Incident investigations are a critical part of your safety program and safety culture. When an incident occurs, when and how you address it is equally as important as what you address and why. There are a number of best practices that an employer should follow when faced with any OSHA inspection. Like most best practices, they start with advanced planning so that everyone is prepared when the inspector shows up. Without consistent and recurring efforts to identify possible failure modes and means to resolve them, the organization will be vulnerable to unknown hazards and threats.

Tips and reasons for conducting internal inspections and incident investigations

By Randy DeVaul, MA, NREMT

I see it all the time. For whatever reason, OSHA is at the door unannounced – to start a random inspection, investigate a safety complaint, to begin an investigation – and everyone from the plant manager to the safety department starts to sweat. Department phones are ringing, radio chatter escalates, the entire site is ablaze with scurrying activity to sweep, clean, hide, find, review, warn, and inform employees to “do it right, the OSHA inspector is here.”

If that describes you and your site, what do you think are your odds of coming out of this “clean?” With years of experience working to help employers either avoid this scene or to recover from this scene, I would say it is not good.

What if you had the written plans, the training records, PPE, the audiograms, the guards in place, LOTO procedures for your specific equipment, an accountability program, and employees who could intelligently describe their roles and tasks, already in place? What if the inspector arrived on “just another day” where people were doing what they were supposed to be doing and doing it right? You might ask, “How does that happen and how would I know?”

If you are prepared for an OSHA visit, you likely also have a better safety program and culture. You likely have trained employees, plans in place, emergency drills up to date, and records ready for review. The title of this article is a bit misleading because if you are ready for an OSHA visit, you likely already have a good safety record and program. You likely have engaged employees who help you find and correct hazards to ensure you have a safe workplace.

To be ready, you should at least conduct and track your own internal inspections and audits. These tasks will identify shortfalls while also identifying what is good.

An inspection is a snapshot of what is happening right now with your employees – to evaluate what is good and what may need to be addressed. An inspection looks for hazards as unsafe conditions and unsafe practices, observing tasks for correctness, ensuring first aid kit contents are not expired, checking that PPE is being worn and used properly. In other words, an inspection shows what is currently being done by employees.

An audit determines what regulatory requirements apply to you, and, for starters, whether you have them. It is a checklist to review required programs, ensure they exist, and then determine if what you are doing matches what the programs require. Examples include locating and ensuring you have all of the written plans in place, noting when you conducted your last emergency drill, checking if you have a response team to meet the 5-minute time requirement, checking to see if you have first aid kits and where they are located, ensuring you are conducting forklift pre-inspections. In other words, an audit shows you what should be done and if you are on track.

Conducting inspections and audits

Who can conduct an internal inspection? Anyone or any team, at any level of the organization can do an inspection if that person or team has knowledge (training) on what to look for. Participants can inspect their own work areas or schedule a walk through other work areas as a fresh set of eyes. They should know that a hazard can be an unsafe action or practice as much as (if not more than) an unsafe condition. Conditions generally don’t exist unless a practice or action creates it. So, teams look for both conditions and practices to make their workplace safer.

An audit is an administrative checklist of required/regulated programs – anyone can conduct an audit because all the person is doing is completing the checklist. Generally, it should be conducted by someone outside of the department being audited. The auditor does not have to know how to do the tasks; the auditor just needs to identify that the programs exist, where they are kept, and that they are current. For example, does the location have emergency evacuation drills? Is there a procedure and employee training on evacuating the premises? When was the last training conducted? When was the last drill conducted (should be at least annually or when the plan changes)?

Documentation

Inspection and audit findings should be documented so if something needs addressing, it gets assigned, followed up, and completed. The document can be a tracker, a spreadsheet, an e-file and should become part of a daily cadence until the items are complete.

Conducting your own inspections and audits will help prepare you for that OSHA visit and increase your employee engagement, which will enhance your safety culture. The inspection eliminates hazards and engages your employees; the audit aids in compliance. Having both in place and in practice will reduce your hazards and improve your readiness.

Incident investigations

Incident investigations are a critical part of your safety program and safety culture. When an incident occurs, when and how you address it is equally as important as what you address and why. If you “tell” employees that safety is important but fail to “show” your commitment through prompt and thorough investigations of incidents, you de-value your word and lose face with your people.

OSHA defines an incident as "an unplanned, undesired event that adversely affects completion of a task." In the past, the term "accident" was used to refer to an unplanned, unwanted event. To many, "accident" suggests an event was random and could not have been prevented. Since nearly all worksite fatalities, injuries, and illnesses are preventable, OSHA now suggests using the term "incident" (a term I have used for 25 years) to address any event in which an unwanted outcome occurs. This includes injury, illness, property damage, or near-miss (I prefer, “near-hit”), otherwise known as a close-call.

When an incident occurs, it is an indication that something has gone wrong. Incidents do not just happen; they are caused. The basic cause(s) of an incident is from one or a series of unsafe acts and/or conditions that sets up circumstances leading to that undesired event. The primary purpose for conducting an investigation for every incident is to determine the cause and initiate corrective action(s) that prevent similar type incidents from recurring. Certainly, the level or depth of an investigation – the amount of detail and effort needed — will vary, depending on the incident. Bear in mind that what may initially appear to be an insignificant event on the surface may shed light on a serious condition or practice that needs immediate attention. What is important, then, is for each incident to get your attention and prompt evaluation.

So, we investigate all incidents, whether an injury or property damage has occurred or not, because the root cause and contributing factors that led to the incident could result in a similar incident leading to the ultimate undesired event — a fatality.

