Berke on Safety: It Happened. Now Investigate the Accident.

July 24, 2008
It’s 3:15 on a Thursday afternoon. You’re answering one last e-mail before heading out for your tee time.

Edited by Jessica Shapiro

The phone rings, and you hear the dreaded words, “We had a close call down here.” In the June 19, 2008 issue of Machine Design, we reviewed what should be in your incident investigation toolkit. Now it’s time to put your tools into practice.

Before hanging up, you confirm that anyone who is injured is being helped and that any immediately hazardous conditions, like gas leaks or fires, are under control. Then you grab your bag of investigation tools and head to the incident site.

Once there, use security tape to protect the site from intrusion and preserve evidence. Identify who was involved and any bystanders who witnessed the event. It is important to keep these people separate from each other so they cannot compare what they think they saw. Interview witnesses as soon as possible after the incident. Record everyone’s statements with your tape recorder. Keeping notes can also be helpful.

Photograph and video-record the accident scene from three or more levels. I concentrate on floor level, eye level, and from a ladder 12 ft or more above the ground. Measure and record evidence locations with pen and paper as well as with a camera.

After you’ve collected all the information, document it in a written report. Others may refer to this report years after the incident, so make sure you include enough context to make it understandable. You and your investigative team will need to thoroughly analyze all the data to get to the root causes of the incident. Your report should identify all immediate causes of the incident and as many symptoms of the root causes as possible. Remember that most incidents have multiple root causes.

Following documented procedures and separating data gathering from analysis helps you guard against common investigation mistakes. These include revising the facts to fit early theories, making assumptions during the data-gathering stage, letting untrained personnel conduct the investigation, starting the investigation after too much time has passed, and wrapping up the investigation before all the facts are recorded. Placing blame is not a constructive part of the incident investigation process.

Do not be tempted to fit the facts to your needs or wants. Anyone who for any reason cannot conduct an honest and unbiased investigation should remove himself from the process.

An effective incident investigation process is one of the safety tools every company should have. Failure to conduct a thorough incident investigation for each and every incident, regardless of severity, is a good indicator of an unsafe workplace.

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 [email protected].

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