Near Misses and Incident Investigation

OSHA strongly encourages employers to investigate all incidents in which a worker was hurt, as well as close calls (sometimes called "near misses"), in which a worker might have been hurt if the circumstances had been slightly different.

In the past, the term "accident" was often used when referring to an unplanned, unwanted event. To many, "accident" suggests an event that was random, and could not have been prevented. Since nearly all worksite fatalities, injuries, and illnesses are preventable, OSHA suggests using the term "incident" investigation.

Investigating a Worksite Incident

Incident investigations are often conducted by a supervisor, but to be most effective, these investigations should include managers and employees working together, since each bring different knowledge, understanding and perspectives to the investigation.

Investigating a worksite incident- a fatality, injury, illness, or close call- provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents.

In conducting an incident investigation, the team must look beyond the immediate causes of an incident. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone was the cause of an incident. To do so fails to discover the underlying or root causes of the incident, and therefore fails to identify the systemic changes and measures needed to prevent future incidents.

When a shortcoming is identified, it is important to ask why it existed and why it was not previously addressed.

For example:

• Did production pressures play a role, and, if so, why were production pressures permitted to jeopardize safety?
• Was the procedure out-of-date or safety training inadequate? If so, why had the problem not been previously identified, or, if it had been identified, why had it not been addressed?
• If a procedure or safety rule was not followed, why was the procedure or rule not followed?

Addressing underlying or root causes is necessary to truly understand why an incident occurred, to develop truly effective corrective actions, and to minimize or eliminate serious consequences from similar future incidents.

These examples illustrate that it is essential to discover and correct all the factors contributing to an incident, which nearly always involve equipment, procedural, training, and other safety and health program deficiencies.

To assist employers and workers in conducting effective incident investigations, and to develop corrective action plans, the following resources can help:

• OSHA. Incident [Accident] Investigations: A Guide for Employers. (2015). This guidance document provides employers with a systems approach to identifying and controlling the underlying or root causes of all incidents in order to prevent their recurrence.
• OSHA Fact Sheet. Root Cause: The Importance of Root Cause Analysis During Incident Investigation.(2016). This fact sheet provides guidance for identifying root causes of incidents and/or near misses in order to prevent their recurrence.
• Washington State Department of Labor & Industries. Accident Investigation Basics. (2009). This PowerPoint-based online training module provides an overview on conducting root-cause workplace incident investigations.
• National Safety Council. How to conduct an incident investigation. (2014). This four-page guidance document, developed by the OSHA/NSC National Alliance, provides brief guidance on conducting an incident investigation.

Source: https://www.osha.gov/incident-investigation

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