Week 5_6 Minerva 200 - Module Incident Investigation PDF

# Incident Investigation ## Welcome - This is a module about incident investigation. ## Learning Objectives Upon completion of this module, you should be able to: - Explain how investigating incidents can benefit an organization's leaders, managers, and engineers. - Define key terms related t...

# Incident Investigation ## Welcome - This is a module about incident investigation. ## Learning Objectives Upon completion of this module, you should be able to: - Explain how investigating incidents can benefit an organization's leaders, managers, and engineers. - Define key terms related to incident investigation. - Describe incident investigation and reporting procedures, including investigation techniques, reporting, and follow-up. - Discuss the CSA (Canadian Standards Association) standard and the role of health and safety committees in incident investigation. - Assess the completeness of the incident investigation system at your university, college, or workplace. ## Topic 1: Introduction To Incident Investigation ### Why Investigate? - Employer, managers, supervisors, and front-line workers share responsibility for the occupational health and safety (OHS) program. - Incident investigation is a key process for maintaining a safe and healthy work environment. - The purpose is to determine how and why an incident happened. - The goal is not to find fault or assign blame, but to uncover the factors that contributed to the incident and, ultimately, the underlying or root cause. - Once the cause has been determined, corrective actions can be taken to prevent the incident from happening again. - An incident investigation allows an organization to learn from incidents and to correct unsafe conditions in the workplace that could cause injury or damage. ### The Benefits Of Incident Investigation - When investigating an incident, engineers and others who may become involved should concentrate on finding the root cause of the event so that the event can be prevented from happening again. - A root cause is often a fundamental systemic failure such as a management system failure. - If these failures are corrected, then the same or a similar incident is unlikely to occur again. - Investigators should always look for deeper causes rather than simply recording the series of events that preceded the incident. - A thorough, properly conducted incident investigation benefits the organization in several ways. - Strengthens the internal responsibility system. - Helps build a positive OHS culture in the workplace. - Prevents similar events from occurring by identifying the root and contributing causes. - The incident report is an integral part of the investigation. - It serves several purposes. - Meets regulatory requirements. - Helps prevent future occurrences. - Helps identify systemic issues by making the data from past incidents available for incident trend analysis. ### Management System Failure - Why do incidents happen in the workplace? - Consider the following example: An employee hurts their back while lifting heavy objects in the workplace? - Why do you think this happened? - How do you think the management system failed to protect this worker? - In this example, the causes may not be as straightforward as you might expect. The management system may have failed because of many factors, including: - No or inadequate practices, procedures, or training about how to lift safely. - No or inadequate assessment to determine which objects should be lifted by mechanical means rather than manually. - No or inadequate pre-job task analysis requirement or monitoring in the managing system. ### Incident Investigation Terminology - As with many activities, incident investigation has its own terminology. - The following are basic terms that have specific meanings when used during an investigation. | Term | Definition | |-----------------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------| | Incident | An unplanned event, or series of events, that disrupts the orderly flow of the work process and results in some form of injury or damage. For example, an explosion at an oil refinery resulted in a fatality and property damage. The explosion was the unplanned event and the fatality and damage were the consequences. | | Near Miss | An unplanned event that did not cause injury or damage but had the potential to do so. This event is also known as a *dangerous occurrence*, but may also be referred to as an incident. | | Incident Investigation | The analysis and account of an event based on information gathered by the investigator or investigation team. The investigator examines all factors about the incident to determine the root and contributing causes and recommends corrective actions be taken to prevent a recurrence. The Center for Chemical Process Safety (CCPS) provides a similar definition. According to the CCPS, an incident investigation is "A systematic approach for determining the causes of an incident and developing recommendations that address the causes and help prevent or mitigate future incidents." | | Unsafe Act | An activity conducted in a manner that may threaten the health and/or safety of an individual or individuals. Unsafe acts in the workplace include: - Using defective equipment. - Using improperly repaired equipment. - Operating machinery when not qualified to do so. - Using tools for other than their intended purpose. - Bypassing or removing safety devices. | | Unsafe Condition | An unsafe condition in the workplace is one that is likely to cause injury or property damage, such as: - Defective tools and