determining the true root cause(s) of accidents and safety incidents incident investigation and...
TRANSCRIPT
![Page 1: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/1.jpg)
Determining the True Root Cause(s)
of Accidents and Safety Incidents
Incident Investigation and Analysis
![Page 2: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/2.jpg)
Training Goal
Participants will be able to develop an
incident investigation protocol at their
respective institutions.
![Page 3: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/3.jpg)
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
![Page 4: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/4.jpg)
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
![Page 5: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/5.jpg)
What should be investigated?
• All incidents that cause– Injury– Illness– Lost time– Property damage
• All near-miss incidents
![Page 6: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/6.jpg)
Where should the investigation be conducted?
The investigation must be conducted at the site of the incident
![Page 7: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/7.jpg)
Who should conduct the investigation?
• Team– Supervisor of the
affected employee– Safety committee
representative for area– Safety officer– Affected employee(s)
![Page 8: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/8.jpg)
When should the investigation be conducted?
Immediately after the incident occurred
• Memories are fresh
• Evidence is in place
• Immediate corrective actions can be initiated
![Page 9: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/9.jpg)
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
![Page 10: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/10.jpg)
Investigate the Facts
• Look at the situation
• Record general information
• Collect evidence
• Interview witnesses
• Review records
![Page 11: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/11.jpg)
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
![Page 12: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/12.jpg)
Investigate the Facts
Record General Information
• Time and exact location
• Injuries
• Medical treatment or first aid
• Anything unusual
![Page 13: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/13.jpg)
Investigate the Facts
Collect Evidence
• Photographs of equipment
• Samples of chemicals
• Broken parts or pieces
![Page 14: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/14.jpg)
Investigate the Facts
Interview Witnesses
• Individually
• At the scene of the incident
• Immediately after the incident, if possible
• With an open mind
![Page 15: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/15.jpg)
Investigate the Facts
Review Records to Identify Trends
• Inspection records
• Previous incident reports
• Maintenance records
• Workers’ compensation insurance forms
![Page 16: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/16.jpg)
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
![Page 17: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/17.jpg)
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
![Page 18: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/18.jpg)
Examining Contributing Factors
Oil was spilled on floor Person stepped in oil
Why?
Machine was beingserviced and oil spilled
Person walked throughwork area
Why?
![Page 19: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/19.jpg)
Machine was beingserviced and oil spilled
Person walked throughwork area
Examining Contributing Factors
Why?
Spill notprevented
Oil spillnot cleaned
Person worked indepartment
Why?
![Page 20: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/20.jpg)
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
![Page 21: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/21.jpg)
Recommend Corrective Actions
Causes: Actions:
Spill was not prevented
Oil spill not cleaned
Person worked in department
?
?
?
![Page 22: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/22.jpg)
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
![Page 23: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/23.jpg)
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.
![Page 24: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/24.jpg)
Reporting
• Do not assign blame, assess liability, or offer opinions in any written documentation
• Forward report to university/agency administration
![Page 25: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/25.jpg)
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
![Page 26: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/26.jpg)
Developing an incident investigation
protocol
Include the following elements:
• Incident investigation procedures
• Responsibilities for incident investigation
• Reporting and record keeping procedures
• Investigator training
![Page 27: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/27.jpg)
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
![Page 28: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/28.jpg)
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
![Page 29: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/29.jpg)
Investigator Training
• Components of training
• Training records
• Hand-on exercises
• Retention exercises
![Page 30: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/30.jpg)
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
![Page 31: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/31.jpg)
Training Records
Remember to complete a training record
• Employee name
• Job title
• Employee signature
• Date of training
• Signature of trainer
![Page 32: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/32.jpg)
Hands-On Exercises
Suggestions
• Set up a mock incident scene
• Use experiences from your organization
![Page 33: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/33.jpg)
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:
![Page 34: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/34.jpg)
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.
![Page 35: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/35.jpg)
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.
![Page 36: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/36.jpg)
Resources
• “Accident Investigation,” Comprehensive Loss Management, Inc.
• “Investigating Accidents,” Business & Legal Reports
• “Incident Investigation,” Safety Solutions
• “Accident (Incident) Investigation,” National Safety Council
![Page 37: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/37.jpg)
Responsibilities for Investigation
Team
• Supervisor
• Safety officer
• Safety committee representative for area
![Page 38: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/38.jpg)
What We’ve Learned Today ...
• The reasons for conducting thorough incident investigations
• How to set up an incident investigation and analysis program
![Page 39: Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis](https://reader035.vdocuments.us/reader035/viewer/2022062421/56649d0d5503460f949e15a7/html5/thumbnails/39.jpg)
Conclusion
When an organization reacts swiftly and positively to incidents, its actions reaffirms its commitment to the safety and well-being of its employees.