Incident Investigation : OSH Answers

What are the steps involved in investigating an incident? · Scene management and scene assessment (secure the scene, make sure it is safe for investigators to do ... Skiptomaincontent Skiptositeinformation Youarehere: Home OSHAnswers HealthandSafetyPrograms OSHAnswersFactSheets Easy-to-read,question-and-answerfactsheetscoveringawiderangeofworkplacehealthandsafetytopics,fromhazardstodiseasestoergonomicstoworkplacepromotion.MOREABOUT> DownloadthefreeOSHAnswersapp Searchallfactsheets: Search SEARCH Typeaword,aphrase,oraskaquestion HELP CLOSEALL Whatisanincidentandwhyshoulditbeinvestigated? Thetermincidentcanbedefinedasanoccurrence,condition,orsituationarisinginthecourseofworkthatresultedinorcouldhaveresultedininjuries,illnesses,damagetohealth,orfatalities.Theterm"accident"isalsocommonlyused,andcanbedefinedasanunplannedeventthatinterruptsthecompletionofanactivity,andthatmay(ormaynot)includeinjuryorpropertydamage.Somemakeadistinctionbetweenaccidentandincident.Theyusethetermincidenttorefertoanunexpectedeventthatdidnotcauseinjuryordamagethattimebuthadthepotential."Nearmiss"or"dangerousoccurrence"arealsotermsforaneventthatcouldhavecausedharmbutdidnot.Pleasenote:Thetermincidentisusedinsomesituationsandjurisdictionstocoverbothan"accident"and"incident".Itisarguedthattheword"accident"impliesthattheeventwasrelatedtofateorchance.Whentherootcauseisdetermined,itisusuallyfoundthatmanyeventswerepredictableandcouldhavebeenpreventediftherightactionsweretaken-makingtheeventnotoneoffateorchance(thus,thewordincidentisused).Forsimplicity,wewillnowusethetermincidenttomeanalloftheaboveevents.Theinformationthatfollowsisintendedtobeageneralguideforemployers,supervisors,healthandsafetycommitteemembers,ormembersofanincidentinvestigationteam.Whenincidentsareinvestigated,theemphasisshouldbeconcentratedonfindingtherootcauseoftheincidentsoyoucanpreventtheeventfromhappeningagain.Thepurposeistofindfactsthatcanleadtocorrectiveactions,nottofindfault.Alwayslookfordeepercauses.Donotsimplyrecordthestepsoftheevent.Reasonstoinvestigateaworkplaceincidentinclude:mostimportantly,tofindoutthecauseofincidentsandtopreventsimilarincidentsinthefuturetofulfillanylegalrequirementstodeterminethecostofanincidenttodeterminecompliancewithapplicableregulations(e.g.,occupationalhealthandsafety,criminal,etc.)toprocessworkers'compensationclaimsThesameprinciplesapplytoaninquiryofaminorincidentandtothemoreformalinvestigationofaseriousevent.Mostimportantly,thesestepscanbeusedtoinvestigateanysituation(e.g.,wherenoincidenthasoccurred...yet)asawaytopreventanincident. Whoshoulddotheinvestigating? Ideally,aninvestigationwouldbeconductedbysomeoneoragroupofpeoplewhoare:experiencedinincidentcausationmodels,experiencedininvestigativetechniques,knowledgeableofanylegalororganizationalrequirements,knowledgeableinoccupationalhealthandsafetyfundamentals,knowledgeableintheworkprocesses,procedures,persons,andindustrialrelationsenvironmentforthatparticularsituation,abletouseinterviewandotherperson-to-persontechniqueseffectively(suchasmediationorconflictresolution),knowledgeableofrequirementsfordocuments,records,anddatacollection;andabletoanalyzethedatagatheredtodeterminefindingsandreachrecommendations.Somejurisdictionsprovideguidancesuchasrequiringthattheincidentmustbeconductedjointly,withbothmanagementandlabourrepresented,orthattheinvestigatorsmustbeknowledgeableabouttheworkprocessesinvolved.Membersoftheteamcaninclude:employeeswithknowledgeoftheworksupervisoroftheareaorworksafetyofficerhealthandsafetycommitteeunionrepresentative,ifapplicableemployeeswithexperienceininvestigations"outside"expertsrepresentativefromlocalgovernmentorpoliceNote:Insomecases,otherauthoritiesmayhavejurisdiction,suchasifaseriousinjuryorfatalityoccurred.Yourorganizationshouldestablish,implement,andmaintainaproceduretocoordinatemanagingincidentswiththeauthorityhavingjurisdiction(e.g.,police,OH&Sinspectors,etc.).Thiscoordinationmayincludetheauthoritytakingcontroloftheincidentscene. Shouldtheimmediatesupervisorbeontheteam? Theadvantageisthatthispersonislikelytoknowmostabouttheworkandpersonsinvolvedandthecurrentconditions.Furthermore,thesupervisorcanusuallytakeimmediateremedialaction.Thecounterargumentisthattheremaybeanattempttoglossoverthesupervisor’sshortcomingsintheincident.Thissituationshouldnotariseiftheincidentisinvestigatedbyateamofpeople,andiftheworkerrepresentative(s)andtheinvestigationteammembersreviewallincidentinvestigationfindingsandrecommendationsthoroughly. Whylookfortherootcause? Aninvestigatororteamwhobelievethatincidentsarecausedbyunsafeconditionswilllikelytrytouncoverconditionsascauses.Ontheotherhand,onewhobelievestheyarecausedbyunsafeactswillattempttofindthehumanerrorsthatarecauses.Therefore,itisnecessarytoexamineallunderlyingfactorsinachainofeventsthatendsinanincident.Theimportantpointisthateveninthemostseeminglystraightforwardincidents,seldom,ifever,isthereonlyasinglecause.Forexample,an"investigation"whichconcludesthatanincidentwasduetoworkercarelessness,andgoesnofurther,failstofindanswerstoseveralimportantquestionssuchas:Wastheworkerdistracted?Ifyes,whywastheworkerdistracted?Wasasafeworkprocedurebeingfollowed?Ifnot,whynot?Weresafetydevicesinorder?Ifnot,whynot?Wastheworkertrained?Ifnot,whynot?Aninquirythatanswerstheseandrelatedquestionswillprobablyrevealconditionsthataremoreopentocorrection. Whatarethestepsinvolvedininvestigatinganincident? First:Reporttheincidentoccurrencetoadesignatedpersonwithintheorganization.Providefirstaidandmedicalcaretoinjuredperson(s)andpreventfurtherinjuriesordamage.Theincidentinvestigationteamwouldperformthefollowinggeneralsteps:Scenemanagementandsceneassessment(securethescene,makesureitissafeforinvestigatorstodotheirjob).Witnessmanagement(providesupport,limitinteractionwithotherwitnesses,interview).Investigatetheincident,collectdata.Analyzethedata,identifytherootcauses.Reportthefindingsandrecommendations.Theorganizationwouldthen:Developaplanforcorrectiveaction.Implementtheplan.Evaluatetheeffectivenessofthecorrectiveaction.Makechangesforcontinualimprovement.Aslittletimeaspossibleshouldbelostbetweenthemomentofanincidentandthebeginningoftheinvestigation.Inthisway,oneismostlikelytobeabletoobservetheconditionsastheywereatthetime,preventdisturbanceofevidence,andidentifywitnesses.Thetoolsthatmembersoftheinvestigatingteammayneed(pencil,paper,cameraorrecordingdevice,tapemeasure,etc.)shouldbeimmediatelyavailablesothatnotimeiswasted. Whatshouldbelookedatasthecauseofanincident? CausationModelsManymodelsofcausationhavebeenproposed,rangingfromHeinrich'sdominotheorytothesophisticatedManagementOversightandRiskTree(MORT).ThesimplemodelshowninFigure1attemptstoillustratethatthecausesofanyincidentcanbegroupedintofivecategories-task,material,environment,personnel,andmanagement.Whenthismodelisused,possiblecausesineachcategoryshouldbeinvestigated.Eachcategoryisexaminedmorecloselybelow.Rememberthatthesearesamplequestionsonly:noattempthasbeenmadetodevelopacomprehensivechecklist.Figure1:IncidentCategoriesTaskHeretheactualworkprocedurebeingusedatthetimeoftheincidentisexplored.Membersoftheinvestigationteamwilllookforanswerstoquestionssuchas:Wasasafeworkprocedureused?Hadconditionschangedtomakethenormalprocedureunsafe?Weretheappropriatetoolsandmaterialsavailable?Weretheyused?Weresafetydevicesworkingproperly?Waslockoutusedwhennecessary?Formostofthesequestions,animportantfollow-upquestionis"Ifnot,whynot?"MaterialToseekoutpossiblecausesresultingfromtheequipmentandmaterialsused,investigatorsmightask:Wasthereanequipmentfailure?Whatcausedittofail?Wasthemachinerypoorlydesigned?Werehazardousproductsinvolved?Weretheyclearlyidentified?Wasalesshazardousalternativeproductpossibleandavailable?Wastherawmaterialsubstandardinsomeway?Shouldpersonalprotectiveequipment(PPE)havebeenused?WasthePPEused?WereusersofPPEproperlyeducatedandtrained?Again,eachtimetheanswerrevealsanunsafecondition,theinvestigatormustaskwhythissituationwasallowedtoexist.WorkEnvironmentThephysicalworkenvironment,andespeciallysuddenchangestothatenvironment,arefactorsthatneedtobeidentified.Thesituationatthetimeoftheincidentiswhatisimportant,notwhatthe"usual"conditionswere.Forexample,investigatorsmaywanttoknow:Whatweretheweatherconditions?Waspoorhousekeepingaproblem?Wasittoohotortoocold?Wasnoiseaproblem?Wasthereadequatelight?Weretoxicorhazardousgases,dusts,orfumespresent?PersonnelThephysicalandmentalconditionofthoseindividualsdirectlyinvolvedintheeventmustbeexplored,aswellasthepsychosocialenvironmenttheywereworkingwithin.Thepurposeforinvestigatingtheincidentisnottoestablishblameagainstsomeonebuttheinquirywillnotbecompleteunlesspersonalcharacteristicsorpsychosocialfactorsareconsidered.Somefactorswillremainessentiallyconstantwhileothersmayvaryfromdaytoday:Didtheworkerfollowthesafeoperatingprocedures?Wereworkersexperiencedintheworkbeingdone?Hadtheybeenadequatelyeducatedandtrained?Cantheyphysicallydothework?Whatwasthestatusoftheirhealth?Weretheytired?Wasfatigueorshiftworkanissue?Weretheyunderstress(workorpersonal)?Wastherepressuretocompletetasksunderadeadline,ortoby-passsafetyprocedures?ManagementManagementholdsthelegalresponsibilityforthesafetyoftheworkplaceandthereforetheroleofsupervisorsandhighermanagementandtheroleorpresenceofmanagementsystemsmustalwaysbeconsideredinanincidentinvestigation.Thesefactorsmayalsobecalledorganizationalfactors.Failuresofmanagementsystemsareoftenfoundtobedirectorindirectcauses.Askquestionssuchas:Weresafetyrulesorsafeworkprocedurescommunicatedtoandunderstoodbyallemployees?Werewrittenproceduresandorientationavailable?Werethesafeworkproceduresbeingenforced?Wasthereadequatesupervision?Wereworkerseducatedandtrainedtodothework?Hadhazardsandrisksbeenpreviouslyidentifiedandassessed?Hadproceduresbeendevelopedtoeliminatethehazardsorcontroltherisks?Wereunsafeconditionscorrected?Wasregularmaintenanceofequipmentcarriedout?Wereregularsafetyinspectionscarriedout?Hadtheconditionorconcernbeenreportedbeforehand?Wasactiontaken?Thismodelofincidentinvestigationprovidesaguideforuncoveringallpossiblecausesandreducesthelikelihoodoflookingatfactsinisolation.Someinvestigatorsmayprefertoplacesomeofthesamplequestionsindifferentcategories;however,thecategoriesarenotimportant,aslongaseachquestionisasked.Obviouslythereisconsiderableoverlapbetweencategories;thisoverlapreflectsthesituationinreallife.Againitshouldbeemphasizedthattheabovesamplequestionsdonotmakeupacompletechecklist,butareexamplesonly. Howarethefactscollected? Thestepsintheinvestigationaresimple:theinvestigatorsgatherdata,analyzeit,determinetheirfindings,andmakerecommendations.Althoughtheproceduresareseeminglystraightforward,eachstepcanhaveitspitfalls.Asmentionedabove,anopenmindisnecessaryinaninvestigation:preconceivednotionsmayresultinsomewrongpathsbeingfollowedwhileleavingsomesignificantfactsuncovered.Allpossiblecausesshouldbeconsidered.Makingnotesofideasastheyoccurisagoodpracticebutconclusionsshouldnotbemadeuntilallthedataisgathered.PhysicalEvidenceBeforeattemptingtogatherinformation,examinethesiteforaquickoverview,takestepstopreserveevidence,andidentifyallwitnesses.Insomejurisdictions,anincidentsitemustnotbedisturbedwithoutapprovalfromappropriategovernmentofficialssuchasthecoroner,inspector,orpolice.Physicalevidenceisprobablythemostnon-controversialinformationavailable.Itisalsosubjecttorapidchangeorobliteration;therefore,itshouldbethefirsttoberecorded.Basedonyourknowledgeoftheworkprocess,youmaywanttocheckitemssuchas:positionsofinjuredworkersequipmentbeingusedproductsbeingusedsafetydevicesinusepositionofappropriateguardspositionofcontrolsofmachinerydamagetoequipmenthousekeepingofareaweatherconditionslightinglevelsnoiselevelstimeofdayYoumaywanttotakephotographsbeforeanythingismoved,bothofthegeneralareaandspecificitems.Alaterstudyofthepicturesmayrevealconditionsorobservationsthatweremissedinitially.Sketchesofthescenebasedonmeasurementstakenmayalsohelpinlateranalysisandwillclarifyanywrittenreports.Brokenequipment,debris,andsamplesofmaterialsinvolvedmayberemovedforfurtheranalysisbyappropriateexperts.Evenifphotographsaretaken,writtennotesaboutthelocationoftheseitemsatthesceneshouldbeprepared.WitnessAccountsAlthoughtheremaybeoccasionswhenyouareunabletodoso,everyeffortshouldbemadetointerviewwitnesses.Insomesituationswitnessesmaybeyourprimarysourceofinformationbecauseyoumaybecalledupontoinvestigateanincidentwithoutbeingabletoexaminethesceneimmediatelyaftertheevent.Becausewitnessesmaybeundersevereemotionalstressorafraidtobecompletelyopenforfearofrecrimination,interviewingwitnessesisprobablythehardesttaskfacinganinvestigator.Witnessesshouldbekeptapartandinterviewedassoonaspossibleaftertheincident.Ifwitnesseshaveanopportunitytodiscusstheeventamongthemselves,individualperceptionsmaybelostinthenormalprocessofacceptingaconsensusviewwheredoubtexistsaboutthefacts.Witnessesshouldbeinterviewedalone,ratherthaninagroup.Youmaydecidetointerviewawitnessatthescenewhereitiseasiertoestablishthepositionsofeachpersoninvolvedandtoobtainadescriptionoftheevents.Ontheotherhand,itmaybepreferabletocarryoutinterviewsinaquietofficewheretherewillbefewerdistractions.Thedecisionmaydependinpartonthenatureoftheincidentandthementalstateofthewitnesses.InterviewingThepurposeoftheinterviewistoestablishanunderstandingwiththewitnessandtoobtainhisorherownwordsdescribingtheevent:DO...putthewitness,whoisprobablyupset,ateaseemphasizetherealreasonfortheinvestigation,todeterminewhathappenedandwhyletthewitnesstalk,listenconfirmthatyouhavethestatementcorrecttrytosenseanyunderlyingfeelingsofthewitnessmakeshortnotesorasksomeoneelseontheteamtotakethemduringtheinterviewaskifitisokaytorecordtheinterview,ifyouaredoingsocloseonapositivenoteDONOT...intimidatethewitnessinterruptpromptaskleadingquestionsshowyourownemotionsjumptoconclusionsAskopen-endedquestionsthatcannotbeansweredbysimply"yes"or"no".Theactualquestionsyouaskthewitnesswillnaturallyvarywitheachincident,buttherearesomegeneralquestionsthatshouldbeaskedeachtime:Wherewereyouatthetimeoftheincident?Whatwereyoudoingatthetime?Whatdidyousee,hear?Whatweretheworkenvironmentconditions(weather,light,noise,etc.)atthetime?Whatwas(were)theinjuredworker(s)doingatthetime?Inyouropinion,whatcausedtheincident?Howmightsimilarincidentsbepreventedinthefuture?Askingquestionsisastraightforwardapproachtoestablishingwhathappened.But,caremustbetakentoassesstheaccuracyofanystatementsmadeintheinterviews.Anothertechniquesometimesusedtodeterminethesequenceofeventsistore-enactorreplaythemastheyhappened.Caremustbetakensothatfurtherinjuryordamagedoesnotoccur.Awitness(usuallytheinjuredworker)isaskedtoreenactinslowmotiontheactionsthathappenedbeforetheincident.OtherInformationDatacanbefoundindocumentssuchastechnicaldatasheets,healthandsafetycommitteeminutes,inspectionreports,companypolicies,maintenancereports,pastincidentreports,safe-workprocedures,andtrainingreports.Anyrelevantinformationshouldbestudiedtoseewhatmighthavehappened,andwhatchangesmightberecommendedtopreventrecurrenceofsimilarincidents. WhatshouldIknowwhenmakingtheanalysisandrecommendations? Atthisstageoftheinvestigationmostofthefactsaboutwhathappenedandhowithappenedshouldbeknown.Thisdatagatheringhastakenconsiderableefforttoaccomplishbutitrepresentsonlythefirsthalfoftheobjective.Nowcomesthekeyquestion-whydidithappen?Keepanopenmindtoallpossibilitiesandlookforallpertinentfacts.Theremaystillbegapsinyourunderstandingofthesequenceofeventsthatresultedintheincident.Youmayneedtore-interviewsomewitnessesorlookforotherdatatofillthesegapsinyourknowledge.Whenyouranalysisiscomplete,writedownastep-by-stepaccountofwhathappened(theteam’sconclusions)workingbackfromthemomentoftheincident,listingallpossiblecausesateachstep.Thisisnotextrawork:itisadraftforpartofthefinalreport.Eachconclusionshouldbecheckedtoseeif:itissupportedbyevidencetheevidenceisdirect(physicalordocumentary)orbasedoneyewitnessaccounts,ortheevidenceisbasedonassumption.Thislistservesasafinalcheckondiscrepanciesthatshouldbeexplained. Whyshouldrecommendationsbemade? Themostimportantfinalstepistocomeupwithasetofwell-consideredrecommendationsdesignedtopreventrecurrencesofsimilarincidents.Recommendationsshould:bespecificbeconstructiveidentifyrootcausesidentifycontributingfactorsResistthetemptationtomakeonlygeneralrecommendationstosavetimeandeffort.Forexample,youhavedeterminedthatablindcornercontributedtoanincident.Ratherthanjustrecommending"eliminateblindcorners"itwouldbebettertosuggest:installmirrorsatthenorthwestcornerofbuildingX(specifictothisincident)installmirrorsatblindcornerswhererequiredthroughouttheworksite(general)Nevermakerecommendationsaboutdiscipliningapersonorpersonswhomayhavebeenatfault.Thisactionwouldnotonlybecountertotherealpurposeoftheinvestigation,butitwouldjeopardizethechancesforafreeflowofinformationinfutureinvestigations.Intheunlikelyeventthatyouhavenotbeenabletodeterminethecausesofanincidentwithcompletecertainty,youprobablystillhaveuncoveredweaknesseswithintheprocess,ormanagementsystem.Itisappropriatethatrecommendationsbemadetocorrectthesedeficiencies.TheWrittenReportTheprepareddraftofthesequenceofeventscannowbeusedtodescribewhathappened.Rememberthatreadersofyourreportdonothavetheintimateknowledgeoftheincidentthatyouhavesoincludeallrelevantdetails,includingphotographsanddiagrams.Identifyclearlywhereevidenceisbasedoncertainfacts,witnessaccounts,orontheteam’sassumptions.Ifdoubtexistsaboutanyparticularpartoftheevent,sayso.Thereasonsforyourconclusionsshouldbestatedandfollowedbyyourrecommendations.Donotincludeextramaterialthatisnotrequiredforafullunderstandingoftheincidentanditscausessuchasphotographsthatarenotrelevantandpartsoftheinvestigationthatledyounowhere.Themeasureofagoodreportisquality,notquantity.Alwayscommunicateyourfindingsandrecommendationswithworkers,supervisorsandmanagement.Presentyourinformation'incontext'soeveryoneunderstandshowtheincidentoccurredandtheactionsneededtoputinplacetopreventitfromhappeningagain.Someorganizationsmayusepre-determinedformsorchecklists.However,usethesedocumentswithcautionastheymaybelimitinginsomecases.Alwaysprovidealloftheinformationneededtohelpothersunderstandthecausesoftheevent,andwhytherecommendationsareimportant. Whatshouldbedoneiftheinvestigationrevealshumanerror? Adifficultythathasbotheredmanyinvestigatorsistheideathatonedoesnotwanttolayblame.However,whenathoroughworksiteinvestigationrevealsthatsomepersonorpersonsamongmanagement,supervisor,andtheworkerswereapparentlyatfault,thenthisfactshouldbepointedout.Theintentionhereistoremedythesituation,nottodisciplineanindividual.Failingtopointouthumanfailingsthatcontributedtoanincidentwillnotonlydowngradethequalityoftheinvestigation,itwillalsoallowfutureincidentstohappenfromsimilarcausesbecausetheyhavenotbeenaddressed.Howevernevermakerecommendationsaboutdisciplininganyonewhomaybeatfault.Anydisciplinarystepsshouldbedonewithinthenormalpersonnelprocedures. Howshouldfollow-upbedone? Managementisresponsibleforactingontherecommendationsintheinvestigationreport.Thehealthandsafetycommitteeorrepresentative,ifpresent,canmonitortheprogressoftheseactions.Follow-upactionsinclude:Respondtotherecommendationsinthereportbyexplainingwhatcanandcannotbedone(andwhyorwhynot).Developatimetableforcorrectiveactions.Monitorthatthescheduledactionshavebeencompleted.Checktheconditionofinjuredworker(s).Educateandtrainotherworkersatrisk.Re-orientworker(s)ontheirreturntowork. CLOSEALL DocumentlastupdatedonNovember26,2019 Addabadgetoyourwebsiteorintranetsoyourworkerscanquicklyfindanswerstotheirhealthandsafetyquestions. GETTHEBADGE What'sNew CheckoutourWhat’sNewlistingtoseewhathasbeenaddedorrevised. Needmorehelp? ContactourSafetyInfoLine 905-572-2981 Tollfree1-800-668-4284 (inCanadaandtheUnitedStates) ASKAQUESTION Telluswhatyouthink Howcanwemakeourservicesmoreusefulforyou?Contactustoletusknow. 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