equipment. - Congestion in the workplace. - Inadequate guards and warning systems. - Unintentional release or spill of hydrocarbons (e.g. from failed equipment). - Poor ventilation. | | Direct Cause | The immediate cause of an event. It is the first cause in a causal chain, the action or condition that initiated the event. Generally, a direct cause is an unsafe act or an existing or unexpected unsafe condition that triggers the incident and is often related to uncontrolled hazards. | | Programmatic Cause | A cause that contributed to an event but, by itself, would not have caused the event. Programmatic causes are the causes after the direct cause. | | Root Cause | The fundamental reason that an event occurred, which, if corrected, would prevent the event from recurring. The root cause is also referred to as the underlying or systemic (i.e. related to the system) cause because it is related to a failure of the management system. | ### Self Check Questions - Why are workplace incidents investigated? Select all that apply. - To prevent similar events from occurring. (Correct) - To meet regulatory requirements. (Correct) - To correct management system failures. (Correct) - To determine who to blame for the incident and impose disciplinary action. (Incorrect) - The goal of an incident investigation is not to place blame but to uncover the root cause and thus prevent similar incidents from happening again. Incidents can often be traced back to a failure of the management system. OHS legislation requires that employers investigate incidents in the workplace. For certain incidents, such as fatalities, provincial governments may initiate their own investigations. - 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: - An unsafe condition. (Incorrect) - An unsafe act. (Correct) - A programmatic event. (Incorrect) - A near miss. (Incorrect) - The technician should have been wearing acid-resistant gloves. She performed an unsafe act and put her health and safety at risk when she wore latex gloves to work with a strong acid. - 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. (Incorrect) - An unsafe act. (Incorrect) - A programmatic event. (Incorrect) - An unsafe condition. (Correct) - Poor ventilation is an example of an unsafe condition in the workplace that threatens the health and safety of employees. Other examples of unsafe conditions include inadequate machinery guards and warning systems and workplace congestion. ## Topic 2: Incident Investigation Procedure ### What Should You Investigate? - When investigating serious incidents, investigators often discover that other similar or related events had occurred before but had been disregarded. - Perhaps it was determined at the time that the earlier incidents were not serious or important enough to warrant an investigation. - But if these earlier incidents had been investigated, then the current incident may not have happened. - So what should be investigated? - All injuries, even very minor ones. - All incidents with a potential for injury. - Property/product damage and near-miss situations. - Violations of OHS and environmental regulations. - As we've mentioned, the goal of an investigation is to determine the direct, programmatic, and root causes of the incident. - This goal is achieved by identifying the contributing unsafe acts or conditions. - To prevent a recurrence, the investigation should result in recommended corrective actions that address each of the direct, programmatic, and root causes. ### Effective Incident Investigation Procedure - There are several models for incident investigation, but, in general, all procedures have the following steps: 1. Manage the incident scene. 2. Gather information. 3. Analyze information and determine causes. 4. Determine corrective actions. 5. Write incident investigation reports. 6. Follow-up. ### Step 1: Manage the Incident Scene - The first step is to eliminate or bring the immediate hazards created by the incident under effective control and to minimize further risk of injury or damage. This requires appropriate personnel to: - Respond promptly to the emergency. - Activate the facility emergency alarm. - Provide first-aid treatment to injured individuals. - Contact emergency first responders such as firefighters and/or paramedics. - You will also need to secure the incident site and possibly notify authorities. #### Secure The Scene - Other than to emergency personnel, try to restrict access to and limit disturbance of the scene until all information is collected. - In some cases, another authority may have jurisdiction at the scene, for example, the inspector from the OHS authority or the police. - Securing the scene may involve: - De-energizing equipment. - Stopping a leak. - Putting out a fire. - Shutting down a process or piece of equipment. - Note that in some instances, such as a jet fire coming from a piece of equipment, it is safer to isolate the vessel and let the fuel burn out than to extinguish the flame, as a leak that continues could cause an explosion. #### Notify Authorities - OHS legislation and other safety-related legislation in different jurisdictions may require the employer to notify authorities if an incident occurs. - Leading organizations in safety also require that organizations report incidents to regulatory authorities as well as the senior management of the organization. - For example, each of the following pieces of legislation includes a requirement to report incidents and specifies who, when, and under what circumstances the authority must be notified. - Ontario Occupational Health and Safety Act, Part VII (Notices). - Health