HSE investigations are required to prevent re-occurrence
HSE investigations are undertaken to identify the immediate causes of an incident or near-miss (what happened) and the underlying causes (why it happened). If only the immediate causes of an accident are addressed, then the accident is likely to happen again. However, if the underlying causes are resolved, it is expected that further accidents will be prevented.
8D is an ideal tool for HSE investigations
The 8 Disciplines (8D) process is a robust investigation and problem-solving process used across many different industries. It incorporates all of the critical aspects of HSE issue management and provides an extremely effective HSE investigation workflow:
- Containment of the problem
- Root cause analysis
- Problem correction
- Problem prevention
HSE investigation workflow
Discipline 0 (D0): Summary
It is important to correctly name the HSE issue to be tackled, this allows teams to easily communicate about the problem-solving task. A short statement to summarise the problem should be defined, this statement will be used to name the H&S investigation report. This can be the Employee name and incident description for example.
Discipline 1 (D1): Investigating team
This step defines the investigating team. The team should include the process owner and other key stakeholders. The names of the team members along with their role and skills are recorded in D1.
Discipline 2 (D2): Description of incident
Describe the workplace, machines, tools, materials, and methods that directly caused or contribute to the incident. For example:
- The guard had been removed from the machine. Allowing the operator's hand to come in contact with the rotor during machining.
- The floor of the area was cracked, causing the operator to trip.
- The current working practices require staff to reach into the tumbler machine creating a splash hazard.
- Water dripping from the ceiling onto the walkway made the floor slippery.
Discipline 3 (D3): Remedial immediate actions
The first priority of an investigation is to identify the immediate, direct cause of the incident because there is a risk that the same circumstances may occur again, and steps must be taken to ensure that there is no repetition of the problem. All immediate actions should be listed and their status recorded in D3. Examples include:
- The machine was taken out of service and quarantined
- A warning sign was erected and staff informed of the hazard
- The operator was immediately provided with safety glasses
- A barrier was constructed around the area
Discipline 4 (D4): Actual probable root causes
This part of an investigation asks why the immediate causes occurred and what brought about the unsafe conditions. We have to know if there is a reason for the immediate cause, such as why did the guard break? If there are underlying reasons for the immediate cause, they must also be fixed to prevent the same circumstances from occurring again. For example. If a handrail fails and the cause is said to be loose fixings, we must follow the trail of underlying causes by asking more questions.
- The guard was removed so that productivity could be increased to meet targets.
- The specified floor material was unsuitable for the area.
- The use of safety glasses is not specified during training.
- The roof is damaged by debris falling from the walkway.
Discipline 5 (D5): Define permanent corrective actions
Identify all possible corrective actions to address the root cause of the problem. Use brainstorming techniques like Six hats and Random word if required. Provide a rationale for each proposed corrective action.
- Work should be routed through the correct machine: X263455.
- The floor should be replaced with a suitably durable surface.
- The use of safety glasses needs to be added to the training plan.
- Roof protection needs to be added to the walkway.
Discipline 6 (D6): Solution deployment
Define and record the implementation plan. Propose completion dates and allocate owners of tasks.
Any data showing that the corrective actions have been effective should be captured and referenced here.
Discipline 7 (D7): Detail procedure changes
Actions necessary to prevent the same problem from arising again are defined here. Consider the following:
- Updating the Quality Management System
- Updating the company standards and procedures
- Updating the audit plan
Consider applying the problem solution to other areas of the business.
Discipline 8 (D8): Summarize and close investigation
The last step of the HSE investigation process is to congratulate the team and publicise success. This generates support for more HSE improvement work and provides feedback on how to improve the investigation process in the future.