Established analysis systems look beyond human behaviour and apportioning blame, and, instead, aim to determine the root causes within a company’s health and safety management system by identifying failures in the processes leading up to the incident at management system level. This is achieved by looking at the procedures that were supposed to prevent an accident from happening. The key aim is to prevent recurrence and provide a permanent solution that avoids repetitive nonconformity. A detailed investigation also sends out a strong message to the workforce and enforcing authorities that you are committed to the safety of those affected by your operations.
The severity of the accident will be key in determining the scope of any investigation, but the overall process should be consistent and follow the requirements within your management system with key stages such as
- responding immediately by coordinating an emergency response; notifying the emergency teams and enforcing authorities; attending to the direct needs at the accident scene; and securing the site and isolating the working area to ensure that a thorough investigation can be carried out. The aim is to preserve the integrity of the scene and to be able to gain a clear understanding of the conditions at the time.
- gathering information by focusing on collecting as much data and evidence about the incident as possible. This involve questioning witnesses about what they saw; gathering key documents ranging from plant and equipment logs to photos of the accident scene; identifying any gaps in the information; and attempting to fill those gaps through additional investigation. It is essential that the investigation remains impartial and that questioning is neutral and refrains from allocating responsibility or blame.
- performing the root-cause analysis. At this stage, the investigation team should have access to all available information and be able to determine what happened and how, and to cite a probable cause. The aim at this stage is to obtain the root cause, which is defined as the initiating event or failing from which all other causes or failings arise. Root causes are generally management, planning or organisational failings.
- developing an accurate investigation report that contains all the facts so that everyone involved in the investigation works from the same controlled documented information and can refer to it when required. The report should include all the documentation obtained during the investigation, a summary of what happened and the conclusions drawn from the investigation process.
- sharing the findings and making improvements. The key value of an accident investigation is to help prevent future accidents from happening. It is vitally important to share the findings and recommendations from your investigation. This will ensure that the conditions that contributed to the accident are comprehended, deeper insights about the gaps in the health and safety management system are understood and, in the future, personnel are encouraged to make the right choices, thus, aiding a change in health and safety culture from the top down.
In conclusion, root-cause analysis is a key tool in identifying the true cause of an accident and helps refine a health and safety management system such that risks are mitigated through gap analysis and preventive measures are implemented at an early stage. Blaming individuals is fruitless and sustains the myth that accidents are unavoidable when the opposite is actually true. The systematic approach of root-cause analysis creates an environment where lessons can be learned from an unnecessary accident, thereby providing safeguards for workers in the future.
For more information, please contact Martin Geer on +44(0)1928 726006.