Incident Investigation and Reporting

Safety Professionals around the world have made all the noise about incidence investigation. Now the question is, does it make sense, or are they simply some set of professionals who want to be loud? It simple; they are RIGHT.

So many disasters have occurred in Nigeria and one wonders why similar unfavorable events keep happening. Professionals have narrowed the cause down to the lack of Incident Investigation and Reporting culture. When we consider the consequence of incident investigation and reporting, the lives we have lost in this country to avoidable Plane crash incidents, auto crash, inferno, electrocution, medical emergencies, to mention a few, it further corroborates the need to find a swift solution to reoccurrence of similar types of accidents.

For the sakes of non-Safety Professionals, an incident as defined by the Occupational Safety and Health Administration (OSHA) is an unplanned event that interrupts the completion of an activity, and that may (or may not) include injury or property damage. When it does not involve injury or property damage, it is called ‘a near miss’ and ‘Accident’ when injuries and/or property damage is involved. It is however clear that all accident can be classified as an incident, but not all incidents is an accident, because it could be a near miss.

However, even near misses must be investigated and reported to prevent them from escalating into accidents. The term incident is also used more in place of accident to reduce tension during communication.

Having said this, a look at the history of plane crash incidents in Nigeria in the last decade is a good case study to achieve the purpose of this article. Not like there had not been Plane crash during periods that pre-dates my bracket of case study, but for brevity.

On 22^nd October, 2005 a Nigerian Bellview Airline Boeing 737 airliner with 117 people on board crashed and disintegrates in flames shortly after take-off from Lagos. Unfortunately, there were no survivors. On 10^th December, 2005 (The same year), a Nigerian Sosoliso Airlines DC-9 crashed in Port Harcourt, killing all 103 on board. Most on board were school children going home for Christmas. Barely a year later, precisely 17^th September, 2006 a Nigerian 18-seater Dornier 228 Air Force transport plane, carrying 15 senior army officers and three crew members crashed leaving only three survivors that sustained serious injuries.

On June 3, 2012, a Dana Airlines Flight 9J 992 carrying 153 passengers on board crashed at a residential area of Iju-Ishaga, Lagos. No one survived the crash, which also claimed lives of residents and properties. On 12^th August 2015, a Bristow Helicopter plunged into Oworonshoki Lagoon and 3 were confirmed dead, while 4 were injured. The question is ‘What role would proper investigation and reporting have played to prevent re-occurrence of these accidents?’

The primary and most important reason for accidents to be investigated and reported is to find out the CAUSE and PREVENT similar incidents in the future. Other reasons include fulfillment of legal requirements, to process compensations, to determine compliance with applicable safety standards, and to determine the cost of an accident.

Could it have been a possibility that if these events of Plane Crash had been properly investigated and the findings reported and perhaps published, we may not have had such long list of reoccurrence? From Safety perspectives, the answer is YES.

Accidents/Near misses are inevitable, albeit we must ensure they don’t, but what we do with the experience will go a long way to determine if there will be reoccurrence.

From history, most investigations have revealed the ‘Human Error’ factor largely contributing to occurrence of accidents. An authority, who understands the mode of operation of the elements involved in the accident is the right personnel to anchor an investigation because he is expected to know the right questions to ask that will lead to the right answers, which will eventually reveal the root cause. This is not applicable to events of plane crash alone, but every work place.

Ensure a culture of incident investigation and reporting. Remember, when near misses are reported, you are saving lives of potential victims of an incident.