There are hazards in all workplaces; risk control measures are put in place to reduce the risks to an acceptable level to prevent accidents and cases of ill health.
The fact that an adverse event has occurred suggests that the existing risk control measures were inadequate.
Learning lessons from accidents and near misses can prevent costly accidents. (The Clapham Junction rail crash and the Herald of Free Enterprise ferry capsize were both examples of situations where management had failed to recognise, and act on, previous failings in the system.) You need to investigate adverse events for a number of reasons.
When incidents are investigated, the emphasis should be concentrated on finding the root cause of the incident so you can prevent the event from happening again. The purpose is to find facts that can lead to corrective actions, not to find fault. Always look for deeper causes.
An investigation can help you identify why the existing risk control measures failed and what improvements or additional measures are needed. It can:
- provide a true snapshot of what really happens and how work is really done (workers may find short cuts to make their work easier or quicker and may ignore rules – you need to be aware of this)
- improve the management of risk in the future
- help other parts of your organisation learn
- demonstrate your commitment to effective health and safety and improving employee morale and thinking towards health and safety