Canada, Canada Consumer Product Safety Act, Section 14 (Duties in the Event of an Incident). - Transport Canada, Transportation of Dangerous Goods Act, Section 18 (Duty to Respond). - Transportation Safety Board Regulations, Section 2.1 (Mandatory Reporting). - Canadian Nuclear Safety Commission, Nuclear Safety and Control Act. - In British Columbia, section 172 of the Workers Compensation Act requires that an employer notifies authorities of any incident that meets the conditions outlined below: (1) An employer must immediately notify the Board of the occurrence of any accident that: - (a) resulted in serious injury to or the death of a worker. - (b) involved a major structural failure or collapse of a building, bridge, tower, crane, hoist, temporary construction support system or excavation. - (c) involved the major release of a hazardous substance. - (c. 1) involved a fire or explosion that had a potential for causing serious injury to a worker, or - (d) was an incident required by regulation to be reported. ### Step 2: Gather Information - The second step in the incident investigation process is gathering information. - Investigators collect different types of information from a variety of sources that will help them learn what happened and why. #### Conducting Interviews - An investigator can learn a lot by talking to the people involved in an incident. - To get a complete picture of what happened, make sure you interview the injured worker or workers (if appropriate), the supervisor, witnesses, and anyone else who you think may have information that can help your investigation. ##### Interview Tips - Conducting an effective interview and extracting useful information from someone takes practice and planning. - Prepare by writing down questions. - Conduct the interview in a quiet and private setting. - Try to put the person at ease. - Interview individuals separately. - Explain that the main purpose of the interview is to uncover the facts, not to assign blame. - Don't ask leading questions, i.e. a question that prompts the interviewee to answer in a certain way. - Repeat what the interviewee tells you to check that you've understood correctly. - Ask specific questions to fill in the gaps in your knowledge. ##### Information - Interviews can help you gather a wide range of information. - Some of the information you may want to gather through interviews include: - Identity of people involved in the incident. - Events that occurred before, during, and after the incident. - Timing and sequence of events. - Location and direction of actions and events. - Possible causes of each action and event. - Witness's suggestions for preventing similar incidents. ##### Sample Questions - It's a good idea to prepare a list of the questions you would like to ask in your interviews. These might include: - Are the workers trained for the standard procedure? - Was this the first time that the task was done? - What failed or malfunctioned? - What could have been done to prevent the incident? ### Step 3: Analyze Information and Determine Causes - Once the information has been gathered, the next step is to analyze the data and determine the sequence of events that led to the incident. - Look at each of the following: #### Equipment - Was the equipment poorly designed? - Was the equipment maintained properly? - Was the equipment used properly and according to procedure? - Were the manufacturer's specifications followed? - Was personal protective equipment used properly? #### Materials - Were materials used in accordance with manufacturer's specifications? - Were hazardous products or materials used? - Were appropriate safety procedures used? #### Environment - Consider the lighting, noise, air quality, weather, cleanliness of the workplace, etc. - Were toxic gases, dust, or fumes present? #### Humans - What do you know about the people involved in the incident? - Evaluate the information you have. - Who was involved: management, workers, visitors? - What was the age, experience, training, workload, stress of those involved? - What was the health status, emotional status, physical capability of those involved? #### Task Control - How were tasks carried out and were controls in place to ensure they were carried out properly? - Was there a safety procedure in place and was it followed? - Were the proper tools available and used? - Did anyone deviate from the normal task procedure? #### Organizational Factors - Had hazards been identified? - Had incident investigation recommendations been implemented in a timely fashion? - Were training and supervision adequate? - Were regular safety inspections carried out? - Were safety procedures communicated effectively? #### Operations - Were there any operating trends or deviations from normal operations? If so, when did these occur? - Were alarms activated? When? - Were safety instrumented systems activated? When? - Were pressure-relieving devices activated? When? - Was any unusual activity or event occurring simultaneously; e.g., operational, maintenance, construction, weather? ### Determining Causes - Recall that in incident investigation there are different types of causes: direct, programmatic, and root. #### Direct Cause - A direct cause is an immediate cause of an event. It is the first cause in a causal chain. - These are unsafe acts or conditions that trigger the incident and are often related to uncontrolled hazards. - Examples of Unsafe Conditions: - Personal protective equipment unavailable. - No handrails on stairs. - No guardrails on elevated work platform. - Exposed steam tracing that can be accidentally contacted. - Machine