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Incident Investigation. Michael Lary, ARM-P, ALCM. Incident Investigation Purpose. The primary purpose of an Incident Investigation is to learn Incident causes and prevent recurrence. Incident Investigation is NOT. A way to attach blame A paper exercise required by someone.

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Incident investigation

Incident Investigation

Michael Lary, ARM-P, ALCM

Incident investigation purpose
Incident Investigation Purpose

The primary purpose of an Incident Investigation is to learn Incident causes and prevent recurrence.

Incident investigation is not
Incident Investigation is NOT

  • A way to attach blame

  • A paper exercise required by someone

Incident investigation is
Incident Investigation is

  • Getting to the ROOT CAUSE

What is root cause
What is Root Cause

A method of determining why things occur by questioning why things are done the way they are or why they occurred

Root cause 5 whys method
Root Cause - 5 Whys Method

Best Practices USED BY:

Lean Methods

Six Sigma

Toyota Motors

Software Debugging

Quality Healthcare Groups

WA Hospitals

Leading Quality Organizations

Accident Investigators

Aircraft Manufacturers

Computer Manufacturers

And others

WHWCP has developed it’s own

Root Cause Form which we will

Cover during this class.

Why take time to do an incident investigation
Why Take Time To Do An Incident Investigation

  • To prevent future occurrences of similar Incidents

  • To show concern from management for the employees

  • Insurance costs are not a fixed expense

  • Required by law, regulation, Hospital and Trust policies

Hidden costs of loss
Hidden Costs Of Loss




Administrative Cost



Lost Profits.


Cost of Hiring and Training

How it all starts
How it all Starts

  • Employee has an incident

    • Obtains First Aid

    • Seeks Medical Treatment

    • Completes the Employee Report of Incident

  • Reports it to supervisor

  • Supervisor Completes their report

Who investigates
Who Investigates

  • WAC 296-800-32020 states that the preliminary investigation for serious injuries must include:

    • Person designated by employer

    • Immediate supervisor of injured worker

    • Witnesses

    • Employee representative (union or elected safety committee member)

    • Any other person with experience and skills

When how what
When, How, What

  • WHEN - ASAP, or when conditions safely permit

  • HOW - Isolate area, locate and interview witnesses, interview injured worker

  • WHAT - Serious injuries, minor injuries, near misses, property damage

Why supervisors investigate
Why Supervisors Investigate

  • Trained the employee

  • Supervise work habits

  • Responsible for safe methods and conditions

  • May be in constant contact with the employee and most familiar with work involved

  • Most familiar with available corrective actions

Investigation techniques
Investigation Techniques

  • Put person at ease

  • Emphasize fact finding

  • Conduct a private interview

  • Ask open not leading questions

  • Verify what is said

  • Explore all the clues

  • Get all sides of the story

  • If re-enacting - use caution

Four causal factor areas
Four Causal Factor Areas





Incident investigation accident sequence


Incident InvestigationAccident Sequence

Direct Cause

Contributing Cause

Root Cause

Direct causes
Direct Causes

  • A sequence of unsafe acts and unsafe conditions that led up to the incident event

Contributing causes
Contributing Causes

  • The reasons “Why” the Direct Cause(s) were allowed to occur, or failed to occur

Root cause
Root Cause

  • Controls which allowed the existence/ occurrence of the Contributing cause(s) and allow them to exist elsewhere

Root cause analysis
Root Cause Analysis

  • Describe Incident

  • Ask about preceding events

  • Ask why each cause was allowed to exist

    • Ask WHY five time to get all issues addressed

    • Review four casual factor areas

  • Use the checklist on the RC form

Investigations summary checklist
INVESTIGATIONS… Summary Checklist

  • Immediately review the incident report once received

  • Remove any immediate hazards or dangers that have the potential to cause injury

  • Initiate the Investigation process ASAP

  • Immediately follow-up on recommendations made and implement corrective measures

  • Ensure corrective measures are effective in preventing a similar repeat incident in future

  • Ensure the Accident and Injury report form is complete, signed off and forwarded as indicated

  • If you have questions or concerns about the Investigation process contact a Safety Advisor in your service area.

Example 1 msi over reaching

Example 2 chemical burn
Example 2 - Chemical Burn

When investigating a Chemical Burntype injury some questions that can be asked are:

  • Was the right chemical being used for the right purpose?

  • Is the MSDS current and readily available?

  • Was Personal Protective Equipment worn as specified? (i.e. gloves)

  • Are there safe work procedures written for the safe use of the chemical?

  • Does the worker have adequate HAZCOM training?

Example 3 slip trip fall
Example # 3Slip/Trip Fall

  • When Investigating a Slip/Trip type injury some questions that can be asked are:

    • What was the tripping hazard?

    • What immediate action needs to be taken?

    • What can be done to ensure the tripping hazard is dealt with over the long term?

    • Who needs to know any new information resulting from the investigation?


  • Incidents are caused

  • Incidents can be prevented if causes are eliminated

  • The same incident will happen again if causes are not eliminated

Corrective actions can include
Corrective Actions Can Include

  • Holding employees and supervisors accountable for safety

  • Improving supervisor/employee communication

  • Improving guards, signs, warning lights

  • Developing and implementing safety policy and procedures

Incident investigation summary
Incident Investigation Summary

  • Understand the critical importance of incident investigation and reporting

  • Use tools presented in this course to determine root causes and corrective actions

  • Understand the importance of corrective action/follow up

Take the time
Take The Time




Questions discussion