13-Incident Investigation and Corrective ActionREVISED - Copy.pdf

Copyright@NIOSH 2005/1 1

Incident Investigation And

Corrective Action

Safety And Health Officer Certificate Course


Learning Objectives

• To describe the importance of incident investigation

• To list 4 types of incident

• To describe principles of investigation


Learning Objectives

• To explain 8 steps in incident investigation

• To explain ways to plan and implement corrective and preventive action


Scope

• Overview of an Incident Investigation

• Principles of Incident Investigation

• Pre-Planning and Strategy of an Investigation

• Corrective Action


What is an Incident?

• Incident is:– An unexpected

– Unplanned event in a sequence of events

– That occurs through a combination of causes

– Which result in:• Physical harm (injury, ill-health or disease) to

an individual

• Damage to property

• A near miss, a loss

• Any combination of these effects


What is a “Near miss”?

• A “Near miss” is:

– An event which did not result in injury or damage to property but had the potential to do so

– Shares the same root causes as an accident. It is only because of chance that no harm or damage occurred

– Needs similar attention as an accident


Four Basic Types Of Incidents

• Minor accidents:

• Paper cuts finger, box of materials dropped

• Serious accidents (cause injury or damage to equipment or property):

• Falling off a ladder, hazardous chemical Spill, forklift dropping a load


Four Basic Types Of Incidents

• Long Term

• Hearing loss, an illness resulting from exposure to chemicals

• Near misses


Accident Causation Model

An accident is the result of a sequence of an immediate cause and an underlying cause.

1. Results of the accident - harm or damage

2. Incident – the accident

3. Immediate causes – symptoms of lack of control

4. Basic (underlying) causes – the real problems


Management Safety Policy

Management Decisions

Personal Factors

Environmental Factors

Unplanned Incidence

Three Basic Accident Causes

Basic Causes

Unsafe

ConditionUnsafe Act

ACCIDENT/ INCIDENT

Direct Causes

Immediate causes


Contributing Factors To

Accidents –

Immediate Causes (Symptoms)

The unsafe acts and unsafe conditionscan be categorised as follows:

1. Human behaviour

2. Design of equipment and plant

3. Systems & procedures including use of materials

4. Environmental surroundings


Root Causes Of Incident -

Management (The Real Problem)

• Personal Factors

– Lack of knowledge or skill, improper motivation, physical or mental conditions

• Job Factors

– Physical environment, sub-standard equipment, abnormal usage, wear & tear, inadequate standards, design & maintenance, purchasing standards

• Supervisory Performance

– Inadequate instructions, failure of SOPs, rules not, enforced, hazards not corrected, devices not provided

• Management Policy & Decisions

– Measurable standards, work in progress measure , work-v-standards, evaluation , corrective action


What is An Incident Investigation

• A management tool by which:

– Work-related injuries, ill health, diseases and incidents are systematically studied so that their root causes and contributing factors can be identified

– The organisation’s Occupational Safety And Health management system can be continually improved


Why Investigate an Incident

• To prevent repetition of the same work-related injuries, ill health, diseases and incidents

• Legal Requirement


Why Investigate an Incident

• Accurate record (for insurance, legal prosecution, public enquiries)

• Organisation’s own policy and business reasons


Who Should Investigate?

Depends On Severity Of The

Incident

• Internal Investigation team

– Individuals involved

– Supervisor, Safety officer

– Upper management

– external consultants

– Members of the Safety and Health Committee


Who Should Investigate?

Depends On Severity Of The

Incident

• External agency involvement

– DOSH and / or DOE, Police, etc.


What & When to Investigate

• All serious and long-term incidents & near misses

• As soon as possible to prevent:

– Scene interference

– Deterioration of evidence

– Losing people’s recollection of the incidence


Principles Of Incident

Investigation


Principles of Investigation

• Carried out according to procedure:

– For all incidents

– By competent persons with participation of workers.



• Should:

– Be systematic and documented

– Be treated as urgent (to prevent productivity loss and deterioration of evidence)

– Be objective (fact finding only)

– Find the underlying (root) cause(s)

– Identify failures in OSH management system

– Implement corrective action



• The results should:

– Be communicated to the Safety and Health Committee who should make appropriate recommendations

– Include external investigation reports such as DOSH and SOCSO

– Be communicated to appropriate persons for corrective action

– Included in management review


Be Prepared –Before The Incident

• Identify who has the authority to investigate and carry out mitigation action and corrective action to completion

• Have a system for notification and recording of all incidents and injuries


Be Prepared –

Before The Incident

• Designated trained and competent investigator

– Only be responsible for investigating


How Much to Prepare

Dependent on:

– The number and type of workplaces

– The equipment required to conduct the investigation

– Ability for investigator to reach an investigation site as soon as possible

– Geographical location

– Reliable transportation requirements


Notification Procedure

• Notification:

– To management after an incident

– Initiated by the person involved

– Should be to his immediate superior

– To visitors and contractors

– Recorded

• Automatic system to notify investigator

• Include members of Safety and Health Committee (if any)


Investigation Procedure

1. For recording evidence

2. For observation and recording of fragile, perishable or transient evidence

e.g. Instrument readings, control panel settings, weather & other environmental conditions, chemical spills, stains, skid marks


Investigation Kit Preparation

• Camera &

Video Camera

• Cassette Tape Recorder

• Flash and Batteries

• Mobile Telephone / Walkie-Talkie

• Clipboard, Pre-printed Forms

• PPE

• Containers for Taking and Storing Samples

• Barrier Tape


Responsibilities

• Employee

– Record in incident book (supervisor checks)

• Supervisor / Manager

– Initiate risk control response: first-aid, fence area, etc. other preventive action

– Inform SHO


Responsibilities

SHO

• Organise camera, tape and report form

• Check line management report

• Investigate if incident is serious and require to notify authorities such as DOSH, DOE, Police, etc.

