Six common roadblocks to optimizing incident investigation

While many employers have an incident investigation process that identifies root causes and corrective actions, some inadvertently include roadblocks to optimizing the value of the investigation. These include:

1. Inadequate time

   There is little doubt that a timely initial investigation leads to better claims management and reduced costs. Details are fresh in the minds of witnesses, the scene of the incident has not been contaminated, and so forth. Although it is important that the investigation begin immediately, there should not be a requirement that the investigation be completed in 24- or 48-hours.

   In the interest of time and efficiency, some supervisors intrinsically link injury reporting, which should be completed in 24-hours, and incident investigation, particularly when minor injuries are involved. However, if the investigation is cut short, it could lead to the wrong conclusions about root causes.

   Consider the example of an employee who fell off a ladder while stocking shelves and suffered only minor bruises. Eyewitnesses noted that the employee was standing on the top step of the ladder, an unsafe action. It would be easy to conclude the injury was a result of human error, yet further investigation found that the ladder was unstable and not the proper height for the employee. Drilling down even further, the supervisor found the facility manager had inspected and recommended replacing the ladder because it was damaged; however, the order was not placed due to budget constraints.

   The time needed to investigate an incident will vary based on the potential for serious injuries or fatalities. Serious and complicated incidents may require a team approach or outside expertise. It's important that those responsible know they have the time and support of management to complete a thorough investigation that will accurately determine the root causes.

2. Lack of accountability

   In many companies, supervisors investigate minor incidents and are in a position to implement remedial measures. Consider the ladder example above. While, on the surface, the solution appears simple - replacing the ladder and reinforcing safety instructions - it involves the larger issue of budget constraints adversely affecting safety. Faced with multiple tasks and concerns about job security, the supervisor may be unwilling to take on the issue, particularly since the injury was minor.

   There are also situations when the supervisor does not have the knowledge or skills to conduct a proper investigation, but is reluctant to seek help. Employers who are disciplined to investigate all incidents have procedures that establish the structure and process of the investigation and give the supervisor flexibility and guidance in such situations.

3. Culture of denial

   Recent research in the International Journal of Human Factors and Ergonomics suggests that workers do not automatically learn from minor incidents or near misses because they adopt a culture of denial. "Dodging a bullet, in and of itself, seems to psychologically encourage workers to adopt the thinking that 'it would never happen here!'" One reason that workers might be in denial is that the workplace has low injury rates.

   With the widespread reduction in injuries, many employees simply do not believe that a workplace injury will happen to them. Some become complacent and overconfident in their ability to do the tasks. When doing the same thing day in and day out, it's easy to forget that an injury can occur. An integral part of an effective safety culture is that employees recognize workplace injuries are possible and that they need to play a proactive role in ensuring not only their own safety, but that of their co-workers, as well. Such an attitude can also mitigate the desire to place "blame" after an incident occurs.

4. Treat as isolated incidents

   Incidents tend to be reviewed as isolated events. Consider again the ladder incident. The department had an excellent safety record and there was no recent history of falls. As an isolated event, it appears to be a minor problem. Yet, the issue here was the lack of an adequate budget for properly maintaining and replacing equipment. Looking at similar incidents in other departments could uncover a number of situations where employees could not perform their jobs safely.

5. Long-term solutions get lost in the shuffle

   Investigative reports often will include both short- and long-term corrective actions to mitigate the possibility of reoccurrence. With management support, short-term solutions tend to be quickly implemented and may mask the possibility of a future problem. There should be a system in place that does not allow long-term solutions to fall through the cracks.

6. Inadequate communication

   Following the completion of the investigative report, it's important to plan how to communicate the results to employees. The goal is to provide a clear roadmap for employees to prevent reoccurrence, not to regurgitate the incident or assess blame. Moreover, spreading the results of the analysis not only with those employees who are directly affected but also with others who could benefit will optimize the impact.