Incident Investigation and Prevention
It is very rare to experience a new type of incident in the workplace, yet incidents continue to occur. Why?
We fail to implement learnings from external and internal incidents into our organisational systems and processes.
We fail to share learnings from other organisations for fear of being told “We just don’t do it like that here.”
We fail to investigate the incident appropriately meaning preventative actions are not identified let alone implemented.
The incident investigation process is critical to identifying and implementing preventative actions (learnings) but how do we ensure our processes are robust? Is the following in place in your organisation?
An incident investigation procedure and guidance documents that are readily available to personnel;
Templates ready for those completing the investigation for example:
Witness statements;
Report only forms;
Full incident investigation report templates;
Communication tools i.e. Escalation notification table and incident alerts templates.
Incident investigation training relevant to your processes. This does not always mean external formal training (i.e. ICAM, TAPROOT), but training should be provided at all levels of the organisation (from a simple toolbox explaining how and why to report to investigation methodology for supervisors) dependent on roles and responsibilities.
A process to engage with those stakeholders impacted by the outcome of the investigation for comment and input on the recommended actions;
Realistic investigation time frames such that the focus is on obtaining all relevant information and not expediting the process to meet unrealistic and unhelpful deadlines;
Incidents are investigated based on their potential severity.
The ability to utilise external incident investigators for serious incidents who can bring an objective viewpoint.
Fundamentally management have a responsibility to ensure the Incident investigation process is timely, flexible and user friendly. It is imperative training and documented guidance is provided to ensure those utilising the system are set up to succeed and not just ticking the box.
Einstein once said “Insanity - doing the same thing over and over again and expecting a different outcome”. We need to start conducting investigations with the intent of identifying sustainable preventative actions and implementing them if we ever expect to stop incidents from occurring.
