Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis
Dec 18, 2015
Determining the True Root Cause(s)
of Accidents and Safety Incidents
Incident Investigation and Analysis
Training Goal
Participants will be able to develop an
incident investigation protocol at their
respective institutions.
Objectives
To meet the training goal, the following objectives will be covered:
• Incident investigation overview
• Desktop incident investigation exercise
• Incident investigation protocol
• Training investigation team
Purpose of Investigation
• Determine sequence of events that led to consequence
• Offer corrective action recommendations to prevent recurrence of the incident
• Never to assign blame or assess liability
What should be investigated?
• All incidents that cause– Injury– Illness– Lost time– Property damage
• All near-miss incidents
Where should the investigation be conducted?
The investigation must be conducted at the site of the incident
Who should conduct the investigation?
• Team– Supervisor of the
affected employee– Safety committee
representative for area– Safety officer– Affected employee(s)
When should the investigation be conducted?
Immediately after the incident occurred
• Memories are fresh
• Evidence is in place
• Immediate corrective actions can be initiated
How to Conduct an Investigation
Focus on finding factfact, not fault
• Investigate the facts
• Review the facts to find the cause
• Recommend corrective measures
• Document findings and actions
• Follow-up
Investigate the Facts
• Look at the situation
• Record general information
• Collect evidence
• Interview witnesses
• Review records
Investigate the Facts
Look at the situation
• Examine the big picture
• Think of the 5 W’s (who, what, why, when, where)
• Outline your approach
Investigate the Facts
Record General Information
• Time and exact location
• Injuries
• Medical treatment or first aid
• Anything unusual
Investigate the Facts
Collect Evidence
• Photographs of equipment
• Samples of chemicals
• Broken parts or pieces
Investigate the Facts
Interview Witnesses
• Individually
• At the scene of the incident
• Immediately after the incident, if possible
• With an open mind
Investigate the Facts
Review Records to Identify Trends
• Inspection records
• Previous incident reports
• Maintenance records
• Workers’ compensation insurance forms
Review the Facts to Find the Cause
• Review all information
• Clarify the facts
• Analyze information
• Examine contributing factors
• List possible causes
• Identify the cause
Do not jump to
conclusions
Examining Contributing FactorsEmploy a process called branching to find root causes
Person slips on oil on floor
Why?
Oil was spilled on floor Person stepped in oil
Examining Contributing Factors
Oil was spilled on floor Person stepped in oil
Why?
Machine was beingserviced and oil spilled
Person walked throughwork area
Why?
Machine was beingserviced and oil spilled
Person walked throughwork area
Examining Contributing Factors
Why?
Spill notprevented
Oil spillnot cleaned
Person worked indepartment
Why?
Recommend Corrective Actions
• Look at each step in the chain of events
• Suggest attainable actions
• Assign responsibility for implementation
• Coordinate a schedule for implementation
• Start with simple solutions; move on to those that will be more complex
Recommend Corrective Actions
Causes: Actions:
Spill was not prevented
Oil spill not cleaned
Person worked in department
?
?
?
Document Findings and Actions
Incident investigation reports usually contain• General information• Description of injury or illness• Description of the incident• Analysis• Corrective actions• Dates for completion
and follow-up
Reporting
According to the subsequent remedial measure rule, documented recommendations for corrective actions are not admissible as evidence in a court of law. Therefore, appropriate corrective actions can be documented and implemented without fear that they will be perceived as an admission of a previously unsafe condition.
Reporting
• Do not assign blame, assess liability, or offer opinions in any written documentation
• Forward report to university/agency administration
Follow-Up
Ensure that recommended corrective actions
• Have been implemented properly
• Are effective in eliminating or reducing future incidents
• Do not create an unforeseen hazard
Developing an incident investigation
protocol
Include the following elements:
• Incident investigation procedures
• Responsibilities for incident investigation
• Reporting and record keeping procedures
• Investigator training
Incident Investigation Procedures
• Priority of incidents to be investigated
• Notification of incident occurrence
• First aid response
• Securing the area
• Gathering evidence
• Interviewing witnesses
• How program will be evaluated and updated
Reporting and Record Keeping
• Who prepares the report
• What will the report contain
• To whom will the report be sent
• How long will the reports be kept
• Who keeps the reports
Investigator Training
• Components of training
• Training records
• Hand-on exercises
• Retention exercises
Training Topics
How to
• Conduct an incident investigation
• Find the facts and not place blame
• Find the cause of an incident
• Complete an incident investigation report
Training Records
Remember to complete a training record
• Employee name
• Job title
• Employee signature
• Date of training
• Signature of trainer
Hands-On Exercises
Suggestions
• Set up a mock incident scene
• Use experiences from your organization
True or False
Every incident should be investigated immediately so that we can determine who was to blame.
Retention Exercises
Commonly known as a QUIZ
• Focus on important concepts, for example:
Retention Exercises
True or False
A “near-miss” should be investigated in the same manner as an actual incident.
True or False
Most incidents have only one contributing factor.
Retention ExercisesTrue or False
The incident scene should be returned to normal as soon as the investigator
arrives.
True or False
Corrective measure should address whatever hazards are uncovered in
investigating the incident.
Resources
• “Accident Investigation,” Comprehensive Loss Management, Inc.
• “Investigating Accidents,” Business & Legal Reports
• “Incident Investigation,” Safety Solutions
• “Accident (Incident) Investigation,” National Safety Council
Responsibilities for Investigation
Team
• Supervisor
• Safety officer
• Safety committee representative for area
What We’ve Learned Today ...
• The reasons for conducting thorough incident investigations
• How to set up an incident investigation and analysis program
Conclusion
When an organization reacts swiftly and positively to incidents, its actions reaffirms its commitment to the safety and well-being of its employees.