Fundamentals of Effective Incident Investigation in HSE

Incident investigation is traditionally perceived as a reactive tool, but with the right approach, it becomes a driver for developing a proactive safety culture. During her presentation, Elena Golenkova, Head of Incident Investigation at NLMK PJSC, details the process of transforming the investigation system using the example of a large manufacturing holding. The speaker shows how to move from formal report filling to real operational risk management.

System Implementation: From Regulation to Practice

Developing a unified regulatory document for multiple sites is only the first step. The speaker emphasizes that without quality training, any regulation remains ineffective. A comprehensive approach is proposed for effective implementation:

• Modular training: dividing the theoretical base into short thematic blocks (informing, creating a commission, report preparation). This prevents formal course completion and improves material retention by employees.
• Practical cases: practicing skills on real scenarios, including building a timeline and conducting interviews. Practice allows commission members to understand the mechanics of identifying systemic causes.
• Methodological support: creating auxiliary materials (quality expertise checklists, brochures) and continuous support of sites by specialized experts.

Incident Classification and Commission Formation

To unify the approach, all incidents are divided into four levels: from near-misses and micro-injuries to severe cases. Special attention is paid to high-potential incidents, where fatal consequences were avoided only by chance. The commission's composition is formed depending on the incident level. For investigating the most serious cases, the commission is headed by top management representatives. This ensures the chairman has sufficient authority to change processes company-wide, not just at a local site.

Interview Psychology and Root Cause Analysis

A key barrier in investigation is workers' fear of disciplinary punishment. The presentation details an approach to conducting interviews without seeking a culprit. If the commission uses pressure, workers hide facts, making it impossible to identify the true causes. The speaker analyzes methods to reduce stress in victims and witnesses, allowing for an objective picture of what happened.

Adapted methods are used to analyze cause-and-effect relationships:

• "5 Whys" (Cause Tree): a universal tool that allows reaching systemic failures from immediate causes (unsafe acts and conditions). The main rule is that each immediate cause must be linked to at least one systemic cause.
• "Swiss Cheese" (Barrier Approach): used primarily to analyze equipment failures. It is important not only to identify failed barriers but also to consider those that fulfilled their function, so new solutions do not conflict with existing protective measures.

Corrective Actions and Lessons Learned

An investigation loses its meaning if the developed measures are not implemented or do not affect the system. The speaker shows by example how the commission's visit to the incident scene (a case involving the manual carrying of a 52-kilogram lining plate) allows for a complete review and mechanization of a hazardous process, eliminating the risk source.

All corrective actions must be formulated according to the SMART principle and be subject to strict execution control. In addition, incident information is transformed into "Lessons Learned" — information sheets distributed to other facilities with similar equipment. This allows for proactive elimination of vulnerabilities before they lead to injuries at adjacent sites.

What you will learn from this webinar:

• How to organize the incident investigation process in a diversified holding and ensure the operation of unified standards?
• Why disciplinary punishments following an investigation destroy the safety culture and lead to incident concealment?
• How to correctly apply the "5 Whys" methodology to guaranteed identify the systemic causes of an incident?
• How to turn investigation results into a proactive tool using a lessons learned system?
• Why the commission chairman should personally visit the incident scene and how this changes the quality of corrective measures?