Incident Investigation

Topics

• Establish an effective incident investigation program

• Learn effective analysis tools relating to incident investigations

• Learn how to conduct an incident investigation that identifies the contributing factors to the incident

• Minimize the recurrence of workplace incidents that are contributing to injuries and illnesses

Why Should We Investigate?

• To prevent or decrease the likelihood of future injury or illness

• To identify and correct unsafe behaviors and conditions

• To identify training needs

When Do You Conduct an Accident Investigation?

• All incidents– All injuries, even very minor ones– All incidents with the potential for injury– Property damage, product damage, and

near miss situations

Steps to Assure a Good Investigation

• Emphasize that safety is a value, not just a priority• Remind employees to report incidents immediately• Explain how accident investigations are critical to

the organization• Ensure quality forms exist to guide your efforts

and provide necessary reminders. • Fix the cause, not the blame• The 2nd, 3rd and 4th items are part of groundwork

that needs to be laid before an incident occurs. These can also be reiterated as part of the investigation.

Steps to Assure a Good Investigation

• Emphasize that safety is a value, not just a priority

“Values do not readily change and remain unaffected by the competing, daily fluctuation of other factors in the work environment.”

“Priorities can change daily in response to situational demands.”

“When safety is a basic value, it becomes the ‘natural way’ of performing a job, anything less is unacceptable.”Making Safety a Basic Value; R.E. Earnest; Professional Safety, August 2000; American Society of Safety Engineers

Unsafe Act Violation of established safety policies/procedures which could result in an incident.

Unsafe Condition A mechanical or physical condition which if not eliminated, guarded or altered could result in and incident.

Unsafe Acts and Conditions

Unsafe Acts:

Cause 90% of ALL incidents *

Unsafe Conditions:

Cause 10% of ALL incidents

*”Industrial Safety and Health Management”; Liberty Mutual , 1995

Unsafe Acts Vs Unsafe Conditions

• *”Industrial Safety and Health Management” by C. Ray Asfahl cites H.W. Heinrich, whose research concluded that 88% of all industrial incidents are from unsafe acts. A 1995 survey completed by Liberty Mutual of 400 Risk Managers and Safety Consultants found that, excluding “acts of God”, 92% of all workplace incidents result from “performance deficit” (unsafe behavior).

*”Industrial Safety and Health Management”; Liberty Mutual , 1995

Before an Incident

Establish• Who should conduct the investigation

– Supervisor, foreman, safety committee, safety director/Coordinator.

– Why? Supervisors know the job. • When incident investigations are to be

completed– ASAP after the incident

• How the investigation will be conducted– Forms used– Procedures

Before an Incident

Establish

• What will be done with findings

– Reviewed by senior management

– Safety committee discussion

– Follow up on corrective actions

– Incident trend analysis

After an Incident• Conduct investigation ASAP

• Control & preserve the scene

• Interview injured worker promptly while information is clear

• Interview witnesses individually

• Ask open ended questions

– Who, What, When, Where, Why, and How?

• Compile background information

• Seek facts not fault

After an Incident

• Document investigation

• Determine cause(s) of incident

• Determine what can be done to prevent a similar incident from happening again

• Implement corrective actions

• Follow-up

Incident Causes

Immediate Cause• A sequence of unsafe acts that led to the

incident Example: Water on the floor

Basic Cause• The reasons why the immediate cause was

allowed to occur or failed to occur Example: Why is the water on the floor?

General Causal Categories

• Materials/equipment• Environment• Personnel• Management• Task

Incident Scene

• Where did the incident occur?

• What was the employee doing when the

incident occurred?

• What steps did the employee take while

performing the task?

• What equipment/tools were being used?

• How were the equipment/tools used?

Incident Description

• What task was being performed?

• What were nearby employees (if any) doing?

• What happened with the equipment/tools

being used?

• What was the injury or damage?

• What steps should be taken to perform this

task safely?

Work environment and equipment

• Was work environment safe?

– Housekeeping?

– Additional factors?

• Noise, heat, lighting, fatigue, height

• Were equipment/tools in good condition?

– Defective?

– Missing guards?

Identify Unsafe Conditions & Unsafe Acts

Procedures

• Are there inspection procedures to detect

hazard?

