INCIDENT INVESTIGATION

1. DIRECT AND INDIRECT CAUSES OF INCIDENTS AND UNSAFE CONDITIONS
2. TO IDENTIFY POSSIBLE CONTROLS TO REDUCE LIKELIHOOD OF INCIDENT OCCURRING

INCIDENT INVESTIGATION

Incident investigation will cover the understanding of direct and indirect causes of incidents. Investigating a worksite incident—a fatality, injury, illness, or close call—provides employers and workers with the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Most importantly, it enables employers and workers to identify and implement corrective actions to prevent future incidents.

Incident investigations that focus on identifying and correcting root causes, not finding fault or blame, also improve workplace morale and increase productivity by demonstrating an employer’s commitment to a safe and healthful workplace.

Incident investigations are often conducted by a supervisor, but to be most effective, they should involve managers and employees working together since each brings different knowledge, understanding, and perspectives to the investigation.

In conducting an incident investigation, the team must look beyond the immediate causes of an incident. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone caused an incident. To do so fails to discover the underlying or root causes of the incident and, therefore, fails to identify the systemic changes and measures needed to prevent future incidents. When a shortcoming is identified, it is important to ask why it existed and why it was not previously addressed.

As per CCOHS (Canadian Centre for Occupational Health and Safety), The term incident can be defined as an occurrence, condition, or situation arising in the course of work that resulted in or could have resulted in injuries, illnesses, damage to health, or fatalities.

Reasons to investigate a workplace incident include: 

• most importantly, to find out the cause of incidents and to prevent similar incidents in the future
• to fulfil any legal requirements
• to determine the cost of an incident
• to assess compliance with applicable regulations (e.g., occupational health and safety, criminal, etc.)
• to process workers’ compensation claims

Who should do the investigating?

Ideally, an investigation would be conducted by someone or a group of people who are:

• experienced in incident causation models,
• experienced in investigative techniques,
• knowledgeable of any legal or organizational requirements,
• knowledgeable in occupational health and safety fundamentals,
• knowledgeable in the work processes, procedures, persons, and industrial relations environment for that particular situation,
• able to use interviews and other person-to-person techniques effectively (such as mediation or conflict resolution),
• knowledgeable of requirements for documents, records, and data collection; and
• able to analyze the data gathered to determine findings and reach recommendations.

Some jurisdictions provide guidance, such as requiring that the incident be conducted jointly, with both management and labour represented, or that the investigators be knowledgeable about the work processes involved.

Members of the team can include:

• employees with knowledge of the work
• supervisor of the area or work
• safety officer
• health and safety committee
• union representative, if applicable
• employees with experience in investigations
• “outside” experts
• representative from the local government or police

Why look for the root cause?

An investigator or team that believes incidents are caused by unsafe conditions will likely try to uncover conditions as causes. On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are caused. Therefore, it is necessary to examine all underlying factors in a chain of events that ends in an incident.

What should be looked at as the cause of an incident?

Causation Models

Many models of causation have been proposed, ranging from Heinrich’s domino theory to the sophisticated Management Oversight and Risk Tree (MORT).

causes of any incident can be grouped into five categories – task, material, environment, personnel, and management

Task

Here, the actual work procedure used during the incident is explored. Members of the investigation team will look for answers to questions such as:

• Was a safe work procedure used?
• Had conditions changed to make the normal procedure unsafe?
• Were the appropriate tools and materials available?
• Were they used?
• Were safety devices working properly?
• Was lockout used when necessary?

An important follow-up question for most of these questions is “If not, why not?”

Material

To seek out possible causes resulting from the equipment and materials used, investigators might ask:

• Was there an equipment failure?
• What caused it to fail?
• Was the machinery poorly designed?
• Were hazardous products involved?
• Were they identified?
• Was a less hazardous alternative product possible and available?
• Was the raw material substandard in some way?
• Should personal protective equipment (PPE) have been used?
• Was the PPE used?
• Were users of PPE properly educated and trained?

Work Environment

The physical work environment, and especially sudden changes to that environment, are factors that need to be identified. The situation at the time of the incident is important, not the “usual” conditions. For example, investigators may want to know:

• What were the weather conditions?
• Was poor housekeeping a problem?
• Was it too hot or too cold?
• Was noise a problem?
• Was there adequate light?
• Were toxic or hazardous gases, dust, or fumes present?

Personnel

The physical and mental condition of those individuals directly involved in the event and the psychosocial environment they were working within must be explored. The purpose of investigating the incident is not to establish blame against someone, but the inquiry will not be complete unless personal characteristics or psychosocial factors are considered. Some factors will remain essentially constant, while others may vary from day to day:

• Did the worker follow the safe operating procedures?
• Were workers experienced in the work being done?
• Had they been adequately educated and trained?
• Can they physically do the work?
• What was the status of their health?
• Were they tired?
• Was fatigue or shiftwork an issue?
• Were they under stress (work or personal)?
• Was there pressure to complete tasks under a deadline or to bypass safety procedures?

