Hazard Identification - Action Item 4

Action Item 4: Conduct incident investigations

Management can do this through the following actions:

• Develop a clear plan and procedure for conducting incident investigations, so that an investigation can begin immediately when an incident occurs. The plan should cover the following items:
  • Who will be involved
  • Lines of communication
  • Materials, equipment, and supplies needed
  • Reporting forms and templates
• Train investigative teams on incident investigation techniques, emphasizing objectivity and open-mindedness throughout the investigation process.
• Conduct investigations with a trained team that includes representatives of both management and workers.
• Investigate close calls and near misses.
• Identify and analyze the root causes of incidents to address the underlying program shortcomings that allowed the incidents to happen.
• Communicate the results of the investigation to managers, supervisors, and workers to prevent recurrences.

OSHA notes that identifying one factor that caused an accident may not be enough. Some good questions to ask include the following:

• "Why?" and "What led to the failure?"
• "Was the worker provided with appropriate tools and time to do the work?"
• "Was the worker adequately trained?"
• "Was the worker properly supervised?"

Note that OSHA has special reporting requirements for work-related incidents that lead to serious injury or a fatality (detailed in 29 CFR 1904.39). OSHA must be notified within 8 hours of a work-related fatality, and within 24 hours of an amputation, loss of an eye, or inpatient hospitalization.

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