HSE Incident Investigation: Goals, Objectives, Methods
Modern HSE culture relies on proactive tools — risk assessments and behavioral audits. However, reactive work with incidents that have already occurred remains a critically important barrier preventing severe injuries. Official statistics often do not reflect the real state of affairs, hiding a huge layer of micro-injuries. In this webinar, Vyacheslav Pachin, Head of the HSE Department at the Agropromkomplektatsiya Group of Companies, details how a large agricultural holding transformed its approach to incident investigation, shifting the focus from finding the guilty to identifying systemic failures.
From Recording Micro-Injuries to Systemic Solutions
The foundation of changes in the company was the refusal to hide minor incidents and classify them as "domestic injuries." The speaker emphasizes that every incident, including micro-injuries, must be investigated. This allows working with precursors before they lead to serious consequences. To prioritize hazards, the company independently implemented risk assessment using the Fine-Kinney method, which helped HSE specialists dive deeper into production processes and equipment technology.
The key thesis of the presentation: investigation is a team process of finding systemic causes and improving technological processes, not a tool for punishment. Only with this approach do production personnel and engineering services begin to interact openly with HSE specialists.
Practical Tools for Finding Root Causes
Vyacheslav Pachin shows with examples how to build a logical investigation chain by sequentially applying three analytical tools. The process begins with gathering facts, not with putting forward hypotheses.
- 5W1H Method. Used at the first stage to describe the circumstances of the incident as accurately as possible. By answering the questions "What? Where? When? Who? Why? How?", the working group moves away from vague wording. The speaker gives an example: a detailed survey helped find out why general workers on the conveyor got cuts, while meat deboners worked safely. It turned out that deboners were protected by chainmail aprons and puncture-resistant gloves, while general workers used ordinary cotton gloves. The introduction of Kevlar cut-resistant gloves in adjacent areas completely solved the problem.
- 4M Analysis (Ishikawa Diagram). The collected facts are systematized in four directions: Man, Machine (equipment), Method (instructions), and Material. At this stage, the working group, which includes foremen, engineers, and the security service, generates all possible causes of the incident, without discarding even unlikely options.
- "5 Whys" Method. Applied to the most probable causes identified at the previous stage to dig down to the fundamental systemic failure that generated the dangerous situation.
Errors in Horizontal Deployment of Measures
Finding the root cause and developing an engineering solution is only half the battle. The presentation details a case involving a worker falling on the wet floor of a sanitary checkpoint. The investigation was conducted correctly: the working group identified a problem in ergonomics and changed the design of the steps, lengthening the threshold. However, a few months later, a similar incident occurred in another workshop.
This example clearly demonstrates the critical importance of horizontal communication. Corrective measures must be scaled to all similar areas and departments of the company, and information about lessons learned must be promptly communicated to the managers of related production facilities.
What You Will Learn from This Webinar:
- How to overcome the formal approach to recording micro-injuries and make them a tool for preventing severe accidents?
- In what sequence to apply the 5W1H, 4M analysis, and "5 Whys" methods to achieve maximum effect?
- How to properly form a working group and involve engineering and technical personnel in the investigation process?
- Why local corrective measures often fail to prevent recurring incidents and how to build a system for sharing experience between workshops?
- How adapting PPE for specific operations of adjacent workers reduces the injury rate on the conveyor?
Comments 21
What indicators do you have in your KPIs? Is there a connection with LTIFR?
There is no connection. My KPIs are currently tied to OHS and environmental projects. For example, PPE cost optimization across the group of companies, reclassifying environmental impact facilities from category 1 to category 2.
Vyacheslav, what a great system — not punishment, but rather engagement with workers! Tell me, do you have an institution of OHS representatives?
We don't. In the holding, I primarily focus on training department staff and developing a proactive approach in their work. The next step is to launch production safety committees and develop a proactive approach among production department managers.
What is the level of support from top management? Was it easy to break the system of "household injury — concealment — micro-injury — real incident"? How exactly did you change the awareness platforms among frontline workers, line managers, and top management?