• Rushed job?

• Were task procedures followed?

• Were correct equipment/tools used?

• Was employee authorized to perform task?

Identify Unsafe Conditions &Unsafe Acts

Contributing Factors – Human Behavior Notes:

• Common to all accidents• Not limited to the person involved in the

accident• Highly probable that the behavior had

occurred previously• Risk behavior that occurs regularly becomes

part of the system• Behavior has been observed, condoned and

encouraged, at least indirectly by management

Behavior

• Was employee supposed to be in vicinity of

incident area?

• Was PPE worn?

– Does employee know PPE is required?

– Did employee know where PPE is stored?

– Was PPE adequate?

• Were safety rules broken?

• Were shortcuts taken?

Identify Unsafe Conditions &Unsafe Acts

Find the Root Causes

• When you have determined the contributing factors, dig deeper!– If employee error, what caused that behavior?– If defective machine, why wasn’t it fixed?– If poor lighting, why not corrected?– If no training, why not?

Find the Root Causes

A man falls off an unstable step ladder with a damaged rung

• Unsafe Act– Climbing a defective ladder

• Unsafe Condition– A defective ladder

• The Correction– Get rid of the defective ladder

Have the root causes been identified?

Find the Root Causes

What are some of the contributing factors?– Why was the defective ladder not found in

normal inspections?– Why did the supervisor allow its use?– Did the employee involved know not to use

it?– Was the employee properly trained?– Did the supervisor examine the job first?

Have the root causes been identified?

Find the Root Causes

Ask yourself, “What was the Root Cause of the Injury?”

Find the Root Causes

Initial information:An employee is using the grinder and is not wearing safety glasses. The glasses are on the workbench near the grinder. The supervisor walks by and sees it, but has other things to take care of. The Plant Manager, who happens to be passing through the plant on his way to the regularly scheduled Operations meeting with senior management, notices both the employee and supervisor, but is in a hurry to get to the meeting.

Find the Root Causes

Additional information:Senior management is having the regularly scheduled Operations meeting. Safety is not on the agenda.

Find the Root Causes

Result:A piece of metal becomes imbedded in the eye

of the employee using the grinder.

Ask yourself, “What were the Root Causes of the Injury?”

Identify Possible Corrective Actions

• Engineering controls• Administrative controls• Personal protective equipment

Do not stop at familiar or favorite corrective actionsLet’s look at a few…

Engineering Controls

• Automate hazardous process/use machine

• Change the job task or equipment

– Substitute high hazard materials for ones of lower hazard

– Specify correct equipment for job tasks

• Modify work station

– Change layout, location or position of equipment

– Change position of employee

– Provide barriers, warning signs or guardrails

– Increase visibility in workspace

Administrative Controls

• Modify employee functions

– Clearly define expectations

– Designate employees authorized to operate equipment

– Enforce disciplinary policy for violation of safety rules

• Provide training for employees

– Equipment, job procedures, reporting procedures

• Review hazards and controls

– Perform job safety analysis and change job procedures

– Review hazards and controls of infrequent tasks

– Change frequency & depth of hazard inspections

Personal Protective Equipment

• Review/specify PPE requirements

• Provide personal protective equipment

• Train employees on purpose and use

• Ensure employees wear adequate protective equipment.

Corrective Action Plan

Develop corrective action plan

• Assign responsibility for corrective action

Follow-up

• Ensure corrective actions are taken

• Prevent similar incidents from occurring

Managing Recommendations for Corrective Action

• Should a policy be revised or developed?• Should the monthly self-inspection checklist be

modified?• Should training be conducted and will retraining on

that topic be needed/provided?• Should a work practice be modified or eliminated?• Should the supervisor monitor the work practice and if

so, how will this be accomplished?

Conclusion

• Incident Investigation is both a reactive and proactive process in that it uncovers the root cause and other contributory factors as well as providing valuable information to prevent similar incidents from occurring in the future.

• We cannot afford, nor is it acceptable to wait for hazards to identify themselves through someone’s accident

Questions

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Woodland Hills, CA 91367   © 2009 Zenith Insurance Company. All Rights Reserved.

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