Christel | Passionate About SHEQ Management

Incident Reporting and Investigation Process as a Reflection of SHEQ status

• October 16th, 2007

We cannot get away from fault finding! The concept of focusing on facts time and again is not practised. So what is really happening in our organizations?

1. We have safety or production bonuses.

How does this work? The lower the incident rate, the higher the safety or production bonus. How do you know for sure that your current incident rate is a true and fair reflection of the current SHEQ status on your site?

Money makes the world go round! If one has a choice between reporting an incident and receiving a safety or production bonus, what will the choice be?

This result in the incidents not being reported unless it is of such a nature that it is impossible to hide. So what is your real incident rate at this moment and time? Are you at ease because there have been no or very little incidents reported over the last six months? Remember the Piper Alpha incident: continuous good news – you worry; no news – you worry! There is always news and some of it will be good and some of it will be bad.

2. We “delegate” accountability down to all levels.

Who is really accountable?

Are we responsible or accountable? According to Section 14 of the South African Occupational Health & Safety Act (Act 85 of 1993), every employee has to look after the health & safety of themselves and of their fellow employees.

Section 8 of the same Act however informs us that the chief executive officer has the duty to inform, train, ensure adequate supervision and do a risk assessment to provide a safe and healthy working environment for all employees.

If one reads Explaining the OHSAct Section 16 (1) it specifically highlights the fact that there is only one person with accountability, the 16 (1) or CEO. He or she can delegate responsibility to other levels, but not accountability. Incident reporting and investigation is the responsibility of all employees, but the accountability of the CEO! Do you use the fear factor and inform your uninformed employees that they area accountable if something goes wrong?

3. We only use the recommendation: “discipline”.

Experience has shown that if we have a look at the most common recommendation measure suggested in the incident investigation process, it has been and still is that of disciplining the employee.

Would the employee out of his/her own free will then embark on a process of reporting incidents if he/she knows that it could possibly lead to their dismissal?

How many incidents are being hidden to prevent negative repercussions?

Other solutions that should be considered before disciplining the employee are effective engineering practices, proper risk assessment exercises, appointing the right person to perform the task (competent), example setting by ALL (including management through visible commitment), evaluating current operating procedures, identifying training needs and many more…

4. We use insufficiently trained employees to investigate incidents.

Who investigates the incidents on-site?

Are they permanently employed, familiar with the machines, processes & conditions in the working environment? Have they received the appropriate knowledge and skill to identify possible hazards and risks involved in performing this task? Do they only report safety hazards and risks (what about health, environment & quality)? Did only one person do the risk assessment?

An effective risk assessment (which should be the starting point of the investigation process) should be done by a multidisciplinary task of which the operator should be a definite member of this task team. The SHEQ department in the enclosure of their office does not do it! Do the average person know what a disease is and when and how to report it?

Does the average employee know what an environmental incident is and how to report it? Do your Induction training course include SHEQ reporting and investigation of incidents, ALL incidents?

Your training should include theory and practical (outcomes-based) on the actual site using where possible the same forms that are normally used to report and investigate incidents. On completion of the course the employee must have done a proper investigation and must have completed the reporting and investigation forms at least once in reality to ensure effectiveness.

5. We have a re-active approach & not a pro-active approach.

Did we foresee this incident as a possibility? If so, why has it occurred? How often has this incident re-occurred over the past twelve months? If it has, how effective was the incident investigation process and specifically the corrective and preventive action implemented?

Our inspection forms reflect corrective action and not preventive action. Our approach should be prevention and not cure. It would be interesting to view statistics on the re-occurrence of incidents as part of the continual improvement process.

One’s approach to reporting and investigating of incidents should be starting with the worst-case scenario. Identify and report as many incidents as possible. Wouldn’t improvement be the only way forward after this approach?

How about a bonus for the department/section/area that reports the most incidents?

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