“All incidents are preceded by unsafe acts and/or unsafe conditions” (Australian Master OH&S & Environment Guide, 2007, 143). The aim of an accident investigation is to determine the main causal factors – enabling the organisation to control those risks to prevent future recurrence. In order for the process to be effective there are a range of elements which must be satisfied in a well-documented process. Most accidents occur without any prior notice, for an investigation to be effective it must be undertaken immediately following the incident. To conduct consistent and credible investigations a documented process should be followed.
Below are several important elements that are necessary for an effective accident investigation process to take place. Each of the below elements are explained and many have relevance to each other. Recommendations are also made through-out the descriptions on how each element should be implemented.
Accident Investigation (and reporting) Policy
All employees should be aware of, and be prepared to participate in the organisations policy for incident reporting and investigation. The objective of this policy should be to establish the causes of incidents so effective controls can be applied to prevent their recurrence.
Blame should not be a factor in the investigation policy and it is important that the policy projects an impartial and objective process with the focus being the establishment of all the causes.
The organisation should (to an extent) pre-determine the composition of the ‘investigation teams’, although the size and make up of these teams should be dictated by the seriousness/complexity of the individual incident, guidelines should be established to show who should be involved, e.g. all incidents should be investigated by:
“When an incident occurs, the investigators must be ready to act immediately – they need training and preparation in advance and a written plan for incident investigation”. (Australian Master OH&S & Environment Guide, 2007, 143).
Members of the investigation team must receive training in the worksites risk assessment methodology, note taking, observation skills, interview techniques, etc. The better trained and more knowledgeable the investigators the more credible their findings will be.
It is also important to remember that any internal report can be requested and viewed by the OHS Authority in the relevant state if it decides to investigate the incident (unless subject to legal professional privilege). This means that information on the report can be used by the authority and it is therefore important that information is recorded clearly and appropriately. If a trained investigator is not available within the organisation a lawyer could be engaged to act on behalf of the employer in very serious accidents.
Incident investigation procedures need to be established, they should be systematic and should direct the investigation team to attempt to answer some specific questions such as:
Identifying the root cause of an incident can be a very complicated process. The investigation may reveal several factors which have formed a chain of causation factors leading to the end result. By providing investigation team members with set procedures the findings will be more consistent and credible. The ‘Australian Master OH&S and Environment Guide’ stated:
“In the events leading up to an incident, there will be a number of essential factors that always have design, environmental, behavioural and managerial/supervisory components. These four components make essential contributions to 100% of incidents”. (Australian Master OH&S and Environment Guide, 2007, 143).
An effective investigation process will address each of these components and ask investigators to consider factors from each in determining the key causation factors.
In the ‘operational readiness philosophy’ (Kingston. J, 2008, 2) there are three sources of criteria: functional, risk-based and ‘codes, standards and regulations’ which should be addressed in an accident investigation procedure.
a) Functional criteria: The investigation tasks are performed in a manner that is acceptable to the managers of the investigation. The procedure should state how an investigation is to be commenced, who should be communicated with, etc.
b) Risk based criteria: The investigation delivers risks that are acceptable to people, assets, timelines, quality and cost of the investigation. The procedure should show how risks need to be assessed (e.g. the organisation should have a separate risk assessment procedure and methodology with set time lines for action on different levels of identified risk).
c) Applicable codes, standards and regulations: The investigation works within the established codes, standards and regulations at all times. The procedure should identify relevant requirements – and the need to consult with external persons when a specific expertise is needed.
Appropriate resources must be assigned in order to effectively conduct an investigation. As shown in the ‘operational readiness philosophy’ published by The Noordwijk Risk Initiative Foundation, resources can be grouped into three elements:
b) Plant and equipment
c) Procedures and management controls
Resource allocations should be defined before an investigation commences, a process for seeking approval for resources should be documented. For example, the investigation team has the ability to remove persons from their usual duties to participate in the investigation process (people resources).
It is important that employees are communicated with effectively during any investigation. Employees should be informed about the process, the objectives and what involvement is required of them at the beginning of the investigation. There are legislative requirements regarding the identification and control of risks and communicating this information to affected employees. Employees that are communicated with effectively will feel engaged with the OHS processes in the workplace, which will help to increase awareness and compliance.
Accident/incident recording system
As a part of an effective OHS Management system (and to be in compliance with the relevant Australian Standard AS/NZS4801:2001) all organisations should establish a system for recording and reporting on workplace incidents. The primary function of this system should be to initiate preventative action and reduce the potential for similar incidents to occur, whilst meeting mandatory legislative reporting/recording requirements. Australian Standard AS 1885.1 provides an easy to use method of recording workplace incidents, this method of recording incidents should be used to enable organisations to measure their performance against comparable data from the national data set, available through SafeWork Australia (http://nosi.ascc.gov.au/).
Overarching management system
“The fact that an incident occurred nearly always means something went wrong in the management system – an omission, oversight or a lack of control of circumstances that permitted the incident to occur”. (Australian Master OH&S & Environment Guide, 2007, 143)
An organisations accident investigation and analysis process is one of many tools that can be used to assess the effectiveness of the overall OHS management system. In an effective accident investigation deficiencies in the organisations OHS system would most likely be identified.
The Management system documentation should give mention to the accident investigation process and its importance in assisting the organisation to continuously improve its safety performance.
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