PRESENTATION 3:ACT UPON REPORTS ON THE IMPLEMENTATION OF FATIGUE MANAGEMENT POLICY

PRESENTATION 3 OVERVIEW

In this presentation you will learn about:

• How to Conduct Fatigue Incident Investigation

• Accidents vs Incidents

• Root Cause Analysis

• Incident Investigation

• Incident Reporting Requirements

FATIGUE INCIDENT INVESTIGATION• analyse information from individual incident reports as well as other company

sources.

• other organisational information might include hours worked on the day of the

incident and during the previous week.

• the questions asked during an investigation can help determine whether a specific

factor contributed to an incident.

FATIGUE INCIDENT INVESTIGATION – GENERAL QUESTIONS TO ASKNote that answers to some of these questions may identify areas that need to be probed

further:

• What was the date and time of the incident/accident?

• What were the planned hours of work for each employee involved in the incident/accident

over the two weeks prior to the incident? [Level 1 controls]

• What were the actual hours of work of employees involved in the incident/ accident over

the two weeks prior to the incident? [Level 2 controls]

• What were the reasons for any additional hours worked beyond the planned hours during

this period? Specifically, was the extra work or overtime foreseeable in advance and how

was it allocated among all eligible employees? [Level 2 controls]

• How many hours sleep did each employee involved in the incident/accident recall having

obtained in the 24 and 48 hours prior to the event? [Level 2 controls]

• How long had each employee involved been awake at the time of the incident/accident?

[Level 2 controls]

• Were any of the employees observed falling asleep or otherwise struggling to remain alert

in the week prior to the incident/accident? If yes, document details. [Level 3 controls]

FATIGUE INCIDENT INVESTIGATION – GENERAL QUESTIONS TO ASK• Does anyone involved in the incident recall having unexpectedly fallen asleep or

otherwise struggling to remain alert during the week prior to the incident/accident? If

yes, document details. [Level 3 controls]

• Did anyone involved in the incident/accident take medications or drugs (prescription or

non-prescription) in the week prior to the event? If yes, then document details and note

any effect the medication or drug is known to have on sleep, alertness, and/or fatigue.

[Level 3 controls]

• Was any employee involved aware of any sleep or other medical disorder that might

have affected sleep, alertness, and/or fatigue? If yes, document details. [Level 3

controls]

• Was any employee involved aware of any personal, financial, or other stress that might

have affected sleep, alertness, and/or fatigue? If yes, then is this stress ongoing?

Document details.

• Did any employee involved have another job or significant responsibility in the

preceding two weeks? If yes, document details.

• Approximately how many minutes is the commute to and from work for each employee

involved in the incident or accident?

WHAT IS AN ACCIDENT OR INCIDENT?

What is an accident?

• An accident is an unplanned, unwanted, but controllable event

which disrupts the work process and causes injury to people. An

accident stops the normal course of events and causes property

damage or personal injury, minor or serious, and occasionally

results in a fatality.

• An accident according to the dictionary is: “an unforeseen event”,

“chance”, “unexpected happening”, or formerly an “Act of God”

• From experience and analysis accidents are “caused occurrences”:

• Predictable - the logical outcome of hazards

• Preventable and avoidable - hazards do not have to exist.

They are caused by things people do or fail to do.

WHAT IS AN ACCIDENT OR INCIDENT?

Accidents

Incidents

WHAT IS AN ACCIDENT OR INCIDENT?

Example of an incident: A 22kg carton falls off the top shelf of a 4m high rack and lands near a worker. This event is unplanned, unwanted, and has the potential for injury.

WHAT IS AN ACCIDENT OR INCIDENT?What is an incident?

• An incident is an unplanned and unwanted event which disrupts the work

process and has the potential of resulting in injury, harm, or damage to

persons or property. An incident may disrupt the work process, but it does

not result in injury or damage. It should be looked as a “wake up call” and

can be thought of as the first of a series of events which could lead to a

situation where harm or damage occurs. Incidents are in a sense “aborted

accidents” and should be reported and investigated.

• Criteria for investigating an incident:

• What is reasonably the worst outcome, equipment damage, or injury to

the worker?

• What might the severity of the worst outcome have been? If it would

have resulted in significant property loss or a serious injury, then the

incident should be investigated with the same thoroughness as an

accident investigation.

ACCIDENTS DON’T JUST HAPPEN

• An accident is not “just one of those things”. Accidents are

predictable and preventable events.They don’t have to happen.

• Most workplace injuries and illness are not due to “accidents”.

More often than not it is a predictable or foreseeable eventuality.

• By “accidents” we mean events where employees are killed,

maimed, injured, or become ill from exposure to toxic chemicals or

microorganisms (TB, hepatitis, HIV)

• A systematic plan and follow through of investigating incidents or

mishaps and altering behaviors can help stop a future accident.

Let’s take the 22kg carton falling 4m for the second time, only this time it hits a worker, causing injury. Predictable? Yes. Preventable? Yes. Investigating why the carton fell will usually lead to solution to prevent it from falling in the future.

