Audits and Incident Investigations are both very important components of our safety management systems. They often relate to each other but have distinct roles.
Let’s consider a common, every day situation. A manager in a national distribution business is doing a regular Safety Audit in the loading dock of a regional warehouse. She is not the Loading Dock Manager but is conducting an audit in another manager’s area as part of the organisations cross-auditing policy. She notices some recent damage to handrails and asks some questions of the operators. The operators are not defensive and tell her about an incident that occurred some days before where a vehicle had struck the handrail but no injury occurred and there was only some paint taken off the truck.
As a good auditor she is not judgmental and gets them to talk more about the incident and discovers that there were people in the area at the time and while the operators were a bit dismissive they did admit that there was some potential for injury to those present.
Follow up reveals that the incident has not been recorded in the Incident Reporting system.
The Auditor has uncovered a serious non-conformance in the organisations Safety Management System. An incident with serious potential has not been reported. The Auditor knows that an incident has occurred but does not know much about why it occurred. She also knows that the incident was not reported but does not know why it was not reported.
What does the Auditor do at this point? Should the Auditor continue to investigate the circumstances of the incident and the absence of a report? This approach could create some problems.
Continuing to investigate the incident is outside the scope of an audit. Audits are designed to test our systems. Audits validate our systems and identify weaknesses for us to rectify. Rectifying other than minor weaknesses usually requires us to initiate another business processes.
If Auditors are required to fully explore every issue they identify then audits will consume a lot of time and Auditors will become reluctant to conduct audits or identify weaknesses.
The Auditor does not have the authority of the Loading Dock Manager to investigate the incident and may not have the necessary technical or investigative skills necessary to investigate the incident.
Should the Auditor immediately report the Critical Non-Conformance to the Loading Dock Manager because it relates to a fundamental component of the Safety Management System and recommend that an Incident Investigation be conducted?
Yes. This is the right action because it firstly ensures that the responsible manager is aware of the incident and can coordinate the necessary response but also facilitates the opportunity for a planned approach to the investigation.
The Loading Dock Manager will utilise the ICAM process Module 01, Immediate Actions.
Even though the incident is a few days old he can, if necessary, have the area where the incident occurred barricaded off so that no further evidence is lost. He can rate the potential consequence of the incident with advice from the Auditor, Supervisors and the Safety Manager and ask the Supervisor to prepare an initial report. Using those same advisers he can decide if an investigation is necessary and appoint a Team Leader and Investigation Team for the investigation.
This process need only take a few minutes and can be conducted over the phone or via email. The Auditor may make a valuable member of the team as she is aware of the Operator’s reactions to her initial questions. The Investigation Team will start ICAM process Module 02, Investigation Planning, to ensure all aspects of the investigation are covered.
This interrelationship of Audit and Incident Investigation can also occur the other way around. If we consider a situation where the incident at the loading dock is reported to the Supervisor by say the truck driver, then the Supervisor would initiate the ICAM process Module 01, Immediate Actions, and in consultation with the Loading Dock Manager the decision to conduct an investigation could be made.
The investigation reveals that damage to loading dock infrastructure is common and often not repaired. Recommendations from a conclusion such as this could include:
Damage to loading docks is often not reported because the Operators do not consider it a problem unless somebody is injured or there is significant damage to a truck. Recommendations could include:
Reinforce to all Loading Dock Operators in Safety Meetings the need to report all damage events.
Conduct weekly Safety Audits of all loading dock operations with an emphasis on reporting incidents, including all damage events. The frequency of these specific audits will be reviewed in 3 months.
By incorporating Inspections and Audits into the Corrective Actions arising from an Incident Investigation we ensure that the Corrective Actions are carried out and are effective. We also help to ensure that the learnings from an incident are ongoing and become embedded in the organisations everyday way of doing things.
Another potential problem we have to look out for is that Incident Investigations do not becomes Compliance Audits. This happens because we usually find numerous problems as we conduct our investigation and then include all these non-conformances in our Investigation Report.
It is very important that we separate the Contributing Factors to our incident from the Non-Contributing Factors.
For instance we discover during our investigation that a truck driver’s induction is one month out of date. What will we do about this? Firstly we must determine if this could possibly have contributed to our incident. Nothing has changed in the induction that relates to the truck driver and the induction is only one month overdue so it is very unlikely to have contributed to our incident. Therefore we report the problem to the person responsible for inductions using the organisations systems and then we put it aside.
If we mention it in our Investigation Report at all it will be under a heading of ‘Non-Contributing Factors’ and we definitely do not include it in our ICAM analysis. We do this because it is important that we do not distract our stakeholders from those issues that can be seen to have directly contributed to the incident and not distract them with side issues.
In conclusion Audits and Incident Investigations are closely related and therefore easily confused with each other. By being clear about our objectives in each activity and carefully planning that activity we can get the most out of them and ensure that they are contributing to a safe workplace.
Interested in Knowing More?
Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Ken Horspool (Investigator/Trainer)
As one of the first consultants with Safety Wise, Ken’s experience has been very broad. He has conducted investigations into many serious incidents in mining, manufacturing and construction industries and trained supervisors and managers in the ICAM process.
Ken has extensive experience in South Africa and South East Asia including auditing investigation quality and Safety Management System performance in challenging cultural environments.
Ken’s career started with BHP Steel in Port Kembla (now Bluescope) as a metallurgist operating and managing Blast Furnaces for 25 years before an MBA focused on organisation development led him into Safety Management.
Incident Investigation fits neatly with Ken's passion for continuous improvement in both process and culture leading to safe, environmentally friendly and profitable businesses