Investigation Irregularities

So what are these irregularities? They are simply facts or findings that because of their unusual nature seem to jump out in front of us as we do our investigations. In a significant investigation we are likely to find a dozen or so of them.

Here are a few examples:

• The Safe Work Procedure was not signed off by management as were other procedures.
• The injured worker was using fall arrest equipment; however, he had no formal training in its use.
• The workers involved had signed but not read the orientation documentation.
• Duct tape was being used to create a seal around the face mask.
• There was confusion amongst supervisors as to what types of respirators were required.
• The Lockout listing was not completed prior to the incident, but rather was done after the fact.

Typically, we would incorporate these findings in our report in areas where they seem most appropriate. The problem being the importance or relevance of them to readers may be lost as any one of these irregularities by themselves may not seem all that significant.

Listing them together early in the report tends to get the “wow!” response from readers. Their interest has been piqued and the question they have in their minds is “how are we going to fix this?” and of course you have the answer for them in your corrective actions.

An even more powerful method of corrective action development is to simply present these irregularities along with other facts and let those involved determine the course of action. When you see irregularities listed as a group, the action required becomes self-evident.

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