Let me be clear: the purpose of an incident investigation is to always identify, address, and correct actions and/or conditions that can lead to a fatal or serious injury. Your employees are most important. The point of the investigation should always be a reinforcement to your employees that it is about improving their safety – both performance and working conditions. The goal of investigating a property damage incident is not to focus on what was damaged or the cost of the damage; the goal is to identify the root cause of the damage to prevent someone from being killed or seriously injured. In other words, it is about improving your safety culture and safety performance at all levels within the organization.

Investigating a worksite incident provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents.

The focus is on identifying and correcting root causes, not finding fault or blame. I have never liked the term, “behavior-based safety.” Whether intended or not, the outcome to behavior-based safety investigations often ended in finding a scapegoat rather than the root cause. Throughout my career, I have addressed safety through integrated performance – including processes, procedures, and employee practices. Looking at the whole picture, from how the process(es) work, what procedures are currently in place and the accuracy of those procedures, to how and why employees practice or follow those procedures, will reveal what went wrong, what caused the undesired event, and how to address it, going forward.

To ensure a thorough investigation, you need multiple people involved. A cross-functional team works best by including the involved employees, the supervisor, the safety department, and may include human resources, maintenance, and engineering. Multiple perspectives and input should be sought to drill down to the actual root cause(s) and contributing factors that led to the incident and ensure findings lead to accurate and prompt correction(s). This may involve changing a procedure. The size of your team will depend on the incident.

There are numerous benefits to investigating all of your incidents. Mentioned earlier, it demonstrates to your employees that safety is a value rather than a changing priority of circumstances. It will also improve workplace morale, increase productivity, increase your employee engagement and participation, and the obvious – identify hazards, whether conditions or practice, processes or procedures – and allow you to eliminate or reduce the hazard while safeguarding your employees through process and procedure review and employee practices that may need to be adjusted.

Incident investigations are critical to your safety culture and benefit your employees and your reputation. Understanding that connection will ensure your investigations have value.

Performance safety

Performance Safety can be defined as an on-going review of processes, procedures, and practices through observation, workplace examinations, and task analysis. It is a simple, yet total and comprehensive review of all performance areas (machine, worker, and environment) to ensure pro-active, continuous improvement at all production levels.

The phrase “behavior-based safety” has always conjured up a fault-driven process, even though it was not intended to be so. Behavior alone cannot create or cause injuries. It is true that unsafe actions contribute to more than 85% of all injuries. But choices made by a worker are not always a reflection of his behavior. It includes the “behavior” of the manager and the safety culture.

For optimum performance, safety includes a three-phase process: practices (employee choices in how to perform assigned tasks); procedures (the overall established method to perform the task); processes (the overall end result in operations and production with equipment, end product, quality control, etc.).

Two examples of Performance Safety in progress

We identified an unsafe “condition” in the installation of new equipment at our site prior to start-up. We got together engineering, the plant manager, a production foreman, a production crew member, the safety professional (that was me), and the construction foreman responsible for the installation at the site (a cross-functional process team). We began brainstorming: How would the task have to be performed (procedures)? How would the task actually or most likely be performed by the employee (practices)? How would the outcome of this task affect the product and tasks “downline” (process)?

The procedures would identify the hazard and means of eliminating the hazard. The employee would need to follow the procedures to ensure safe performance. The procedures would have to be written clearly to encourage the employee to make the right choices and protect him from taking a “short-cut” (practices).

We first thought of a $15,000 engineering fix to remove the hazard. Then we asked what would happen if that engineering solution broke – it wouldn’t hold up within the work environment. After a few more ideas, a light bulb came on. The equipment operator suggested that the hazard could be corrected with a $200 part easily handled by one person which allowed the employee to follow procedures without risk or taking a shortcut. The procedure was developed with the newly-installed part and the employee could follow the procedures logically and safely, ensuring he followed safe practices to perform the task. Had we not looked at the problem with all of the connected people in the process, we would have spent $15,000 that would not fix the problem.

In the second example, an employee had to enter a tunnel with a sledgehammer to unclog material getting stuck at a transfer point on a conveyor line. I was asked what could be done to minimize the employee’s exposure to the myriad of hazards that developed from having to clear the jam. The material was getting stuck because it was too large for the engineered design of the transfer point. The material was too large because the crusher upline had recently been “opened up” to allow for greater tonnage output. As a result, the down-line transfer was getting jammed.

Keep the big picture in view

Rather than address the specific hazards now caused by the change, we were able to treat the root cause of the problem. Once the crusher settings were re-adjusted back to the engineered design, the hazards and exposures were gone. When the material upline was at the “right” size, it passed through the downline transfer point. There was no longer employee exposure to noise, dust, tunnel hazards, shoulder pain, or continued beating on the transfer box because the sledge was no longer needed. It created the optimal performance of the entire system, thus correcting the need to fix a practice in an exposed environment.

Everyone understood that a change in the process created a set of other problems that, on the surface, could not be seen. The transfer point was too far downline in the process to connect the dots with the change in the upline process. The old saying, “You can’t see the forest for the trees” certainly fit in this case.

Performance Safety helps keep the big picture in view while addressing specific issues. In the above example, it was not my job to tell an experienced manager how to do his job. But in understanding the process, we could identify a situation that ultimately also helped the manager’s production numbers.

Anyone with knowledge of conducting incident investigations knows to ask questions that get to the “root cause” of the incident. In the same way, getting to the hazard’s root cause to identify process, procedure, or unsafe practice concerns will allow you to correct the problem rather than correcting a symptom that never seems to go away.

Randy DeVaul, MA, NREMT, is an author, writer, and experienced safety professional in OSHA- and MSHA-regulated industries and in workers' compensation best practices. Randy conducts webinars regularly on safety/health and workers’ compensation topics. He is the founder of MOST (Mine/Occupational Safety Training), creator of the “Safe at Home” series, and Rapid Response CPR, providing BLS/emergency response courses for healthcare professionals, first responders, and response teams. Randy resides in Central Florida.