______6. Accidents are investigated for root causes.

Attributes:

• Workplace policy requires a thorough investigation of all accidents and incidents.
• All accidents and incidents are investigated as required by policy.
• All investigations are conducted by personnel trained in accident/incident investigation techniques.
• All investigations include input from all affected parties and witnesses, where possible.
• All investigations determine "root causes" and underlying factors.
• Recommendations designed to adequately address root causes are made as a result of all investigations and result in prompt corrective action.
• Completed investigative reports are routed to appropriate levels of management and knowledgeable staff for review.
• Investigations are done by management and employees.
• Results of investigations are shared with the work force.
• Top management reviews all accidents and incidents to review if root cause was identified adequately.
• Standard forms are used to document all accidents and investigations.
• Top management participates in investigations.

Discussion

• Be sure the accident investigation is conducted as a formal (written, structured) procedure, even if your organization is small. Establish policies to ensure that thorough and timely "root cause" accident investigations are designed, performed, and documented.
• Your accident investigation plan should (1) require investigation of incidents as well as all injury accidents, (2) assign responsibilities for conducting investigations, preferably with line supervisors/managers, and (3) adopt a standard form for all accident investigations.
• The objective of an accident investigation must not be to assign blame, but to identify root (SHMS)causes of the accident so that corrective actions and system improvements are completed. Considerable knowledge and skills is often required to uncover root causes of an accident. The root cause analysis phase of an accident investigation should be conducted by a qualified person such as the safety manager or safety committee.
• Look at records and completed accident investigations to determine if root causes are being discovered and addressed by your organization. As a rule-of-thumb, any accident investigation that attributes a single cause for an accident has not adequately addressed root causes. Have root causes (system design and/or performance weaknesses) contributing to accidents been mitigated? If they have, root cause analysis is effective.

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