Incident Investigation and Reporting
Investigate causes, not culprits
Secure and photograph the scene, identify and interview witnesses separately and soon, and collect records such as training, maintenance history, and the job hazard analysis. Reconstruct the sequence of events. Separate immediate causes (the unguarded blade, the wet floor, the missing lock) from root causes (no guarding verification step, schedule pressure, deferred maintenance, unclear accountability). Useful methods include 5 Whys, cause-and-effect (fishbone) diagrams, fault trees, and events-and-causal-factors charts. Corrective actions must address root causes, have a named owner and due date, and be verified closed.
Reporting clocks you must not mix up
- Fatality: report to OSHA within 8 hours.
- In-patient hospitalization, amputation, or loss of an eye: within 24 hours.
- Record the case on the OSHA 300 log within 7 calendar days of learning of it.
- Retain the 300, 301, and 300A for 5 years; post the 300A from February 1 through April 30.
Traps
- Swapping the 8-hour and 24-hour clocks.
- Recording first-aid-only cases, which are not recordable.
- Skipping the "new case" test when a prior injury recurs.
- Assuming near misses belong on the 300 log - they do not, but they should still be investigated.
Rule of thumb: the 24-hour hospitalization clock starts when the employer learns of the in-patient admission, not when the worker visits the emergency room.