Incident investigations are intended to determine the cause of an incident, to identify unsafe conditions or acts, and to recommend corrective actions so that similar incidents don't occur in the future. The purpose is prevention, not blame. It is always important for your organization to investigate incidents on its own to be able to better understand and learn from the incident. But how do you investigate? Below is a list of six steps to help get your organization moving in the right direction.
Step 1 – Immediate action
In the event of an incident, immediate action to be taken may include making the area safe, preserving the scene, and notifying relevant parties. The investigation begins even at this early stage, by collecting perishable evidence, e.g. CCTV tapes, samples, and photographic or video evidence.
Step 2 – Plan the investigation
Planning ensures that the investigation is systematic and complete.
- What resources will be required?
- Who will be involved?
- How long will the investigation take?
- For severe or complex incidents, an investigation team will be more effective than a single investigator.
Step 3 – Data collection
Information about the incident is available from numerous sources, not only people involved or witnesses to the event, but also from equipment, documents, and the scene of the incident.
Step 4 – Data analysis
Typically, an incident is not just a single event, but a chain of events. The sequence of events needs to be understood before identifying why the incident happened.
When asking why, we need to identify the root and underlying causes, as well as the direct causes. Failures and mistakes don’t just happen by themselves; organizations allow error-enforcing environments that encourage direct causes to develop and persist. Such environments, and the basic management failings behind them, are the root causes – the ultimate source of the incident.
While human error plays a part in the majority of incidents, people are not generally stupid, lazy, forgetful, or willfully negligent. Human errors occur because of influencing factors associated with the work, the environment, an individual’s mental or physical abilities, the organization, and its management systems. Any investigation which sets out to find someone to blame is misguided.
Step 5 – Corrective actions
Many investigations make the mistake of raising actions that deal only with the direct causes – a quick fix, putting last-lines-of-defense back in place. By ignoring the root and underlying causes, not only do they miss an opportunity to reduce the risk of recurrence of the incident, but they also leave open the possibility that other, dissimilar incidents may also occur, arising from the same, common root cause.
Step 6 – Reporting
The investigation is concluded when all outstanding issues have been closed out and the findings have been communicated so that lessons can be shared. Communication mechanisms include formal incident investigation reports, alerts, presentations, and meeting topics.
The above is a very basic overview of an incident investigation. An actual investigation can be much more comprehensive involving many more steps depending on the type of incident. If you would like to discuss this topic further, please contact our office.
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