Currently, the level of support is high. Regarding incidents, I explained that we have fewer risks if we document everything according to the law. A couple of worker complaints helped — about receiving injuries that the employer concealed. This position was reinforced by a similar complaint where the worker demanded a large sum from us, but we had all the investigation documents and ultimately he lost the case.
In the case of micro-injuries, after eliminating the causes of the most frequent ones, downtime at the site decreased and, accordingly, productivity increased.
What percentage of workers are union members?
About 50%
Do you participate in discussions of draft government OHS documents?
Not for OHS. I recently raised this question. The answer was: monitor document publications on the portal and write comments there (meaning the government portal where documents are posted before adoption for public assessment). Regarding environmental protection, the Ministry of Agriculture periodically sends regulatory document texts requesting comments and suggestions.
How do you communicate micro-injury investigation results to workers? And second question — do you use the worker-to-worker method? (e.g., the worker who got a micro-injury comes to the center at the nearest shop floor meeting and tells colleagues how it happened)
We inform at 5-minute meetings in shops and through managers. As needed, I have conversations with workers: I gather them in the foremen's room, show a video of the incident (related to their work), and ask them to describe what was done wrong and how the work should have been performed correctly.
How are suggestions from workers accepted? Feedback boxes, email, personal inquiries?
Feedback boxes are installed at production sites, there are "pockets" on information boards. And as I mentioned, within the next month we'll launch an OHS section in the chat bot, which will include a section for worker suggestions.
How do you determine the commissioner of the incident investigation (the one who will oversee corrective actions and allocate resources)?
We sign the report collectively. It specifies deadlines and responsible persons.
Based on the results, responsible persons report to the OHS specialist.
If the investigation is complex, we schedule status meetings and monitor the implementation process.
How would you assess employee engagement in OHS and safety culture matters at your agricultural holding?
Honestly, I'd rate it between a strong 3 and a weak 4 out of 5. The culture varies somewhat across departments. For example, at factories with modern equipment, a younger staff, and most importantly younger managers, the culture level is higher. Managers pay a lot of attention to safety. It's harder to instill culture in crop production and transportation, where people of the "Soviet school" find safety requirements and any changes in general harder to accept. We engage them through professional skill competitions and practical drills.
How do you deal with red and orange risks?
Where possible, we reduce risks. Where it's not possible, we accept the risk, conduct additional training, briefings, and establish heightened oversight of the area. Experienced employees are assigned to the work.
How do you assess the causes of human errors (it's always very tempting to end the investigation at the point that the person made an error and got injured, but behind that error there is always a set of causes)?
In the report, we describe the motives of the action where possible (haste, lack of process knowledge, manager's instruction, deliberate violation, etc.). Then we work with the causes of those motives.
Is there an analysis of fatal and severe injuries in agriculture?
There is none industry-wide. Companies are not ready to share such information. Moreover, the level of safety culture in the industry varies dramatically across companies.
Do you rank incidents by the level of resources required for investigation, or do you allocate the same resources to all incidents?
We rank them. But given our structure and the assignment of specialists to specific areas, I haven't yet faced a resource shortage problem. If needed, I personally get involved and conduct the investigation.
What tools and methods of interaction with OHS specialists in the field? How often are online and offline meetings? How do you motivate field workers? How do you assess the level of OHS specialists in the regions?
In the regions, I have department heads who ensure operational work on the ground. I hold general meetings online weekly. For operational tasks, we may have calls several times a day. I physically visit each region monthly. I try to develop and train specialists. We have a specialized online system connected; in this system, I assign employees both professional training programs and programs aimed at developing management skills. The company provides material and non-material motivation tools. Employees can advance in position; several specialists have already grown into heads of OHS and environmental departments in the regions.
Are investigation results and the fact of incidents used in implementing other safety culture development tools?
Yes, they are. For example, additional PPE. Purchase of portable ladders (gangways) for working at height after identifying fall risks. Creation of animated safety videos in departments.
Do all managers at enterprises understand the need for such an investigation tool? How do you combat the formal approach to prevent tick-the-box investigations?
It can be difficult with line managers. To prevent the formal approach, OHS specialists take the leading role.
Do you often encounter logic failures when analyzing with the 5 Whys method, and how do you deal with them?