guards not properly maintained. - Poor housekeeping practice. - Examples of Unsafe Acts: - Improper use of equipment. - Not maintaining three-point contact when climbing ladders. - Not holding railing when going up or down stairs. - Not following safe work procedures properly. - Improper use of personal protective equipment. - It has been estimated that an unsafe act is the direct cause of 88% of all incidents and an unsafe condition is the direct cause of 12% of all incidents. - Incident investigators must look beyond unsafe acts and unsafe conditions, however, and seek the root cause that allowed that unsafe act or condition to exist in the first place. #### Programmatic Cause - Programmatic causes are those events, conditions, or acts that contribute to the incident that, by themselves, would not have caused the incident. - Examples of Programmatic Causes: - Deficiencies in health and safety programs, e.g. safe work practices not communicated. - Deficiencies in management systems, e.g. issues with task training and workload or issues with scheduling and conducting of inspections. #### Root Causes - Root (or underlying) causes are the "real" causes of incidents, and they are not always immediately evident. - Often there are underlying systemic causes related to management systems and organizational issues. - Examples of Root Causes: - Insufficient resources for executing necessary programs. - Management unaware of workers' poor knowledge of workplace practices. - Management's failure to monitor workers' compliance with workplace procedures. - When an investigation reveals human factors, the root cause could be: - Managers and/or supervisors do not provide meaningful feedback on employee performance. - Management has low-performance standards. #### Reviewing Causes - Sometimes an investigator will determine that an incident was caused by human errors or equipment failure but look no further. - However, when the investigator looks further, the investigator will often discover the real programmatic and root causes of the incident. - For example, if the investigation reveals that a worker was not trained adequately to operate the equipment safely, ask yourself: - Why was the individual not trained? - Why was the individual allowed to work with the machine? ### Matching Exercise - In incident investigation, there are several different types of causes. - In the exercise below, match the example or description with the type of cause. - Click on an example or description below and drag it onto its corresponding cause. - When you have matched all the examples and descriptions, click the 'Next' button to continue. | Cause | Example | |-----------------|------------------------------------------------------------------------------------------------------------------------------| | Unsafe Act | Removing the safety guards from a piece of equipment. | | Unsafe Condition | Overcrowded, congested workspace. | | Direct Cause | The first cause in a causal chain. | | Programmatic Cause | Safe work practices are not communicated. | | Root Cause | Poor knowledge of workplace practices. | ### Step 4: Corrective Actions - Corrective actions are actions that will prevent or minimize the incident from occurring again or minimize the probability and/or consequence of the incident to an acceptably low level. - Corrective actions should address the programmatic and root causes of an incident. - They should not be a collection of nice-to-have recommendations. - Corrective action recommendations should: - Be as specific as possible. - Be developed with worker participation. - Identify the parties responsible for their implementation. - Identify contributing factors. - Identify target dates for implementation. - Identify a follow-up date. - List the required sources for implementation. e.g., human, material, equipment, finances. ### Types of Corrective Actions - Corrective actions can be categorized according to the type of control they offer: engineering, administrative, or personal protective equipment. - The most effective controls are engineering controls. - Administrative controls and PPE are weaker than engineering controls and should not be used as an alternative to engineering controls that are deemed reasonably practicable to implement. - Administrative controls and PPE are used to further minimize personnel injury risks after engineering controls are implemented. #### Engineering Controls - Engineering controls involve changing the equipment or process to reduce or remove the hazards. - Automate hazardous processes or use machines. - Change the task/equipment: - Substitute high hazard with lower hazard materials. - Specify the correct equipment/tool for each task. - Provide automatic trips to prevent operating outside safe operating limits. - Modify workstation: - Change layout, location or position of equipment. - Change the position of employee. - Provide barriers, warning signs, or guardrails. - Increase visibility in the workplace. #### Administrative Controls - Administrative controls include organizational policies to implement a level of control. - Examples include: - Modify employee function: - Clearly define expectations. - Designate employees authorized to operate the equipment. - Enforce disciplinary policy for violation of safety rules. - Provide employee training: - Safety orientation and certification with periodic recertification. - Equipment, task procedures, reporting procedures. - Review hazards and controls: - Perform task safety analysis and change task procedures. - Review hazards and controls of infrequent tasks. - Change frequency and depth of hazard