Copyright@NIOSH 2005/1 1
Incident Investigation And
Corrective Action
Safety And Health Officer Certificate Course
Copyright@NIOSH 2005/1 2
Learning Objectives
• To describe the importance of incident investigation
• To list 4 types of incident
• To describe principles of investigation
Copyright@NIOSH 2005/1 3
Learning Objectives
• To explain 8 steps in incident investigation
• To explain ways to plan and implement corrective and preventive action
Copyright@NIOSH 2005/1 4
Scope
• Overview of an Incident Investigation
• Principles of Incident Investigation
• Pre-Planning and Strategy of an Investigation
• Corrective Action
Copyright@NIOSH 2005/1 5
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
Copyright@NIOSH 2005/1 6
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
Copyright@NIOSH 2005/1 7
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
Copyright@NIOSH 2005/1 8
Four Basic Types Of Incidents
• Long Term
• Hearing loss, an illness resulting from exposure to chemicals
• Near misses
Copyright@NIOSH 2005/1 9
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
Copyright@NIOSH 2005/1 10
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
Copyright@NIOSH 2005/1 11
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
Copyright@NIOSH 2005/1 12
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
Copyright@NIOSH 2005/1 13
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
Copyright@NIOSH 2005/1 14
Why Investigate an Incident
• To prevent repetition of the same work-related injuries, ill health, diseases and incidents
• Legal Requirement
Copyright@NIOSH 2005/1 15
Why Investigate an Incident
• Accurate record (for insurance, legal prosecution, public enquiries)
• Organisation’s own policy and business reasons
Copyright@NIOSH 2005/1 16
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
Copyright@NIOSH 2005/1 17
Who Should Investigate?
Depends On Severity Of The
Incident
• External agency involvement
– DOSH and / or DOE, Police, etc.
Copyright@NIOSH 2005/1 18
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
Copyright@NIOSH 2005/1 20
Principles of Investigation
• Carried out according to procedure:
– For all incidents
– By competent persons with participation of workers.
Copyright@NIOSH 2005/1 21
Principles of Investigation
• 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
Copyright@NIOSH 2005/1 22
Principles of Investigation
• 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
Copyright@NIOSH 2005/1 23
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
Copyright@NIOSH 2005/1 24
Be Prepared –
Before The Incident
• Designated trained and competent investigator
– Only be responsible for investigating
Copyright@NIOSH 2005/1 25
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
Copyright@NIOSH 2005/1 26
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)
Copyright@NIOSH 2005/1 27
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
Copyright@NIOSH 2005/1 28
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
Copyright@NIOSH 2005/1 29
Responsibilities
• Employee
– Record in incident book (supervisor checks)
• Supervisor / Manager
– Initiate risk control response: first-aid, fence area, etc. other preventive action
– Inform SHO
Copyright@NIOSH 2005/1 30
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
Copyright@NIOSH 2005/1 31
Responsibilities
Investigator
• Visit and survey incident scene
• Eliminate the hazards:
– Control of chemicals
– De-energise
– De-pressurise
– Light it up
– Shore it up
– Ventilate
Copyright@NIOSH 2005/1 33
Steps In Incident Investigation
1. Gather information
2. Search for and establish facts
3. Isolate essential contributing factors
4. Determine the causes & root cause
Copyright@NIOSH 2005/1 34
Steps In Incident Investigation
5. Determine corrective actions
6. Report, review the findings
7. Analyze incidents
8. Implement corrective actions
Copyright@NIOSH 2005/1 35
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
Copyright@NIOSH 2005/1 36
Gathering Information
• Identify people involved
– Excellent source of first hand knowledge
• Interview injured, witnesses, supervisors and others
Copyright@NIOSH 2005/1 37
Gathering Information
• Get preliminary statements as soon as possible from all witnesses
• May present pitfalls in the form of:
– Bias, perspective, exaggeration, hidden agenda
Copyright@NIOSH 2005/1 38
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
Copyright@NIOSH 2005/1 39
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
Copyright@NIOSH 2005/1 40
Gathering Information -
People (Questioning)
• Make sure the witness understands questions
• Use sketches and diagrams to help the witness
Copyright@NIOSH 2005/1 41
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
Copyright@NIOSH 2005/1 42
Gathering Information -
Recording Interview
• Differentiate what is directly observed and what is hearsay and note accordingly
• Verify claims afterwards
Copyright@NIOSH 2005/1 43
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
Copyright@NIOSH 2005/1 44
Gathering Information -
Closing The Interview
• Get signed statements where possible
• Thank the interviewee
Copyright@NIOSH 2005/1 45
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
Copyright@NIOSH 2005/1 46
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
Copyright@NIOSH 2005/1 47
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
Copyright@NIOSH 2005/1 48
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
Copyright@NIOSH 2005/1 49
Findings
• Find Root Causes. Ask:
What caused behaviour? Why equipment was not fixed? Why condition was not corrected?
Copyright@NIOSH 2005/1 50
Determine Corrective Action
• Recommendations made for corrective actions
• Recommendations for corrective actions to improve OSH management system
Copyright@NIOSH 2005/1 51
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
Copyright@NIOSH 2005/1 53
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
Copyright@NIOSH 2005/1 54
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
Copyright@NIOSH 2005/1 55
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
Copyright@NIOSH 2005/1 56
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.