Not often. I try to approach analysis rationally and teach this to colleagues. If the true cause becomes clear at the 2nd or 3rd why, there's no need to make things up and go to the 5th just because you're supposed to ask the question 5 times.
Do all employees have access to "flash alerts"? If so, how is it ensured?
Managers have access to flash alerts. Workers are informed at 5-minute meetings in workshops and through managers.
We had an accident where the victim went — not on the foreman's or manager's instruction — to a location from which he subsequently fell from height and died. Nobody directed him there; it was literally a couple of minutes after a break when he went there and the accident happened. Is this a workplace accident?
We had a similar case, but not related to height. A worker disassembled equipment and climbed inside, it's unclear why, and it was completely unrelated to his duties. We investigated it as a work-related accident with involvement of all government agencies.
We have many surveillance cameras installed at our production facilities, which greatly helps in investigating incidents (in 90% of cases there is a recording of the incident).
Please advise, when working as a team, do you consider all types of safety?
We try to consider all types. We have elevated safety requirements in the company. There is a separate biosafety direction.
Were there cases when a micro-injury over time turned into an injury?
There were not. By agreement, if a person goes to a medical facility in case of a bruise (or other minor injury), we classify it as a workplace accident.
Do you investigate micro-injuries and accidents in the same way?
Approximately the same way. It all depends on the incident — sometimes the cause may be obvious from the start and lies on the surface. In that case, there's no point in assembling large commissions and going deep.
Do you directly involve the manager on whose site the accident occurred?
Not clear what "involve" means here. If in the investigation — yes, in implementing follow-up measures — definitely yes.
Are incident causes "fundamental" or "root"?)
True ones)
How do you familiarize workers with root causes of incidents and the corrective action plan? Are there always enough resources to implement measures aimed at preventing incident recurrence?
We inform at 5-minute meetings in workshops and through managers. Resources are sufficient for now. Here, the bigger question is probably how to get managers interested in this. I try to convey the necessity of implementing measures through money and production plan fulfillment + company image: Any injury means an employee's absence from the workplace, which entails a risk of not meeting the plan, overtime costs, search and recruitment of personnel. + Negative coverage on social media, in the worker's area of residence. Given the personnel shortage in rural areas, this is critical.
As a result, it's cheaper for the company to implement corrective measures: provide additional PPE, purchase tools, etc.
Would an incident be work-related if a third party attacked an enterprise employee?
We will definitely investigate, but whether it's work-related or not will depend on the circumstances.
How are micro-injuries collected?
Through medical stations at the enterprises.
Tell us about the enterprise structure and the OHS department structure. How many employees, how many divisions, how many OHS specialists? What is the workload?
Total headcount is 11 thousand. Divisions in 4 regions. Total OHS department size is 30 people (OHS and Fire Safety, Environmental Protection, Industrial Safety). The workload on specialists is high. Additional complexity comes from the high business diversification (crop production, livestock, processing) and recruiting specialists to regions. On the positive side, I can say that dialogue with managers is established, and when needed and with sufficient justification, we expand the staff.
Does the incident investigation methodology include an assessment of the OHS specialist's actions, regarding their influence on the occurred event?
I'm not sure what format of assessment was meant. I can say that the specialist's actions are assessed in terms of fulfilling organizational OHS requirements (conducting introductory briefings, preparing training documents, familiarization with workplace assessment reports, risk maps), and the control function (audits conducted in the department).
According to your incident investigation methodology, if an employee is injured at work, who is at fault?
We work with causes in detail. During the investigation, incorrect actions of both the worker and the manager may be identified. As I said, we don't look for someone to blame. We look for gaps in processes, equipment, and methodology. The true causes are usually there.
Do you focus employees' attention on following safety requirements not only at work but also in daily life?
During training, we emphasize this and in awareness materials. For example, we made a video on safe winter driving, guidelines for walking in winter, actions in hot weather, etc. — in these, we did not separate rules into work/home. These were general safety rules for people.
What risk assessment methods did you try before choosing the US Navy method?
We tried the matrix method. But we switched to Fine-Kinney for more precise risk grading. This allowed us to address the most critical ones first.