Conducting an incident analysis after an accident is one of the most effective tools to learn why an incident happened, which in turn gives an organization information to eliminate future safety incidents. Also, many jurisdictions give the employer and insurer a very narrow window (usually 21 days) to accept or deny a claim. Most employers do not realize the importance of getting all the facts to the adjuster quickly so he or she can make a compensability decision, as many jurisdictions will bar an employer from presenting facts if those facts were discoverable before the claim was accepted. A good example might be a willful misconduct defense raised because the employee willfully refused to follow safety rules. If the employer does not send this information to the adjuster until months after the claim was denied, the judge could rule that this is not “newly discovered” evidence and throw it out. So, getting the adjuster the facts in a timely fashion is critical to the management of the claim. But as we began this discussion, the real benefit of conducting an incident analysis is to discover why an incident (or near miss) happened to help improve the safety culture on a go-forward basis.
Root Cause vs. Immediate Cause
The incident investigation process is sometimes also referred to as a “root cause analysis”, and while the root cause should be investigated, there are other factors to keep in mind. EHS Today defines the two main types of causes as:
- Root Cause: The management system causes that result in unsafe conditions existing; these causes affect the entire system and as a result could lead to future incidents and operational problems.
- Immediate Cause: The unsafe acts and conditions that could lead to one specific incident; examples include unsafe conditions, improper tools, or failing to wear protective gear.
Both factors should be investigated during the analysis. The immediate cause will demonstrate what led to that particular incident occurring, but a root cause analysis will help you to understand the operational practices that led to that immediate cause being present and able to cause an incident. An immediate cause is important to know, but without understanding the root cause, your business will likely continue to see on-the-job incidents.
After the claim has been reported and the incident site has been secured, it’s time to gather as much information about the incident as is possible. As stated earlier, this should occur as soon as possible in order to ensure that any eyewitnesses will be able to recall the incident and that any evidence of the incident is not altered or eliminated through regular work operations. OSHA recommends keeping these four questions in mind when performing an incident investigation:
- What happened?
- How did it happen?
- Why did it happen? Remember, you typically have to ask why 5 times to determine the root cause!
- What needs to be adjusted going forward?
There are a number of steps that should be taken in an incident investigation:
Step 1 – Make sure that the injured employee, their supervisor, the employer, and any witnesses to the incident are present. Some organizations form an incident investigation committee (as part of their safety committee) to conduct the incident investigation.
Step 2 – Gather as much information about the incident as possible. In addition to gathering testimony from eyewitnesses, talk to workers who say that they did not see the incident, just to make sure that you can create a complete picture of what happened. In addition to eyewitness testimonies, find as much documentation as you can. Take photographs and find diagrams of the incident setting, look for surveillance footage if you have any, and use any logs that you keep (such as employee logs and equipment logs).
Step 3 – Once you’ve gathered as much information as you can, develop it into a clear and easily comprehensible report that presents the facts of the incident in chronological order with all necessary documentation. This will help to better ascertain the cause of the incident and will be helpful to have in the event that the claim evolves into a lawsuit.
Things to Keep In Mind
During this process, it’s important that you carry out the investigation properly. Make sure that you use a good form, and train all supervisors on how to properly complete the form. We have a model incident analysis form and supervisor training to assist your efforts. Once the form has been completed, it should be passed on to your organization’s safety committee, so they can use the information to adjust future safety and training programs.
Though you are looking for the cause of the incident, take care to not – whether it is intentional or inadvertent – place blame on any one individual, or act in a way that leads employees to think that they may receive consequences as the result of the incident. The most important part of these investigations is getting the facts (and using the gathered facts to tweak safety policies, procedures, and training to avoid future incidents), and if your employees are more concerned about their employment status, you are likely to not receive all of the information you need.
Don’t Ignore Near Misses
You should consider extending your incident reporting program to near misses. Near misses are predictors of future claims. Consider for every 300 near misses there are 30 minor accidents and 1 major accident. If you are investigating a major accident, chances are there were hundreds of near misses leading up to the accident. If you can learn from near misses and modify your safety program, you can eliminate major injuries.
About Compass RMS
The risk management firm Risk Management, Inc. has specialized in workers’ compensation since 1996, creating the CWCP (Certified Workers’ Compensation Professional) program in 1999 and the P4 process in 2000. We launched our Compass Risk Management platform in 2008 and recently released version 4.0. For more information about our services, give us a call at (770) 534-2042 to speak with one of our consultants.