blink of an eye, the worst happens. A serious injury occurs on the job to one of your workers.
As the supervisor of the injured worker, you now find yourself responsible for a vital task. You are required by your employer, and OSHA, to fill out a report of the incident. This has now become your priority and needs to be completed promptly, interrupting the plans you had in place for the day.
Here is where a crucial mistake often occurs. A mistake that could jeopardize the safety of other employees in the future. In a rush to complete paperwork, meet regulatory requirements, and continue with the plan for the day, supervisors may downplay the importance of truly understanding the hazard and its root cause. Potentially this could mean more injuries.
OSHA tells us the incident investigation report should thoroughly answer four important questions:
- What happened?
- How did it happen?
- Why has it happened?
- What needs to be corrected?
A key question to ask in answering the above is, "What’s the hazard?" Failure to answer this question correctly can result in an incorrect root cause analysis and a missed opportunity to prevent similar injuries in the future.
How do we ensure that we do not make this crucial mistake? Let's dive into the heart of incident investigation and explore the guidance provided by OSHA for effective root cause analysis.
OSHA’s tools for effective root cause analysis
To avoid the common mistake of overlooking the true hazard, supervisors can use OSHA's recommended tools for guidance on effective root cause analysis. OSHA’s fact sheet, “The Importance of Root Cause Analysis During Incident Investigation,” provides the following tools:
- Five whys;
- Brainstorming;
- Checklists;
- Logic/Event trees;
- Timelines;
- Sequence diagrams; and
- Causal factor determination.
Simpler incidents may only require a few tools such as five whys, brainstorming, or a checklist. More complex incidents may require a more systematic approach with logic trees, diagrams, or even a combination of the tools. It is up to the investigator to determine the appropriate tool(s) with the sole purpose of recognizing the true hazard and providing an effective solution.
Consider this scenario
An employee sustains an injury on the shop floor. The initial report indicates a slippery floor, and the supervisor's solution is a reminder to be more careful when working in that specific area.
However, a deeper investigation, utilizing root cause analysis tools, reveals a hidden culprit. The presence of a leaky floor pipe is causing a consistent buildup of moisture, creating a puddle that is forming a hazardous slippery situation. In this case, the hazard is not just the slippery floor but the leaky pipe.
Identifying the true hazard allows for a targeted and effective solution. By fixing the leaky pipe, the supervisor prevented the hazard from occurring again and protected future employees working in the area from potential injuries.
Key to remember: By avoiding the crucial mistake of overlooking the true hazard, we can create safer workplaces and prevent the recurrence of injuries.