• Complete incident record form

• Summary report to Safety and Health Committee


Responsibilities

Investigator

• Visit and survey incident scene

• Eliminate the hazards:

– Control of chemicals

– De-energise

– De-pressurise

– Light it up

– Shore it up

– Ventilate


On-Site Investigation Strategy


Steps In Incident Investigation

1. Gather information

2. Search for and establish facts

3. Isolate essential contributing factors

4. Determine the causes & root cause


Steps In Incident Investigation

5. Determine corrective actions

6. Report, review the findings

7. Analyze incidents

8. Implement corrective actions


Gathering Information

• Time is of the essence

• Take samples, photos, measurements and sketch diagrams,

– Preserve and protect data, Information and evidence

– Collect in order of fragility

• People, Positions, Parts and Papers; (4Ps)

• Record injury types & groups



• Identify people involved

– Excellent source of first hand knowledge

• Interview injured, witnesses, supervisors and others



• Get preliminary statements as soon as possible from all witnesses

• May present pitfalls in the form of:

– Bias, perspective, exaggeration, hidden agenda


Gathering Information -

People ( Witnesses)

• One-to-one in private

• Put them at ease

– Make it clear the objective of the investigation is to avoid recurrence, not to apportion blame

• Do not interrogate but Question!

– Let each witness speak freely on their version


Gathering Information -People (Questioning)

• Strategic questioning - No leading questions

• Obtain facts not opinions

• Ask What, Where, When, Why, Who and How

• Get observation on events before, during and after the incident



People (Questioning)

• Make sure the witness understands questions

• Use sketches and diagrams to help the witness


Gathering Information -Recording Interview

• Take notes without distracting the witness

• Record the exact words used by the witness to describe each observation

• Use a tape recorder only with consent of the witness



Recording Interview

• Differentiate what is directly observed and what is hearsay and note accordingly

• Verify claims afterwards


Gathering Information -Closing The Interview

• Identify the designation and qualifications of each witness (name, address, occupation, years of experience, etc.)

• Supply each witness with a copy of their statements



Closing The Interview

• Get signed statements where possible

• Thank the interviewee


Gathering Information -Position

• Document the incident scene before any changes are made:

• Victim location

• Position of each witness on a master chart (including the direction of view)

• Machinery, energy and chemical sources

• Other contributing factors

• Take photos, draw scaled sketches

• Record measurements


Gathering Information -Parts

• Around incident scene prior to, during or after the incident that may have influence

• Materials, pieces of plant, tools, equipment, buildings

• May require qualified person to examine or comprehensive testing or sophisticated equipment

• Reports by “expert witness." will form part of the investigation evidence


Gathering Evidence –Paper

• Production schedules or process diagrams

• Check current working procedure

• Check qualifications

• Check training records

• Check corrective actions

• Check equipment maintenance records

• Check incident records


Findings

• Isolate essential contributory factors

“Would the incident have happened if this particular factor was not present?”

• Determine Causes

Employee actions, environmental conditions, equipment condition, procedures, training


Findings

• Find Root Causes. Ask:

What caused behaviour? Why equipment was not fixed? Why condition was not corrected?


Determine Corrective Action

• Recommendations made for corrective actions

• Recommendations for corrective actions to improve OSH management system


Incident Investigation Report

• Clear, complete description and accurate information of events leading up to the accident

• Clear, complete and correct identification of all causal factors

• Recommendations

• Supporting documentation

• Proper review and sign off


Preventive And Corrective

Action


Corrective And Preventive

Action

• Preventive and corrective action should be carried out for:

• Incidents

• Management system non-conformances

• Recommendation(s) for preventive and corrective actions must be communicated clearly


Corrective And Preventive

Action Planning

• Procedure for handling investigation and preventive and corrective action

• Identification and authority for personnel handling investigation and preventive and corrective action

• Authority for initiating and confirming the completion of corrective action


Implementing Corrective And

Preventive Action

• Must be based on root causes

• Appropriate to the problem at hand

• Reviewed through risk assessment process to ensure that the correction will not introduce a new hazard

• Strict time table for implementation established

• Follow up conducted


Summary

• Aim of investigation is to find root causes.

• Purpose is so that similar incident will not be repeated.

• Prepare organisation, procedure and equipment in anticipation of incidents.

• Corrective and preventive action should be carried out for incidents and management system non-conformances.

Documents

13-Incident Investigation and Corrective ActionREVISED - Copy.pdf