Management

Management holds the legal responsibility for the safety of the workplace. Therefore, the role of supervisors and higher management and the role or presence of management systems must always be considered in an incident investigation. These factors may also be called organizational factors. Failures of management systems are often found to be caused by direct or indirect factors. Ask questions such as:

• Were safety rules or safe work procedures communicated to and understood by all employees?
• Were written procedures and orientation available?
• Were the safe work procedures being enforced?
• Was there adequate supervision?
• Were workers educated and trained to do the work?
• Had hazards and risks been previously identified and assessed?
• Had procedures been developed to eliminate the hazards or control the risks?
• Were unsafe conditions corrected?
• Was regular maintenance of equipment carried out?
• Were regular safety inspections carried out?
• Had the condition or concern been reported beforehand?
• Was action taken?

What are the steps involved in investigating an incident?

First:

• Report the incident occurrence to a designated person within the organization.
• Provide first aid and medical care to an injured person(s) and prevent further injuries or damage.

The incident investigation team would perform the following general steps:

• Scene management and scene assessment (secure the scene, ensure it is safe for investigators to do their job).
• Witness management (provide support, limit interaction with other witnesses, interview).
• Investigate the incident and collect data.
• Analyze the data and identify the root causes.
• Report the findings and recommendations.

The organization would then:

• Develop a plan for corrective action.
• Implement the plan.
• Evaluate the effectiveness of the corrective action.
• Make changes for continual improvement.

Physical Evidence

Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses. In some jurisdictions, an incident site must not be disturbed without approval from appropriate government officials such as the coroner, inspector, or police. Physical evidence is probably the most non-controversial information available. It is also subject to rapid change or obliteration; therefore, it should be the first to be recorded. Based on your knowledge of the work process, you may want to check items such as:

• positions of injured workers
• equipment being used
• products being used
• safety devices in use
• position of appropriate guards
• position of controls of machinery
• damage to equipment
• housekeeping of area
• weather conditions
• lighting levels
• noise levels
• time of day

You may want to take photographs before anything is moved

Witness Accounts

In some situations, witnesses may be your primary source of information because you may be called upon to investigate an incident without being able to examine the scene immediately after the event. Witnesses should be kept apart and interviewed immediately after the incident. Suppose witnesses have an opportunity to discuss the event among themselves. In that case, individual perceptions may be lost when accepting a consensus view where doubt exists about the facts. Witnesses should be interviewed alone rather than in a group.

Interviewing

The purpose of the interview is to establish an understanding with the witness and to obtain his or her own words describing the event:

DO…

• put the witness, who is probably upset, at ease
• emphasize the real reason for the investigation, to determine what happened and why
• let the witness talk, listen
• confirm that you have the statement correct
• try to sense any underlying feelings of the witness
• make short notes or ask someone else on the team to take them during the interview
• ask if it is okay to record the interview if you are doing so
• close on a positive note

DO NOT…

• intimidate the witness
• interrupt
• prompt
• ask leading questions
• show your own emotions
• jump to conclusions

Ask open-ended questions that cannot be answered simply “yes” or “no”. The actual questions you ask the witness will naturally vary with each incident, but some general questions should be asked each time:

• Where were you at the time of the incident?
• What were you doing at the time?
• What did you see or hear?
• What were the work environment conditions (weather, light, noise, etc.) at the time?
• What was (were) the injured worker(s) doing at the time?
• In your opinion, what caused the incident?
• How might similar incidents be prevented in the future?

Asking questions is a straightforward approach to establishing what happened.

What should I know when making the analysis and recommendations?

At this stage of the investigation, most of the facts about what happened and how it happened should be known.

There may still be gaps in your understanding of the events that resulted in the incident. You may need to re-interview some witnesses or look for other data to fill these gaps in your knowledge.

When your analysis is complete, write down a step-by-step account of what happened (the team’s conclusions) working back from the moment of the incident, listing all possible causes at each step. This is not extra work: it is a draft for part of the final report. Each conclusion should be checked to see if:

• it is supported by evidence
• the evidence is direct (physical or documentary) or based on eyewitness accounts, or
• the evidence is based on assumption.

Why should recommendations be made?

To prevent recurrences of similar incidents. Recommendations should:

• be specific
• be constructive
• identify root causes
• identify contributing factors

The Written Report

The prepared draft of the sequence of events can now be used to describe what happened. Always communicate your findings and recommendations with workers, supervisors, and management. Present your information ‘in context’ so everyone understands how the incident occurred and the actions needed to prevent it from happening again.

How should follow-up be done?

Follow-up actions include:

• Respond to the recommendations in the report by explaining what can and cannot be done (and why or why not).
• Develop a timetable for corrective actions.
• Monitor that the scheduled actions have been completed.
• Check the condition of the injured worker(s).
• Educate and train other workers at risk.
• Re-orient worker(s) on their return to work.

Reference: HSG 245