Conducting Post-incident Investigations in the Workplace
Workplace incidents requiring follow-up investigation fall into several categories, ranging from accidents that result in serious injuries, death, and/or major property damage to lesser events involving minor injuries and/or negligible property damage and even extending to “near-miss” incidents which—while not resulting in direct injury or damage—expose the strong potential for such outcomes in the future. Progressive employers are likely to have what they believe to be a strong and comprehensive investigation procedure in place, espousing the need to determine the root cause(s) of accidents and near-miss incidents and to follow up with appropriate corrective actions to ensure that such incidents will not reoccur.
Determining the true root-cause factors that contribute to a workplace accident is a goal that should indeed be pursued, as should the subsequent formulation, implementation, and “tracking-to-completion” of proposed corrective actions that are deemed to constitute an effective response. However, as some of the more astute readers of my first paragraph likely noted, I wrote that many employers “believe” that they have a strong procedure in place when it comes to conducting such investigations. Sadly, this is often not the case.
First and foremost, I should begin by addressing the elephant in the room (or on the page, as it were). I’m a former career cop, having spent twenty years in law enforcement before beginning my second career in industrial loss control and risk management. Having conducted (and supervised) countless criminal investigations—often involving the most serious aspects of human misjudgments, prevarications, and failures—I bring a perspective and experience base to the table that is understandably missing from most private-sector managers and supervisors.
That said, I’m fully aware and appreciative of the fact that, to cultivate a positive and proactive culture of safety within an organization, the investigation systems and procedures should be framed within the context of identifying and correcting problematic circumstances rather than by seeking to assess blame and inflict punishment on the part of involved individuals. Unfortunately, in their well-meaning efforts to ascribe to such a standard, company executives may put policies into place that subvert the necessity to truly determine root-cause factors, thus skewing the results of their investigations.
From my own experience and observations, most companies use some form of root-cause analysis to frame their incident investigation process. Further, while pursuing potential causative factors, many companies commonly break down their areas of inquiry into three main categories: 1) administrative/procedural, 2) physical/equipment, and 3) human-caused. These groupings are all relatively self-explanatory: a policy or written procedure that was unclear or provided unsafe or conflicting direction would fall under category number 1. Failure of a piece of equipment or physical safeguard would be an example of number 2, and an employee who failed to knowingly follow a prescribed safety procedure would be an example of number 3. Everything seems relatively straightforward, right? So what’s the problem?
Not to seem overly jaded, but as is quite often the case, people are often the biggest problem. Gaps, inconsistencies, or misinterpreted direction in written policies and procedures can usually be ascertained fairly quickly when their written content is subjected to a critical, investigative review. Likewise, determining the causative contribution of a mechanical failure is often a relatively straightforward exercise. (Although potentially contributing maintenance factors which may have led to such failures will often lead to the more problematic “human” category.) In the same manner that human conduct (such as minimization, rationalization, fearfulness, dishonesty, self-justification, et cetera, et cetera) so often complicates criminal investigations, so can these human failings lead to substantial roadblocks when conducting workplace incident inquiries.
Think Like a Detective
In their zeal to create a culture of “non-blaming, collaborative fact-finding,” I’ve seen more than a few companies make what I believe to be a fatal mistake in the structure of their investigative process, declaring: “We will be conducting a root-cause investigation of INCIDENT-X in the conference room at 2 p.m. tomorrow; the facility superintendent, the shift’s crew boss, the two involved employees, and two witnesses who were on scene will all be at the table as we run down the list of potential causative factors, providing input as necessary.”
Sadly, this approach has already set the company up for potential failure.
When conducting criminal investigations, there are solid and justifiable reasons why suspects are immediately separated and interviewed individually. And, while not trying to “criminalize” the workplace investigation procedure or place emphasis on “blame assessment,” one simply cannot expect to gain candid and truthful admissions and statements from frontline workers on a consistent basis, particularly if there are notable issues involving unsatisfactory and/or unethical supervision taking place. Think about it: if a strongly controlling, mid-level supervisor has provided unsafe and/or contradictory direction to their subordinates (which, unfortunately, can and does occur more frequently than we would often like to think), do you really think that those subordinates, when questioned, will feel comfortable in speaking up when seated at the table with that same supervisor?
While I’m a strong supporter of seeking input from all levels of personnel involved in any workplace incident, I am also a fierce advocate for the formation and utilization of a pre-investigation review panel, which should be staffed primarily with health, safety, and risk personnel and should purposefully exclude anyone within the direct supervisory chain of the involved work crew.
In conducting an initial review of scene evidence and discussing the most likely causative factors, the main function of a pre-investigative panel should be to determine the probability or likelihood of the following:
- Does it appear that there were likely human-caused factors which led to the incident? (E.g., failure to follow procedures, failure to wear appropriate protective equipment, et cetera.)
- Does it appear that human-caused factors could have been the result of non-existent, poor, or improper supervision?
- Have there been other incidents or anecdotal information on the jobsite indicating potential problems or issues with the involved supervisor(s)?
If the answer to any of these questions is “yes”, it’s incumbent upon the company’s safety supervisor to work with senior leadership in structuring an investigation and interview process that will facilitate the open and truthful answering of necessary questions at all levels of the personnel structure. Frontline employees who were directly involved in the incident may need to be interviewed separately, away from direct supervisors, with a human resources representative present to provide assurances regarding fears of retaliation, any necessary whistleblower protections, et cetera.
Don’t get me wrong: the majority of managers, frontline supervisors, and employees are all good people, working hard on a daily basis to try and get things done in a safe and efficient manner. Unfortunately, there will be those occasional times when a supervisor is not living up to standards, and their lapses in supervision result in a workplace accident. When such conduct and behavior result in an incident involving subordinate employees, it is not reasonable to place those employees at the same table with their immediate supervisor and then expect them to voice their honest and open feedback.