Incident Registration and Investigation Practices

From Formality to Real Causes: Transforming the Investigation Process

Incident investigation is a fundamental element of the HSE management system, but in practice, it often comes down to formal paperwork and finding a scapegoat. The transition from superficial conclusions to a deep analysis of root causes is impossible without changing the process architecture itself and involving top management. During his presentation, Alexander Pivikov, Production Safety Director at the Vyksa Steel Works, analyzes in detail the practice of transforming the investigation system, which helped the enterprise achieve an 88% reduction in occupational injuries over five years.

Delegating Responsibility and the Trap of Pseudo-Causes

Traditionally, incident investigation falls on the shoulders of HSE specialists, which is fundamentally wrong. The center of responsibility should shift to line managers. However, the speaker shows by example how this process can reach a dead end: the shop manager passes the task down to the foreman, who passes it to the team leader, and ultimately the worker writes the report themselves. This leads to the formation of pseudo-causes and ineffective corrective actions. For the system to work, investigations must be conducted by permanent commissions involving technical specialists and chaired by high-level managers, demonstrating real management commitment to safety issues.

Depth of Analysis: A Dropped Load Case Study

The speaker examines the difference between superficial and high-quality investigations using a real-world example of incidents involving magnetic cranes. The initial investigation revealed only "training deficiencies" and operator error. Repeated incidents forced the commission to dig deeper. It turned out that the problem was systemic: ranging from the lack of a procedure for checking uninterruptible power supplies and design flaws in the electrical circuit to the absence of standards for the number of sheets being moved. This case proves that without technical expertise and a deep dive into the process, it is impossible to break the chain of recurring incidents.

Combating Concealment and a New Notification Scheme

A key problem in any investigation is the concealment of incidents at the initial stage. The immediate supervisor is often interested in hiding the fact of an incident out of fear of punishment. To solve this problem, the enterprise changed its notification scheme: an eyewitness reports the incident not to their boss, but directly to a 24/7 independent dispatcher. Simultaneously, a strict rule was introduced: punishment follows not for the incident itself or an error, but exclusively for concealing the incident or missing investigation deadlines. This removes the barrier of fear and allows the company to see the real picture of what is happening.

Controlling Recurrences and Lessons Learned

The investigation report is not the final point. The presentation details the mechanism for working with lessons learned through an internal corporate portal. Statistical analysis makes it possible to identify problem areas (for example, communication breaks during excavation work) and initiate targeted safety months. At the same time, the final approval of investigation reports remains with the Safety Director, which guarantees quality control of the analysis and verification of how previous similar cases were taken into account.

What you will learn from this webinar:

• Why delegating investigations to lower management levels leads to ineffective measures and how to avoid this?
• How to exclude the line manager from the initial notification chain to minimize the risk of incident concealment?
• Why punishing those responsible for an incident destroys the safety culture and what sanctions should actually be applied for?
• How to use internal IT portals to monitor corrective actions and deal with recurrences?
• How to organize the work of commissions to meet tight deadlines without losing the quality of analysis?