Digging Deeper – A Human Factors Approach To Incident Investigations

They are about finding causes, not culprits. And they’re as important to workplace safety as post mortems are to medicine.

We’re talking about incident investigations — the ones required by regulation after near-misses and minor injuries that warrant medical attention. And when they’re done properly, they give every workplace a chance to get it right, by fixing a task or work practice to stop a serious injury in its tracks.

The purpose of incident investigations is critical: to find out what led to injuries or potentially harmful close calls, and to make the changes necessary to prevent similar incidents in the future. But not all incident investigations are created equal. New research confirms the importance of a “human factors’ approach” to investigations — one that goes beyond frontline worker behavior, and looks at the systems that failed to support safe performance in the first place.

With the help of go2HR’s industry health and safety ski hill technical advisory committee, and Human Factors specialists Heather Kahle and Jenny Colman, Whistler Blackcomb Ski Resort recently revamped its incident investigation methods toward a human factors’ approach. “We knew we were really good at reporting incidents. But completing a review of our safety program made us realize we weren’t as strong at investigating them,” says the resort’s COR (certificate of recognition) program supervisor Miriam Bougie.

“Before, we focused on what caused an injury,” she says, “be it contact with the ground, or a worker twisting a knee by losing his or her balance skiing in low-light conditions. Despite our prevention efforts, we weren’t seeing a significant decrease in injuries from season to season. We weren’t looking deeply enough.”

Consequently, the ski area decided to approach their incident investigations differently, by adapting go2HR’s new incident investigation form. Now investigators now go beyond the “what” and “how” of a specific injury and identify the mechanical, human, management, and environmental factors underlying an incident. “It focuses less on what happened and more on how and why it happened,” Bougie says.

Their form follows the human factors’ approach, breaking down the elements of the workplace into four basic areas: software (procedures, inspection records, first aid reports, and safety committee meeting minutes, etc.); hardware (flooring, footwear, and warning signage, etc.); liveware (vision, line of sight, hearing, fatigue, communication, and supervision, etc.); and environment (equipment, maintenance, glare, lighting, temperature, and noise, etc.).

“We began using the new form on our intranet in December of 2012, and will have the ability to pull valuable data by the end of the winter season. We’ll now be able to identify trends and develop prevention initiatives before next season.”

NEW-AND-IMPROVED PAPERWORK FOR INVESTIGATING INCIDENTS

Bruce Jackson, WorkSafeBC’s senior manager of Prevention Quality, wants to make that kind of analysis possible for other employers through an updated incident investigation form and reference guide — which incorporate basic human factors’ principles. The purpose of the form is to guide employers through the investigative process, from gathering the right information to analyzing the causes.

“Application of the information in the guide will make it easier for employers to identify the factors that contribute to an incident, and, in doing so, help them develop recommendations for making their work processes and practices safer,” Jackson says. “Because, believe me — there’s nothing easy about a fatality or serious injury when it happens on your watch.”

The revised Employer Incident Investigation Report (form 52E40) and reference guide are now available on WorkSafeBC.com. A PDF of the form can be printed, completed manually, and mailed to WorkSafeBC. Or it can be downloaded, completed, saved, and submitted to WorkSafeBC via email. Employers can also avail themselves of a new reference guide. The guide shows how to construct a sequence of events and how to conduct a more thorough and detailed analysis of events associated with the incident.

Jackson has seen first-hand the problem with investigations that lack such analysis. He recalls an incident that took place nearly two decades ago in a warehouse operation. A forklift operator was seriously injured after the forklift tipped over. The employer’s incident investigation report concluded the driver was to blame for driving too fast.

“Had the investigation been conducted using the new reference guide, investigators would have made additional inquiries,” he says. “They would have learned that the warehouse had recently been reconfigured, requiring the forklift operator to drive farther, and therefore faster, to keep up with production — key factors that led to the injury.

“Blaming the worker would have done nothing to mitigate the underlying risk or to prevent future injuries, or worse, a fatality.”

Unfortunately, superficial investigations like the one done by the warehouse are all too common, Jackson says. “Employers either fail to do investigations at all,” he says, “or they fail to do them thoroughly. Conducting an incident investigation is too often seen as an administrative task, rather than an opportunity to evaluate work practices and figure out how to make them safer.”

That approach has to change, Jackson says. “Incident investigations must be taken more seriously.”

RESEARCH CONFIRMS THE VALUE OF THOROUGH INVESTIGATIONS

The research done by WorkSafeBC’s Human Factors team clearly demonstrates the potential for improving the quality of incident investigations to manage risks and prevent injuries.

