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Improving safety performance through incident investigations

by Bruce Johnson

There are a number of steps organisations can take to strengthen safety performance and reassure workers of the necessity and importance of timely and accurate reporting of incidents.

Over the years there has been significant improvement in reporting workplace incidents across organisations from small business through to large multinational organisations ranging across the various industry sectors, from construction, resources, energy, manufacturing, business, rail, logistics, agriculture and services.

These improvements directly align to management understanding and addressing the importance of being well informed and proactive to manage what is occurring across their operations and workplaces. This has been extensively demonstrated through organisations reviewing and implementing improved incident management processes, ensuring consistency across all operations, educating personnel in timely and accurate incident reporting and investigations, moving from just paper-based reporting to comprehensive electronic databases, and incorporating the use of mobile devices to register incident information.

Areas that have been a catalyst towards this improvement include organisations’ awareness and requirement to:

  • understand their defined and assigned accountability and responsibility for statutory obligations within the relevant legislation/s

  • reduce the cost of injury to the employer, both indirect and direct, such as workers’ compensation

  • reduce production downtime and become more efficient, leading to increased profit

  • provide a healthy and safe working environment.

In addressing the above, upper management have understood the necessity for a robust incident reporting culture, followed by quality investigations to determine systemic deficiencies and implement appropriate corrective actions to learn from what has occurred (the incident) to prevent recurrence of a similar incident. It is commonplace now for organisations to promote and deliver healthy and safe work groups, and safe and efficient workplaces.

Although significant improvements in incident reporting have been made, there still exists varying levels of acceptance across industry as to what is the standard required. To understand, qualify and quantify an organisation’s level and improvement in their reporting culture requires a transparent approach with openness across the organisational hierarchy from operators to upper management, and the accuracy of performance markers.

In my experience as investigator/trainer, conducting incident investigations, training incident investigation methodology (Incident Cause Analysis Method, ICAM) and working closely in the operational and safety departments of organisations across the various industry sectors has given insight into various incident management regimes and subsequently incident reporting levels. Experience has shown that when asking an individual their opinion or perception of the organisation’s reporting culture with respect to incidents, the comments can significantly vary from those of the operator, maintainer, supervisor, manager, board, and so on. These varied responses can be contributed to the varying levels of reporting within the organisation where “pockets of excellence” exist with some departments and/or sites producing a high standard of reporting, while other areas in that same organisation may be below that standard.

The organisation may have the systems and processes in place to support good reporting. Management may assume that if systems are in place, reporting must be to a good standard. However, the system alone does not mandate good reporting is occurring across the business. The organisation’s safety performance markers do not always accurately reflect the various reporting standards across the organisation due to poor behavioural discipline in adhering to process and how the performance is measured. While low reporting in one area may indicate good safety performance from the current statistics, this may be misleading in that this “good” performance is only sustained in the short term. Incidents are still going unreported, leaving latent systemic deficiencies remaining unaddressed with the organisation vulnerable long term, leading to deteriorating safety performance and catastrophic consequences.

Generally, there is improvement in incident reporting across industry, with some of industry achieving a high standard; however, there still exists further opportunities to enhance the reporting culture specific to incidents.

Common gaps and challenges

What is observed in many organisations is certain types of incidents are reported to a high standard while other incidents remain unreported. The incidents that are generally reported to a high standard are typical of incidents having a tangible outcome, such as property damage, injury, loss of production; that is, putting it simply, what is noticeable. On the other hand, an incident such as a near miss or near hit is more likely to go unreported due to the nature of the incident being without injury or damage, but having the potential to do so.

There are several reasons, or gaps in systems and processes, why incidents – including near misses – go unreported, diminishing the organisation’s reporting culture. These reasons include:

  • no appreciation of the learnings and benefits from reporting and follow up

  • near miss incidents are not clearly defined and understood in the organisation

  • fear of blame or embarrassment having negative repercussions that someone had worked unsafely

  • the organisation has minimal structure or an unclear reporting process

  • perceived time constraints caused by the organisation’s focus on production

  • minimal or no communication across all levels of the business about the outcomes following reporting of the incident

  • the work member did not consider it worthy of reporting, because no one got injured

The above-mentioned gaps relate to the underreporting of incidents. Management must be aware of these issues and what is relevant to, and/or adversely impacting on, their operations. Some gaps are easily dealt with, such as developing a system and process, defining terms, roles and responsibilities, and education and awareness sessions. However, other gaps can be more challenging to address.