inspections. #### Personal Protective Equipment - Personal Protective Equipment (PPE) includes those items worn to help protect the worker; however, PPE does not remove or eliminate the hazard itself. - With respect to PPE, employers should: - Specify PPE requirements, i.e. which protective equipment should be used or worn when using a machine or tool or performing a job task. - Provide PPE that was not available at the time of the incident. - Train employees on the purpose and use of PPE, raising awareness on the potential incidents and injuries. - Enforce their use via supervisory procedures. - Note that administrative controls and PPE are less effective than engineering controls and should not be used as an alternative to engineering controls if the latter can be reasonably implemented. - Administrative controls and PPE are used to further minimize risk after engineering controls are implemented. ### Step 5: Incident Investigation Report - The investigator's findings should be compiled into an organized report. - Copies of the report should be communicated to the OHS committee and the management team. - Note that the investigator must remove workers' confidential information before communicating the findings. - An incident investigation report should include: - Place, date, and time of the incident. - Injured worker's name and job title. - Witnesses' names. - A concise description of the incident. - Sequence of events preceding the incident. - Analysis of root and direct causes. - Recommendations for corrective actions. - Outline of the follow-up procedure. - Supporting documentation and evidence (summary of interviews, pictures of physical evidence, etc.). - A number of sample incident (accident) investigation forms are available. - If you are using a template, take the time to modify it to suit the workplace or situation you are investigating. ### Step 6: Follow-Up - The incident has been investigated, the root cause has been identified, and the report has been written. - One important step remains in the investigation procedure and that's to follow up. - All the work done investigating the incident, identifying the cause, and determining corrective actions will be wasted if there is no follow-up to ensure the recommendations that the report contains have been acted on. - Follow-up procedures must be documented, and responsibilities assigned to the appropriate individuals for: - Implementing corrective actions. - Procedures. - Equipment. - Training. - Meeting timelines for implementing corrective actions. - Evaluating the effectiveness of corrective actions. - Communicating the effectiveness evaluations to management, OHS committee or representatives, and workers in the affected workplace area. ## Topic 3: The OHS Committee and Incident Investigation ### Role of the OHS Committee in Incident Investigation - The members of the workplace OHS committee have a role to play in incident investigation. - The OHS committee or representatives may participate as a member (or members) of the investigation team. - They can help management: - Receive and review incident investigation reports to ensure: - The incident investigation procedure is followed. - Root causes are identified. - Trends in injury, illness, and property damage are identified. - Recommendations for corrective actions are provided. - Implementation, follow up, and evaluation of corrective actions is completed. - Review any requirements for improved management systems, procedures, and training that may have arisen as a result of the incident investigation. ### Activity - Universities and colleges, especially those with laboratories and workshops, should have documented procedures in place for reporting and investigating incidents. - For this assignment, review your faculty's or school's incident investigation procedures, then answer the following questions. - To indicate your answer, click on the appropriate box. - If you answered 'No' to question 1, click the 'Next' button to continue. - If you answered 'Yes' to question 1, proceed to question 2. - When you have answered all questions, click the 'Next' button to continue. - Question 1: My school/faculty has documented incident investigation procedures in place for professors or students to follow. - Yes No - Question 2: My school/faculty's incident investigation procedures identify the role of the health and safety committee in incident investigations and how incidents and lessons learned are to be communicated to other departments. - Yes No - Question 3: My school's investigation procedures include the following steps for professors or students to follow: - a. Manage incident scene. - Yes No - b. Gather information. - Yes No - c. Analyze information and determine causes. - Yes No - d. Determine corrective actions. - Yes No - e. Write incident investigation reports. - Yes No - f. Follow-up. - Yes No ## Module Summary - You have reached the end of this module. - You should now be able to: - Explain how investigating incidents can benefit an organization's leaders, managers, and engineers. - Define key terms related to incident investigation. - Describe incident investigation and reporting procedures, including investigation techniques, reporting, and follow-up. - Discuss the CSA standard and the role of health and safety committees in incident investigation. - Assess the completeness of the incident investigation system at your university, college, or workplace. - You can review the course content anytime by accessing the course menu. - If you are ready to take the module exam, click the 'Complete' button below to close this module and access the exam.