Incident Investigation Overview

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Questions and Answers

Why are workplace incidents investigated? Select all that apply.

To prevent similar events from occurring. (correct)

To meet regulatory requirements. (correct)

To determine who to blame for the incident and impose disciplinary action.

To correct management system failures. (correct)

While working with concentrated sulphuric acid, a laboratory technician knocks over a flask spilling some of the acid, burning her hand. She is wearing latex gloves instead of acid-resistant gloves. This incident is an example of:

A near miss.

An unsafe condition.

A programmatic event.

An unsafe act. (correct)

An accounting company moved into new offices last year. Since the move, staff have begun to complain of headaches, chronic congestion, and irritated eyes. At least one employee has taken extended sick leave because of chronic respiratory illness. An investigation has discovered mould in the ventilation system. This is an example of:

A near miss.

A programmatic event.

An unsafe act.

An unsafe condition. (correct)

What should you investigate?

All incidents with a potential for injury. Signup and view all the answers

What are the steps in the effective incident investigation procedure?

Follow-up. Signup and view all the answers

What are the different types of corrective actions?

Personal protective equipment Signup and view all the answers

What are some examples of unsafe conditions?

Exposed steam tracing that can be accidentally contacted. Signup and view all the answers

What are some examples of unsafe acts?

Improper use of equipment. Signup and view all the answers

What are some examples of programmatic causes?

Deficiencies in health and safety programs, e.g. safe work practices not communicated. Signup and view all the answers

What are some examples of root causes?

Management's failure to monitor workers' compliance with workplace procedures. Signup and view all the answers

In incident investigation, there are several different types of causes. Match the example or description with the type of cause.

Overcrowded, congested workspace. = Unsafe condition Poor knowledge of workplace practices. = Root cause The first cause in a causal chain. = Direct cause Removing the safety guards from a piece of equipment. = Unsafe act Safe work practices are not communicated. = Programmatic cause Signup and view all the answers

Match the task with the appropriate stage in the incident investigation process.

Gather information. = Gather information Determine corrective actions. = Determine corrective actions Assign responsibilities to appropriate individuals. = Follow-up Restrict access to the scene to avoid disturbing evidence. = Manage incident scene Consider equipment, materials, the environment, task control and other factors. = Analyze information and determine causes Write an incident investigation report. = Write incident investigation reports Manage incident scene. = Manage incident scene Follow-up. = Follow-up Analyze information and determine causes. = Analyze information and determine causes Determine ways to prevent or minimize the incident from occurring again. = Determine corrective actions Examine logbooks and training records. = Gather information Include a concise description of the incident, analysis of the causes, and recommendations. = Write incident investigation reports Signup and view all the answers

Study Notes

Incident Investigation Overview

Incident investigation aims to understand how and why incidents happen.
The goal is not blame but to uncover contributing factors and root causes.
Investigations benefit organizations by identifying unsafe conditions.
Investigations prevent similar incidents by implementing corrective actions.

Benefits of Incident Investigation

Strengthens internal responsibility systems.
Fosters positive health and safety (OHS) cultures.
Prevents future incidents by identifying root and contributing causes.
Supports regulatory compliance.
Aids in identifying systemic issues through trend analysis.

Management System Failure

Incidents can arise from various management system failures.
Inadequate practices, procedures, and training for safety-critical operations can be contributing factors.
Insufficient assessment of tasks or objects requiring mechanical assistance instead of manual handling.
Lack of pre-job assessments or monitoring in the management system.

Incident Investigation Terminology

Incident: An unplanned event or sequence of events that disrupts a work process or routine and causes injury or damage.
Near Miss: An unplanned event with the potential for injury or damage but no actual harm.
Unsafe Act: An activity performed in a manner that endangers the health or safety of individuals. Examples include using defective equipment, operating machinery when unqualified, or bypassing safety devices.
Unsafe Condition: Situations in the workplace that are likely to cause injury or damage. Examples include defective tools, congestion, and inadequate safety systems, inadequate guards or warnings, or spills and leaks. (e.g. of hydrocarbons).
Direct Cause: The immediate cause of an event, the action or condition that triggered an incident. It is usually an unsafe condition or act.
Programmatic Cause: A cause that contributed to an incident but would not have caused the event by itself. This is a deeper systemic issue in management or policies.
Root Cause: The fundamental reason an incident occurred. This is the ultimate cause, if addressed, would prevent similar incidents. A root cause is often a failure in management systems.

Incident Investigation Procedure

Step 1: Manage the Incident Scene: Immediately control immediate hazards. Secure the area, render first aid, alert responders (police, fire, paramedics), de-energize equipment, stop leaks or fires.
Step 2: Gather Information: Collect information from witnesses, involved personnel, supervisors, etc.
Step 3: Analyze Information and Determine Causes: Define the sequence of events leading to the incident; analyze factors (equipment, materials, environment, humans, task control, organizational factors, operations).
Step 4: Determine Corrective Actions: Implement corrective measures to eliminate identified causes. Be specific and practical, involve relevant personnel.
Step 5: Write Incident Investigation Reports: Create a detailed report that documents the incident's conditions, causal factors, corrective actions, and follow-up procedures. Include supporting documentation (photos, witness statements, etc).
Step 6: Follow-Up: Monitor implemented measures to ensure effectiveness and take further actions depending on need. Review if additional measures are needed. Ensure that recommendations are implemented, responsibilities are assigned, and timelines are met.

OHS Committee and Incident Investigation

OHS committees play a vital role in incident investigations by helping determine safe procedures and improving the quality of the processes needed to reduce the risk of incidents.
A committee should be versed in the roles of the respective members' roles in incident investigation.
The OHS Committee members should follow investigation procedures as defined by the OHS Committee members (and/or by their institutions).

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Description

This quiz covers the fundamentals of incident investigation, aiming to understand the causes of incidents without placing blame. It highlights the benefits of conducting thorough investigations, such as identifying unsafe conditions and fostering a positive safety culture. Learn how effective investigations can prevent future incidents and support compliance.