Improving Incident Investigations in the workplace
There is no doubting the importance work health and safety plays in the workplace. With most large organisations spending millions of dollars annually on compliance, it would be generally accepted that the benefits would offset the cost. Most would also agree that’s its our moral obligation to ensure we don’t send our work colleagues and friends into harms way or into an environment without proper precautions.
Within the health and safety arena, incident investigations are generally carried out by internal (business) Health and Safety Representatives and by regulatory bodies in the event of a tragic incident. The key outcomes for incident investigations include:
- To prevent or decrease the likelihood of illness or injury;
- To identify and correct unsafe behaviours and conditions; and
- To identify any training needs.
Our many clients within the resource sector and the like (other private corporations and government institutions) often ask me how they can improve the quality of incident investigations within the workplace.
Through the many hours spent with health and safety specialists, I have found two key shortfalls that can impede incident investigations in the workplace if not conducted effectively.
1. Incorrect Investigation practices
Most health and safety representatives have completed some type of Root Cause Analysis (RCA) training. This is always a good thing. RCA however, needs to be conducted after proper investigation of the facts. It means applying a systematic approach to the investigation before considering and reviewing risks and implementing appropriate control measures to manage them.
As with any other administrative investigation, all findings (which are used for RCA) need to be logical probative evidence and not based on assumptions and/or guesswork. This means any information (often displayed by way of a timeline for RCA) needs to be properly scrutinised and corroborated before used as incident findings.
This is because although the purpose of conducting the investigation is to establish the cause(s) of the incident and not apportioning blame, incident investigations commonly conclude that the injured person’s conduct contributed in some way to the outcome. Even though in most instances that behaviour is seen to arise from inadequate procedures and systems, there have been situations where the behaviour has warranted disciplinary action.
Whilst this sits outside of the scope of the health and safety representative and outside of that department itself, facts drawn from the investigation can be used to attribute responsibility to that person. Therefore, any subsequent disciplinary action must be proved “on the balance of probabilities” because any such action can be subject to appeal.
2. Poor Interviewing techniques
Physical evidence will always be valuable in any investigation. This is a no brainer! The number one priority is always to correctly identify and seize all physical evidence for analysis.
The majority of information however, comes from witnesses to the event. Is the evidence of witnesses affected by human frailty? Yes it is. This is not an excuse to avoid or minimise the interviewing of witnesses within an investigation (as I have heard by some people). It should reinforce the reason why the information should be obtained carefully and corroborated by other sources.
Whilst many people have been trained on various investigative practices, very few have been taught to interview beyond the understanding of “ask open questions”. In fact, the reason why most interviews fail is because it is adhoc and conducted with no set structure. These are some of the lessons identified in the United Kingdom and applied within law enforcement world-wide.
In the early 1990’s, the police in the United Kingdom came under intense scrutiny in the way officers were conducting interviews. As a result, a Steering Party co-ordinated by the Home Office (UK), conducted research to gauge why police conducted interviews so poorly.
Following the outcomes of this research, a National (UK) interviewing training package, (called “Investigative interviewing”) commenced in 1993 with its theoretical structure now adopted worldwide, including policing jurisdictions within Australia.
It is important to remember that whilst the majority of incident investigations remain in-house, a small number do get scrutinised be external agencies. There is also an even smaller possibility that investigators conducting an investigation may end up in a court or tribunal explaining what they did or did not do in regards to the matter. This is why as investigators, we must ensure each and every investigation is completed fully according to the scope. Your reputation and that of the organisation depends on it!