ROOT CAUSE ANALYSIS (RCA)• Root cause analysis (RCA) is a systematic technique that focuses on finding the origin of a problem

and dealing with that, rather than just dealing with its symptoms. It uses a specific set of steps,

with associated tools, to find the primary cause of the problem, so that you can:

• Determine what happened.

• Determine why it happened.

• Figure out what to do to reduce the likelihood that it will happen again.

• A root cause is the cause that, if corrected, would prevent recurrence of this and similar

occurrences.

• When conducting a Root Cause Analysis what are three causes that may be determined:

• Direct Cause – Unplanned release of energy or hazardous materials

• Indirect Cause – Unsafe acts and/or unsafe conditions

• Root Cause – policies and decisions, personal factors, environmental factors

• RCA requires you to keep asking a basic question - “What caused or allowed this condition/practice

to occur?” until you get to root causes.

ROOT CAUSE ANALYSIS (RCA)

THE ACCIDENT WEED

ROOT CAUSE ANALYSIS (RCA)The five whys

•  The “five whys” is one of the simplest root cause analysis methods. It is a

question-asking method used to explore the cause/effect relationships underlying

a particular problem. Ultimately, the goal of applying the 5 Whys method is to

determine a root cause of a defect or problem.

•  The following example demonstrates the basic process:

•  My car will not start (the problem): 

• Why? - The battery is dead. (first why)

• Why? - The alternator is not functioning. (second why)

• Why? - The alternator belt has broken. (third why)

• Why? - The alternator belt was well beyond its useful service life and has

never been replaced. (fourth why)

• Why? - I have not been maintaining my car according to the recommended

service schedule. (fifth why and the root cause)

ROOT CAUSE ANALYSIS (RCA)The benefits to asking the five whys include:

•  Simplicity - it is easy to use and requires no advanced mathematics or

tools.

• Effectiveness - it truly helps to quickly separate symptoms from causes

and identify the root case of a problem.

• Comprehensiveness - it aids in determining the relationships between

various problem causes.

• Flexibility - it works well alone and when combined with other quality

improvement and trouble shooting techniques.  

• Engaging - by its very nature, it fosters and produces teamwork and

teaming within and without the organization.

• Inexpensive - it is a guided, team focused exercise. There are no

additional costs.

INCIDENT INVESTIGATION

Incident investigation helps determine the causes of

an incident so you can take steps to ensure that the

same incident will not happen again. The benefits

include:

• Prevent future incidents (leading to accidents).

• Identify and eliminate hazards.

• Expose deficiencies in process and/or equipment.

• Reduce injury and worker compensation costs.

• Improve worker morale.

• Meet WH&S legislation requirements that you

investigate serious incidents / accidents. 

INCIDENT INVESTIGATIONConduct and document an investigation that answers:

• Who was present?

• What activities were occurring?

• What happened?

• Where and what time?

• Why did it happen?

Also answer:

• Is this a company or industry recognised hazard?

• Has the company taken previous action to control this hazard?

• What are those actions?

• Is this a training issue?

HOW TO PERFORM AN INVESTIGATION

There are six main steps involved in performing an investigation:

• Develop a plan

• Assemble an applicable investigation kit

• Investigate all incidents and accidents immediately

• Collect facts

• Interview witnesses

• Write a report

HOW TO PERFORM AN INVESTIGATIONDevelop a plan

• Your plan might include:

• Who to notify in the workplace?

• How to notify outside agencies?

• Who will conduct the internal

investigation?

• What level of training is needed?

• Who receives report?

• Who decides what corrections will be

taken and when?

• Who writes report and performs follow

up?

HOW TO PERFORM AN INVESTIGATION

• Some expansion questions on the above points are: 

• Who will be trained to investigate?

• Who is responsible for the finished report and what is the time

frame?

• Who receives copies of the report?

• Who determines which of the recommendations will be

implemented?

• Who is responsible for implementing the recommendations?

• Who goes back and assures that fixes are in place?

• Who assures that fixes are effective?

HOW TO PERFORM AN INVESTIGATIONAssemble an applicable investigation kit

Camera equipment First aid kit

Tape recorder Gloves

Tape measure Large envelopes

High visibility tape Report forms

Scissors Graph paper

Scotch tape Sample containers with labels

Personal protective equipment Items specific to your worksite

HOW TO PERFORM AN INVESTIGATIONInvestigate all incidents and accidents immediately

• How do you start your investigation?

• Notify individuals according to your “plan”

• You must involve an employee representative, the immediate supervisor, and other

people with knowledge

• Grab your “investigation kit”

• Approach the scene

• Actions at the accident scene:

• Check for danger - make sure you and others don’t become victims! Always check for

still-present dangerous situations.

• Help the injured - help the injured as necessary.

• Secure the scene - secure the scene and initiate chains of custody for physical evidence.

• Identify witnesses and physical evidence - separate witnesses from one another to

preserve facts; stabilize physical evidence.

• Gather the facts - begin as quickly as possible with interviews.

