It's important to remember that all levels of the organization should have the opportunity for ownership as each loss prevention tool is developed. First, the safety manager should sit down with a cross section of hourly employees from all departments. In the session, the safety manager should explain the overall objectives of the investigation process and ask the group what they think their role should be for loss investigations. The safety manager should conduct the same kind of session with supervisors and another session with managers. After all levels of the organization have had an opportunity for input, operations management must make the final decision regarding the various investigation roles. What typically works most effectively is something like the following scenario:

The investigation is conducted by a few hourly employees from the area in which the injury occurred.

The supervisor of this area reviews the investigation report with this group of investigators and consensus is reached concerning the root cause(s) of the injury and the solution(s) to prevent recurrence.

Managers are usually responsible for reviewing the investigation report for quality. Primarily, they evaluate if the root cause, rather than a symptom, has been identified, and if a reasonable solution has been developed to eliminate or minimize the chance the injury could recur. Then, managers either approve the solutions, meet with the supervisor to modify the solutions, or direct that the identification of the real cause or formulation of solution be redone. If the investigation has to be recycled, managers must be sure to provide a detailed explanation as to why the initial causes or solutions are not acceptable.

The role of the safety manager is to serve as a "system check and advisor" in the overall investigation process. In other words, if coaching is needed during the investigation, at whatever level, the safety manager functions as an advisor. After the investigation is completed, the safety manager follows up to ensure that the solution is implemented as intended and ultimately determines if the solution is effective in elimination of the injury hazard.

Any injury may have one or more root causes relating to the injured person, his/her peers, and the supervisor. These causes should be referred to as "personal factors." In addition, there may be root causes pertaining to the system within which the injured person was working. These causes should be referred to as "job factors." Investigators should ask the following questions in an attempt to identify the real root cause:

Did the injury happen as a result of the following personal factors?

    -- Lack of knowledge or skill.

    -- Doing the job according to procedures or acceptable
        practices takes more time and/or requires more effort.

    -- Shortcutting procedures or acceptable practices is
        positively reinforced or tolerated.

    -- Did not follow procedures or acceptable practices in
        the past and no incident occurred.


Did the injury happen as a result of the following job factors?

    -- Lack of operational procedures or work standards.

    -- Inadequate communication of expectations regarding
        procedures or acceptable practices.

    -- Inadequate tools or equipment.

The root cause(s) could be any one or a combination of these seven possibilities or some other external factor. In the vast majority of injury cases, the root cause is very much related to one or more of these seven factors.

There are a couple of rules of thumb to follow when deciding what solutions to implement. In most cases, investigators should adhere to these guidelines:

Solutions should be practical. In other words, effective solutions to most injury hazards address basic worker activities, developing and maintaining standards for job procedures, providing and using the right tools, etc.

The most effective solutions are those that focus on personal or job factors over which the worker or supervisor has control. In the case of back injuries, for example, the National Safety Council reports that the worker is in almost total control of the major risk factors leading to back pain, injury and disability.

Most solutions need not be expensive. Companies generally don't need a million dollar solution to a one hundred dollar hazard. The majority of effective solutions are relatively inexpensive and implemented with resources within an organization.

Before the final commitment is made to any solution, investigators should consider whether or not the organization can live with the solution indefinitely and not merely for a week or month. If solutions are implemented that can't be maintained long range, the solution must be redone. Otherwise, the road is being paved for loss in credibility.

What information about the injury investigation should be communicated? Who should prepare the information for communication? How, when, and by whom should this information be communicated?

The following information about the injury investigation should be communicated:

    -- A description of how the injury happened.

    -- An explanation of why the injury occurred.

    -- Identification of the root cause(s) of the injury.

    -- Summary of the approved solution(s) that will be
        implemented to eliminate the hazard.

Typically, the safety manager prepares the communication because he/she can complete the work most efficiently and effectively due to his/her overall involvement and knowledge of the entire operation. The safety manager should take the investigation report and very succinctly summarizes the four points listed above.

After the safety manager distributes copies of the investigation summary, each supervisor should discuss the case with his/her respective work group. It is more meaningful for this discussion to be led by the supervisor rather than the safety manager.

This discussion should take place as soon as is practical, normally within 48 to 72 hours of the injury occurrence. An exception to this time frame would be when a major injury occurs or when there is a near loss with a high probability for a severe injury. In this case, there should be immediate communication of the work circumstances leading up to the injury and an explanation of how the injury happened. The purpose of this immediate communication is to make everyone aware of the incident so that it does not occur again on the next shift. After the investigation is completed, follow-up communication can be completed regarding the injury causes and solutions.

This communication should be a discussion, not merely the supervisor reading a paragraph to the work crew. All supervisors should be working from the same injury investigation summary sheet and should encourage questions and discussion of the incident, particularly as the hazard might have existed for their work group.

It is important to verify that the solutions have been implemented as described in the investigation report. Companies often make outstanding solutions to eliminate an injury hazard, yet the solutions are never implemented. After completing 90% of the process, the solutions remain a written document only.

Another necessary step in completing the process is to validate that the solutions are effective in neutralizing the hazard. If the solutions are not totally effective in the elimination of the hazard or do not greatly reduce the likelihood that the injury will recur, then the investigation must be recycled. (Recycling the investigation does not mean starting all over. It merely means that the investigation members have to make additional solutions or slightly modify solutions in order to eliminate the injury problem.)

The safety manager can most objectively evaluate the state of the solutions to verify implementation and validate effectiveness; therefore, he/she should be the one to perform these tasks.


After an organization compiles the needed information and makes the appropriate decisions in response to the seven questions, a few administrative tasks remain. These include the development of an injury investigation form, completion of written documentation for investigation procedures and guidelines, conducting investigation training classes, etc.

Conclusion
When an organization implements an injury investigation system that thoroughly addresses the main points of these seven questions, and also adheres to the fundamental principles of ownership and participation at all levels of the organization, workers' compensation costs will be reduced as injury incidence and severity measures decline.

Copyright © 2002  Dr. James D. Bennett, Loss Prevention Systems