This is a spoken guidance video (transcript) explaining OSHA's recommended four-step systems approach for investigating near-miss workplace incidents. The video emphasizes investigating to determine root causes (not assign blame), preserving and documenting the scene, collecting information (eyewitness interviews, records, manuals), performing root-cause analysis by repeatedly asking "why," and producing detailed, root-cause-specific corrective-action recommendations (who/what/when/how). It also stresses having clear notification/reporting procedures and implementing corrective actions to prevent future incidents and reduce direct and indirect costs.
Chapters
As previously discussed, OSHA policy strongly recommends that a team investigate all near miss incidents as part of a workplace occupational safety and health management program. The purpose of the investigation should be to determine the root cause of the incident, not assign blame. Determining and fixing the root cause of an incident saves companies direct costs like workers compensation claims, as well as indirect costs like lost production, time schedule delays or low morale. Remember, the goal of the investigation is to identify root causes of the incident and to use those findings to correct hazards in equipment, processes, training and or procedures so similar events are prevented in the future. To do this, incident investigation programs should include a clear, easy to follow plan that outlines how and when management should be notified of a near miss incident, the process of notifying OSHA, who will conduct the investigations, timelines of the process, who will receive the investigation recommendations, and who will be responsible for taking corrective actions. To streamline this process, OSHA has developed a four step systems approach where teams preserve and document the scene, collect information, determine the root cause, and implement corrective actions. Step one is to preserve the scene of the incident and ensure no material evidence is removed or altered. This can be done using cones, tapes or other safeguards. The incident facts must also be documented, including the date and who is performing the investigation. This includes recording the names, job titles and contact information of anyone involved, along with the date, time, location, and a detailed description of what occurred. The investigative team can also document the scene through video photographs or sketches. Once this is done, it's time to collect information about what happened. This can be done through eyewitness interviews as soon as possible following the incident, follow best practices that include interviewing in the employee's native language, using an interpreter as needed, stating that the purpose of the interview is to get information, not place blame, and that the goal of the interview is to prevent any further incidents. Allow the interviewees to tell their version of what happened without interruption and take notes. During the interview, investigators should ask clarifying questions as needed, especially in the event of any inconsistencies, and ask the employee what they think could have prevented the incident. Finally, employees do have the right to representation if available and or appropriate. In addition to interviews, investigators may get additional information from external sources like equipment manuals, industry guidance, documents, established company policies and records, maintenance and training logs, previous reports, and any previous corrective action recommendations. Now that all the information has been gathered, it's time to determine the root cause of the incident. Root causes often lead back to issues with management, design, planning, or operational failings. Remember that determining the root cause of an incident is accomplished by asking why repeatedly. For example, if an employee is almost injured during a near miss incident, simply stopping at the idea that the employee didn't follow safety protocol isn't enough. Why didn't they follow safety protocol? Were they not trained properly? Was time an issue? These are all important questions to ask to really address the root cause of the incident. Once the root cause of the incident has been determined, the team must provide corrective action recommendations to be implemented. Corrective actions should be root cause specific and detailed. For example, if the root cause is determined to be that the employees were given insufficient training on safety protocols in a specific area, it's not enough to simply say that employees will be trained. Corrective action should outline how, when, by whom, and what the training will entail. While some corrective actions may take time and perseverance, it's important that they're implemented to reduce the risk of future incidents. In addition to determining how near miss incidents will be investigated, it's also important that companies have a policy in place on how they should be reported.
