ISBN 978-0-8412-2817-7

educated in fire safety because it was not taught. Often a key rootcause of an incident is a weak or missing safety culture—leadershipsays safety is important but places little value on it, as evidenced bythe failure to invest significant time, effort and resources, and by theavoidance of taking responsibility for safety.Important elements of a strong safety culture include establishinga system for reporting and investigating incidents, identifyingdirect and root causes, and implementing corrective actions. Thecomponents of an incident investigation system are:• An incident reporting system that includes students. AnOSHA-required incident reporting system is in place foremployees. Incidents should be reported within 24–48hours, so facts are easily remembered. Close calls andnonreportable incidents should also be included in anincident reporting system.Often a key rootcause of an incidentis a weak or missingsafety culture—leadership says safetyis important butplaces little value onit, as evidenced bythe failure to investsignificant time, effortand resources, andby the avoidance oftaking responsibilityfor safety.• An incident investigation system that collects reports ofincidents, conducts investigations of incidents, and reportslessons learned to faculty, staff, and students. The extent of an investigation is determinedby the seriousness of the incident, but all incidents should be investigated as soon aspossible and serious incident scenes (injuries or serious damage) should be preserved untilrelease by investigators. This system includes an investigation reporting system, so lessonslearned may be shared and appropriate actions can be taken to prevent future incidents.• An incident database that contains incident and investigation reports, including close callsand nonreportable incidents. This database is used to look for tracking, trends analysis,and systemic problems, and to track implementation of corrective actions. This informationshould be used to teach lessons through proactive communications to others to prevent orminimize future incidents.Incident investigations can be used as safety education and training tools in classrooms, groupdiscussions, or seminars. They should be topics of discussion in departmental safety committees,as well as in higher level meetings in the institution. The focus of incident investigations shouldalways be on learning the direct and root causes of the incident, so corrective actions can bedetermined and implemented. Investigations should not focus on affixing blame or assessingpenalties. Punitive actions will drive the faculty and staff to stop reporting incidents. OSHAprohibits retaliation for reporting safety issues. In a truly strong safety culture, incidents areeffective learning tools and information is freely shared without fear of retaliation.Incidents will never be eliminated but in a strong safety culture, serious incidents are rare. Mostserious incidents are the result of a series of bad decisions and steps that ignore proper safetymeasures. In a strong safety culture, it is much more likely that fewer poor decisions and misstepswill take place, so serious incidents are avoided.31