But reacting
only to “lost time” incidents means ignoring 99% of
the opportunities to make the workplace safer. An
effective close-call and accident investigation program
with employee buy-in is the cornerstone of a
safe workplace.
An accident is any unplanned, undesired event. It is not necessarily
injurious or damaging, but it disrupts the completion of a task. By this
definition, close calls fall under the “accident” umbrella. Every incident,
from personal injury accidents to close calls, should be thoroughly investigated
to identify and address root causes.
Having a company-wide Incident Investigation Plan (IIP) in place,
incident investigation materials and equipment readily available, and key
people trained to lead the investigation makes it easier to examine every
aspect of the incident and ultimately identify the root causes.
The IIP should tell those involved or those who witness an incident
whom to contact. This can include volunteer firefighters and paramedics
in the workforce who can lend immediate assistance. It should also list
trained incident investigators by title, not by name. People get promoted,
get fired, retire, etc., and if they are being searched by name it may be difficult
or impossible to find them.
The team members should have all the equipment close at hand for a
proper incident investigation. They should be able to grab a back pack
or gym bag and know it contains a note pad and pen, call list, security
tape, still camera, flash, extra film or memory card, video camera, tape
measure, tape or digital voice recorder, flashlight, extra batteries for all
electronics, checklist or questionnaire designed for that workplace, and
any other workplace-specific equipment.
The questionnaire aims to answer the following questions: Were there
defects in the products, machines, or machine systems, including component
failures? Was operator error or misuse, such as not following a job
safety analysis write-up, a factor? Did environmental conditions come
into play? Were warnings sufficient and did they function properly? Were
the instructions adequate and understandable? Were there errors in or
information missing from the owner’s manuals?
Investigations should start as soon as possible after the incident, when
blood is still wet on the floor, so to speak. The investigation should be the
top priority of the investigation team, not squeezed into an investigator’s
schedule when it’s convenient. In addition to recording vital evidence before
it disappears and quickly reducing the risk of future incidents, an immediate
response to an incident shows that management is serious about
the company’s safety program, and not just giving it lip service.
Having the right physical and administrative tools in place is half the
battle when it comes to successfully investigating an incident and using it
to improve workplace safety. We’ll discuss the other half, using the tools
in an incident investigation, in the July 24 issue of Machine Design.
Lanny Berke is a registered professional engineer and Certified Safety
Professional involved in forensic engineering since 1972. Got a question
about safety? You can reach Lanny at lannyb@comcast.net.