1. Originally published in the February 23, 2015 issue of Safety+Health Magazine
&
Once you’ve finished an
incident investigation, how do
you use investigation data to
prevent similar incidents from
occurring again?
B
y their very nature, incident investigations are
reactionary. But properly collecting and studying
investigation data, and then clearly communicating
the findings, will provide the best opportunity to
prevent similar incidents in the future.
A decision is only as strong as the data it’s based on, and an
investigator must properly collect data about the incident under
investigation. In most cases it will make sense to use a fault tree
analysis, root cause analysis or what-if checklist. These tools
can be obtained from OSHA or by following the OSHA Process
Safety Management Standard (29 CFR 1910.119). Adhering to
the OSHA hierarchy of controls is the preferred model to identify
the root cause of an incident. During the data collection phase,
you can also identify any significant human factors and potential
cultural issues within the organization/department.
Most safety professionals are already familiar with the tools
mentioned above. However, this knowledge can lead many
to approach the investigation with a preconceived solution in
mind, which can derail an investigation before it has begun.
Keep in mind that performing an investigation will help you
determine what caused a single incident, and an analysis of
larger behavioral trends is the first step in preventing a range of
similar issues going forward.
QUESTION: Once you’ve finished an incident
investigation, how do you use investigation data
to prevent similar incidents from occurring again?
Responding is Tim Page-Bottorff, CSP, senior
safety consultant at SafeStart, Belleville, Ontario.

2. To avoid future incidents you need to put the data you’ve
collected to good use by thoroughly and impartially
analyzing it. Examine the metrics to see if the incident
is part of a larger pattern. At a minimum, you should be
looking at data that covers several years of organizational
and departmental safety performance. If you are trending
in certain areas you can make adjustments to your safety
management system.
There are two main types of trends you will notice. A series
of incidents that are all functionally identical may point to a
problem with the hierarchy of controls, and an engineering
solution may be a suitable course of action.
However, engineering solutions are often unable to
completely address issues such as slips, trips and falls –
or workers making poor decisions, taking safety shortcuts
or forgetting to wear their personal protective equipment.
A broader pattern of incidents may indicate that your
company will be best served by implementing a long-term
solution to address human factors in addition to ensuring
the hierarchy of controls is sufficiently robust.
Don’t underestimate the value of properly communicating
the results of an investigation. You should deliver a detailed
report to management and also post a summary of your
findings for employees. If you are implementing an
engineering solution, then outline any changes that will be
made to help prevent that incident from happening again.
If human factors played a role in
the incident, then communicating
corrective measures to employees
may be more challenging because
nobody is intentionally trying to
get hurt. Simply telling them to
stop unsafe behavior will only
provide a temporary fix at best; you
will most likely be better served by
integrating regular human factors
training alongside the existing
hierarchy of controls.
Although both are necessary and important, the big difference between
engineering and human factors solutions is that engineering improvements
typically only prevent the exact same incident from occurring again
(installing a guardrail at that location) whereas addressing the human
factors (keeping eyes and mind on task or looking before moving) will
prevent similar incidents from occurring throughout the plant or even off
the job. An impartial assessment of your safety data will guide you in
determining which type of solution will provide the biggest benefit.
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SafeStart, a division of Electrolab Limited
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Copyright © 2015 by Electrolab Limited
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Tim Page-Bottorff, CSP is a senior safety consultant at
SafeStart, past president of the ASSE Arizona Chapter
and a former United States Marine. As an OSHA trainer
he is well-versed in how to facilitate effective training
sessions and he frequently speaks about training and
other safety topics at national safety conferences.
Learn more at safestart.com/tim.
About the Author