Incident Investigation & Root Cause Analysis: Prevent Future Incidents
Master the art of incident investigation and root cause analysis to prevent workplace accidents, improve safety performance, and create a safer work environment.
Understanding Incident Investigation
Incident investigation is a systematic process for identifying the underlying causes of workplace accidents, injuries, and near-misses. Effective investigation goes beyond immediate causes to identify root causes and systemic issues that contributed to the incident.
A thorough incident investigation helps organizations understand what went wrong, why it happened, and how to prevent similar incidents in the future. This systematic approach is essential for continuous safety improvement and risk reduction.
Root Cause Analysis Methods
5 Why Analysis
Ask "why" five times to drill down to root causes
Example:
- Why did the machine fail? - Because the bearing wore out
- Why did the bearing wear out? - Because it wasn't lubricated
- Why wasn't it lubricated? - Because the maintenance schedule wasn't followed
- Why wasn't the schedule followed? - Because there was no reminder system
- Why was there no reminder system? - Because maintenance procedures weren't documented
Fishbone Diagram
Visual representation of cause-and-effect relationships
Categories to Consider:
- • People: Training, experience, fatigue, communication
- • Methods: Procedures, policies, work instructions
- • Materials: Equipment, tools, supplies
- • Environment: Physical conditions, weather, lighting
- • Management: Supervision, planning, resources
Fault Tree Analysis
Systematic approach to identify failure modes
Process:
- Define the top event (incident)
- Identify immediate causes
- Break down each cause into sub-causes
- Continue until reaching basic events
- Analyze probability and impact
Investigation Process
1. Immediate Response
- Secure the scene and prevent further injuries
- Provide medical attention to injured persons
- Preserve evidence and document the scene
- Notify appropriate authorities and management
2. Investigation Team
- Assemble qualified team with clear roles and responsibilities
- Include safety professionals, supervisors, and subject matter experts
- Ensure team has necessary training and authority
- Establish investigation timeline and milestones
3. Data Collection
- Gather physical evidence and photographs
- Collect witness statements and interviews
- Review relevant documentation and records
- Analyze equipment and environmental factors
4. Analysis
- Use systematic methods to identify root causes
- Identify contributing factors and system failures
- Prioritize findings based on impact and likelihood
- Document findings and recommendations
5. Corrective Actions
- Develop and implement preventive measures
- Assign responsibilities and timelines
- Monitor implementation and effectiveness
- Share lessons learned across the organization
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