Mastering the art of investigating workplace incidents requires a shift from fault-finding to fact-finding. It’s an approach championed by Steven Tusa, President of Risk Management Advisors LLC, and backed by his more than 30 years of experience in health, safety, and risk management.
Recently, Tusa joined our monthly Risk Control Webinar series. During his presentation, Tusa challenged conventional investigation approaches and outlined a methodology to help organizations learn more effectively from workplace incidents.
Continue reading for an overview of Tusa’s presentation.
Tusa began his presentation by addressing persistent myths in safety training, particularly the Heinrich Pyramid and its variations that suggest a predictable relationship between minor incidents and serious injuries.
“These pyramids continue to show up in safety training and education, and they’re just not accurate,” Tusa said.
He revealed a troubling trend in the workplace safety data. While the Occupational Safety and Health Administration (OSHA) recordable rates have declined from 1992 to 2022, the number of serious incidents and fatalities has increased during the same period.
Tusa highlighted research from the Society for Human Resources Management that illustrated just how disengaged people can be in the workplace.
“Three out of ten people are focused on the task at hand. [The rest] are thinking about something else,” Tusa said, describing workers operating machinery, driving vehicles, or working on construction sites around heavy equipment. “That’s a frightening thought when people are really close to risk.”
When workplace incidents occur, organizations need to learn from them. Tusa identified several unintentional barriers that prevent effective incident investigations, including:
“Your prior actions teach people in your organization who, in turn, teach your new hires,” Tusa said, explaining how negative past experiences influence reporting behavior.
Tusa devoted significant attention to how terminology shapes perception and reporting behavior.
“Terms like failure, error, and mistake are all common words that make people feel like they’re being blamed,” Tusa said.
To encourage prompt reporting, Tusa recommended calling everything an “incident.”
“An ‘incident’ is non-threatening,” said Tusa. “Stop labeling your injuries, accidents, and near-misses and start defining everything as an ‘incident.’”
Tusa outlined a proven methodology that organizations can implement immediately:
Ensure proper care and immediate notification through simple documentation processes. If you have any doubt about calling 911, make the call.
Use caution tape to preserve the area and prevent modifications. Assign someone to meet emergency personnel if necessary.
Begin by explaining that the purpose is to prevent recurrence, not to assign blame. The immediate leader should quarterback the investigation at the actual incident site.
Begin by considering what happened before the employee arrived at work, recognizing that personal circumstances can impact their focus. Progress through the timeline to understand all contributing factors.
Examine equipment, materials, and processes in that order — starting with objects rather than people to avoid creating defensiveness.
Involve employees, eyewitnesses, and leaders in creating actionable insights.
Utilize technology to simplify and make documentation accessible.
Tusa challenged the concept of “root cause analysis,” arguing instead for identifying multiple contributing factors.
He compared treating symptoms versus causes to a doctor prescribing medication without conducting diagnostic tests — the treatment might work, but without understanding the underlying condition, problems persist.
When examining contributing factors, Tusa recommended starting with the following:
Tusa shared three questions he considers essential for every investigation.
Allow time for people to reflect on the areas they’ve identified as risky during their work.
Obtain details about the exact location, including whether it’s in a specific facility, loading dock area, or other designated workspace.
This reveals valuable ideas workers have been holding onto about reducing risk.
Throughout the presentation, Tusa demonstrated how mobile technology simplifies reporting and investigation. He demonstrated smartphone apps that enable voice-to-text incident reporting with GPS coordinates, automatic notifications to leadership, and photo documentation — all of which can be completed in minutes, rather than requiring lengthy paperwork.
“Nobody wants to spend time doing paperwork during or after the workday, especially if the paperwork is multiple pages long,” Tusa said.
Tusa concluded the presentation with three action steps for organizations:
Make the investigation goal crystal clear.
Follow the simple seven-step process, teaching and practicing it until teams become adept at conducting thorough investigations.
Eliminate paperwork and use technology to make the process efficient and accessible.
“We want to learn from every incident,” said Tusa. “It’s important you show up with a learning approach — with care and to learn all the facts.”
This presentation was part of Captive Resources’ Risk Control Webinar Series — regular installments of webinars to educate the group captive members we work with on topics like workplace safety, organizational leadership, and company performance. The thoughts and opinions expressed in these webinars are those of the presenters and do not necessarily reflect Captive Resources’ positions on any of the above topics.
