Your organization may have a well-developed safety committee that performs accident investigations, or you may pull together a group including management, human resources and department managers to tackle the “what happened and why?” questions about incidents. However you choose to proceed, taking these steps will help you find the answers you need to help prevent similar accidents.
Start immediately
The first thing you should always do is ensure the injured employee receives proper medical care. After that you will want to:- Shut down the equipment and make adjustments to prevent further injuries
- Interview employees who witnessed the accident
- Look over the site for clues, take photos before moving anything and take notes
- Retain all components, such as damaged equipment, in case the items are necessary for insurance purposes
Delve into the root cause of the accident
It’s easy to assign blame to one thing when actually the cause was something totally different. To discover the root cause of the incident, try a technique known as “The 5 Whys.” This involves starting with an obvious statement of what happened, followed by asking a series of questions on why the event happened, working toward each next logical step to uncover what the real cause was.Here’s an example of this process:
- Question 1: Why did Bob lose the tip of his pointer finger when repairing a press machine?
- Answer: The machine started suddenly and the ram came down.
- Question 2: Why did this happen to the press?
- Answer: Another person started the machine because no energy lockout was performed.
- Question 3: Why wasn’t the lockout procedure followed?
- Answer: Bob was never trained on the lockout procedure.
- Question 4: Why was he not trained?
- Answer: Management was unwilling to spend money on training procedures.
In this case, only four questions were needed to get to the root cause of the accident. It’s typical that three to five questions will get to the true cause of an incident.
Another method of uncovering the root cause(s) is Root Cause Analysis. This process involves looking at what happened, how it happened, why it happened and what needs to be corrected.
For example, if a worker slips on a puddle of oil on the floor and falls, it’s easy to say that the cause of the accident was the oil spilled on the floor, but doing an analysis might include questions such as:
- Why was the oil on the floor?
- What is the source of the oil?
- What tasks were underway when the oil was spilled?
- Why did the oil remain on the floor?
- Why wasn’t it cleaned up?
- How long had it been there?
Finding the answers to these questions will lead to the discovery that the oil came from a compressor, that the leak in the compressor had not been detected, and that the compressor was not inspected regularly because it was not a part of the company’s routine maintenance and repair program.
Investigating using either The 5 Whys or Root Cause Analysis process may involve brainstorming, accident mapping, looking at timelines or sequencing events, and using logic trees to examine the details in depth and with an open mind.