These challenges include:

  • building trust across the workplace by removing blame and implementing a “fair and just culture” model where accountability (both individual and organisational) is identified and managed accordingly

  • ensuring the reporting process, including electronic database, is user friendly

  • delivering and maintaining a robust feedback communication mechanism to all personnel

  • ensuring good operational discipline to process across all levels of the organisation’s structure

The above challenges, especially those which are behavioural based, must be supported by management commitment to process, responsibility, accountability, and provision of credible data. Credible data following reporting the incident is achieved using a systems-level investigation methodology, such as ICAM. A systems-level investigation identifies the contributing factors to the incident, thus defining human error, organisation deficiencies and inadequate safe systems of work.

From a solid reporting structure, management can implement initiatives, such as an investigation to determine what happened, why it happened, what they are going to do about it, and what is learnt to share. Therefore, a good reporting culture leads to a good, informed and learning culture, giving management a solid platform for continuous improvement directly attributed to commitment and responsibility across all roles and sectors of the business.

Incident investigation trends

Currently, organisations are in various phases of their reporting culture, ranging from (i) management accepting there is serious room for improvement, to (ii) those organisations requiring minor enhancements and sustaining the existing high level of reporting. For the organisations with significant room for improvement, the trend is to re- evaluate their current systems, processes and practices in respect to incident management and prioritise consistency across all operations and worksites.

The emphasis is on incident category, classification and defining a near miss as well as clearly defining and aligning reporting responsibilities to specific roles. Simultaneously, the database is customised to align to the procedures and ensure consistency across all sectors with the application being user friendly. Some organisations believe that once the reporting mechanism – such as the database – is implemented, this instantly improves reporting. Unfortunately, this is not the case as credible data must be obtained and entered so meaningful information is provided.

No matter where the organisation sits within the spectrum of their reporting culture, organisations have seen the need to not only be satisfied with the incident being reported, but ensure the situation and consequences are managed and applied to show continual improvement. This must be communicated to all personnel to demonstrate the commitment to a safer workplace. Where employees see beneficial change, they value the need to report.

The years ahead are seeing organisations committed to quality investigations into the incidents because reporting is not enough on its own; it is how management react and implement change to prevent recurrence. The better quality the investigation the better the outcomes, which directly influence improved or sustained reporting.

What is becoming more and more evident over time is the shift in ownership of the incident where responsibility and accountability is moving towards operational personnel rather than sitting with the safety department. In addition, the organisation should set the appropriate scorecard to measure change and success.

Improving investigation outcomes

To improve incident reporting, an organisation should:

  • identify the current level of reporting in the workplace and what is the minimal standard accepted and then what is to be tolerated

  • consult with all levels in the organisation, from the operators to management, and determine where the gaps exist – this includes both process and behaviours

  • review existing procedures, systems and databases for effectiveness and user friendliness

  • assign responsibilities and accountabilities to set the business expectations

  • implement a robust process of investigation to determine learning and corrective actions

  • develop and/or enhance communication and feedback mechanisms to all personnel

  • introduce and apply a transparent “fair and just culture” model so identified levels of accountability through performance management are accurately and consistently dealt with by managers – this elevates the level of trust across the work teams and management, reinforcing positive behaviours

  • ensure outcomes are visible in the work area

  • make time available to relevant personnel for accurate reporting and investigations

  • undertake ongoing education and awareness sessions

  • monitor and review effectiveness of both process and behaviours

Unless incidents including near misses are reported, organisations are unable to address potential systemic problems that could lead to a serious injury or incident. Missed opportunities to learn also result in lost productivity and inefficiencies, as well as increased costs to business. The reporting of incidents with a proactive approach by management to implement corrective actions focusing on continual improvement can be used effectively as a “leading indicator” as opposed to the traditional “lagging indicator” of incidents.

Advice for OHS professionals

When management take the opportunity and be proactive to improve reporting and/or maintain a high standard, OHS professionals must grasp the moment and take a leadership role (initially) to drive change. Assuming this leadership role, OHS professionals must consider any implications that may evolve through the journey of change. The end play must be identified. What is this space going to look like?

A major risk, through the transition, which must be avoided is that incidents remain or fall back to the responsibility of the OHS professional. In order to eliminate this risk, OHS professionals must include and consult operational personnel through this journey. This is a transition phase where the ownership of incidents shifts from the OHS professional to operations.

Roles and responsibilities must be defined and made clear within the incident management process where operational personnel report and manage incidents within their scope of work. The role of the OHS professional becomes that of:

  • custodian of incident management procedures and process

  • mentor and coach to operational personnel

  • governance of process

  • monitoring and reviewing of process and reports

  • quality assurance

Where ownership is taken by operational personnel, from the reporting of the incident to implementing corrective actions, together with management commitment and OHS professional support, this strengthens the safety performance for the organisation and reassures workers of the necessity and importance of timely and accurate reporting of incidents.

#icam #incidents #investigations #riskmanagement