As part of a broader effort to reduce “stubborn-risk” incidents (incidents that keep occurring despite repeated attempts to address them), the research focused on eight similar incidents within the same manufacturing sector. All eight involved inadvertent contact with energized equipment. Each incident was investigated by the employer using a range of investigation methods. WorkSafeBC investigators also analyzed the incidents using a human factors’ approach.

Once the investigations were complete, the team compared the results. They found that the human factors’ approach identified safety issues that were overlooked by the employers’ methods. Furthermore, they discovered the employer investigations tended to focus on individual behaviours, rather than the systems each workplace used, and whether or not those systems were compatible with safe workplace behaviours. As a result, employer investigations offered limited safety benefits over the long term.

Such findings were no surprise to Kahle, a member of the team. Typical investigations, she says, don’t go further than the “what” and the “how.” The human factors method answers the “why.

“And it’s that knowledge,” Kahle says, “that allows us to develop control measures or change the work setting so that the behaviour leading to the incident is less likely to happen in the future.”

What did surprise Kahle was that the employer investigations only went as far as they did, given that many of the investigated incidents involved equipment capable of doing significant damage by crushing, tearing, or cutting the person using it. “Despite the high stakes, there was little effort to look beyond the rules and whether the employee was following them.”

STOP THE BLAME GAME

Jackson says one of the barriers to more thorough investigations is a high learning curve and a lack of experience. “It’s a set of skills that — frankly — we don’t want employers to have to apply often. However, because serious incidents are relatively rare in most workplaces, employers lack the opportunity to develop these skills.”

Another barrier is our blame culture. “In that culture, once a culprit has been identified, there’s no need for further investigation,” he says.

Jackson has certainly seen his fair share of finger-pointing: incident reports that noted as the cause, “worker was careless,” “worker wasn’t paying attention” or “worker wasn’t using common sense.”

“Blaming the worker is the easy route,” Jackson says. “It’s what people do when they are feeling squeezed for time. But nobody plans to go to work one day and get injured or killed. There are so many other things at play that influence the outcome.”

A thorough investigation should ask, “Do we have the safe processes in place that allow workers to do the job safely?” Take signage, for example, Jackson says. “Can it be read easily? Do people respond to the words in the desired way? A sign that reads, ‘Make sure equipment is stopped before changing the blades,’ seems straightforward enough. But someone might interpret that sign to mean, ‘you don’t need to de-energize the equipment.’ You have to keep digging until you get to the underlying factors.”

DON’T WAIT FOR SOMETHING SERIOUS TO HAPPEN

Jackson says employers shouldn’t wait for a serious injury to conduct an investigation. “Near-misses and minor incidents are opportunities to gain experience with the investigative process, review work procedures, and manage risk more effectively.

“And, a better management of risks leads to fewer incidents. Yes, investigations require resources. But accidents cost money too. And, these near-misses or minor-incident investigations are an opportunity to interrupt more serious injuries — and the tremendous human and financial costs that go along with them.”

AN INCIDENT INVESTIGATIONS PRIMER

It’s all there under section 69 of the Workers’ Compensation Act. All injuries requiring medical aid, whether serious or minor, must be investigated immediately. Furthermore, incidents not involving injuries — but with the potential for causing serious injury to workers — must also be reported and investigated. The only time the regulation doesn’t apply is in the event of a work vehicle crashing on a public street or highway, since these investigations are typically under police jurisdiction.

What happens if an employer doesn’t comply with the regulation? “Near-misses are tricky,” says WorkSafeBC occupational safety officer Andrew Lim, “because we can only track them if they are reported to us or if we find out there was one during the course of an inspection. But any claim, regardless of severity, can prompt an officer to see whether an investigation was performed. At the very least,” Lim says, “if an investigation is not done when required by the Act, or if it’s not performed in accordance with the legislation, it’s a violation. And a prevention officer will be writing an Order to address it.”

At the same time, not all incident investigations have equal value, and the legislation offers only broad parameters for conducting them. “A more thoughtful investigation should not only fulfill legal requirements, but also be deep enough to get at the root of the issues,” Lim says. “Using the new human factors’ approach should provide more insight into the near-miss incidents, where cause and effect may not be so obvious.”

Human Factors specialist for WorkSafeBC’s Investigations Services Heather Kahle says higher investigation standards require the following four steps:

• Collect information regarding all the elements of the workplace system.
• Create a sequence-of-events diagram, a visual representation of all the events leading up to an incident.
• Identify the significant safety-related events leading up to the incident.
• Develop control measures to eliminate the risk and list them in priority sequence, starting with the most effective means of controlling the risk.

By Helena Bryan. Reprinted with the permission of WorkSafe Magazine, WorkSafeBC.