HOW TO PERFORM AN INVESTIGATIONCollect facts

• Where and how can you find facts?

• Witnesses and physical evidence

• Employees/other witnesses

• Position of tools and equipment

• Equipment operation logs, charts, records

• Equipment identification numbers

• Take notes on environmental conditions, air quality

• Take samples

• Note housekeeping and general working environment

• Note floor or working surface condition

• Take many pictures

• Draw the scene

HOW TO PERFORM AN INVESTIGATIONConsider the type of incident scene that you are dealing with:

• Some scenes are more delicate then others:

• If items of physical evidence are time sensitive address those first.

• If items of evidence are numerous then you may need additional

assistance.

• Some scenes will return to normal very quickly:

• Are you prepared to be able to recreate the scene from your

documentation?

• Consider creating a photo log - the log should describe the date,

time, give a description of what is captured in the photo and

directionality.

• Link to sketch of accident scene.

HOW TO PERFORM AN INVESTIGATIONInterview witnesses

Your method and outcome of interview should

include:

• who is to be interviewed first,

• who is credible,

• who can corroborate information you know is

accurate,

• how to ascertain the truth bases on a limitation

of numbers of witnesses.

• Be respectful - are you the best person to

conduct the interview?

• If the issue is highly technical, consider an

internal or external specialist for assistance.

HOW TO PERFORM AN INVESTIGATION

Consider the following method:

• Interview promptly after the incident

• Choose a private place to talk

• Keep conversations informal

• Talk to witnesses as equals

• Ask open ended questions

• Listen. Don’t blame, just get facts

• Ask some questions you know the answers to

HOW TO PERFORM AN INVESTIGATION

Write a report

• Remember that your report needs to be based on facts. All recommendations should be

based on accurate documented findings of facts and all findings and recommendations

should be from verifiable sources.

• The report should include:

• An accurate narrative of “what happened”

• Clear description of unsafe act or condition

• Recommended immediate corrective action

• Recommended long-term corrective action

• Recommended follow up to assure fix is in place

• Recommended review to assure correction is effective.

• How and why did the accident happen?

• A list of suspected causes and human actions

• Use information gathered from sketches, photographs, physical evidence, witness

statements

HOW TO PERFORM AN INVESTIGATION• Answer the following in the report:

• When and where did the accident happen?

• What was the sequence of events?

• Who was involved?

• What injuries occurred or what equipment was damaged?

• How were the employees injured?

•  Report conclusions should answer the following:

• What should happen to prevent future accidents?

• What resources are needed?

• Who is responsible for making changes?

• Who will follow up and insure changes are implemented?

• What will be the future long-term procedures?

HOW TO PERFORM AN INVESTIGATION

• If additional resources are needed during the implementation of

recommendations, then provide options. Having a comprehensive

plan in place will allow for the success of your investigation.

Success of an investigation is the implementation of viable

corrections and their ongoing use.

• It is important to commence interviews immediately and keep

witness separated so the facts can be recalled truthfully as

possible without undue influence from other parties.

The outcome of an investigation of the 22Kg carton falling off the top shelf of the 4m high rack might include correction of sloppy storage at several locations in the warehouse, moving unstable/heavy items to floor level, conducting refresher training for stockers on proper storage methods, and supervisors doing daily checks.

WHS REQUIREMENTS FOR INCIDENT REPORTING• The Work Health and Safety Act (WHS Act) requires the

regulator to be notified of certain ‘notifiable incidents’.

Notifying the regulator of ‘notifiable incidents’ can help

identify causes of incidents and prevent similar incidents

at your workplace and other workplaces.

• In summary Part 3 of the WHS Act requires:

• immediate notification of a ‘notifiable incident’ to

the regulator after becoming aware of it

• if the regulator asks—written notification with 48

hours of the request, and

• preservation of the incident site until an inspector

arrives or directs otherwise (subject to some

exceptions).

•  Failing to notify is a criminal offence and penalties

apply.

WHS REQUIREMENTS FOR INCIDENT REPORTINGWhat is a ‘notifiable incident’:

• A ‘notifiable incident’ as outlined in the WHS

Act is:

• the death of a person

• a ‘serious injury or illness’, or

• a ‘dangerous incident’

• arising out of the conduct of a business or

undertaking at a workplace.

• ‘Notifiable incidents’ may relate to any person

— whether an employee, contractor or member

of the public.

• Only the most serious safety incidents are

intended to be notifiable, and they trigger

requirements to preserve the incident site

pending further direction from the regulator.

WHS REQUIREMENTS FOR INCIDENT REPORTING

Who is responsible for notifying?

• Any person conducting a business or undertaking (PCBU) from

which the ‘notifiable incident’ arises must ensure the regulator is

notified immediately after becoming aware it has occurred.

• Procedures should be put into place to ensure work health and

safety incidents are promptly brought to the relevant individual’s

attention, for example a manager and then notified to the

regulator, if required.

WHS REQUIREMENTS FOR INCIDENT REPORTINGWhen and how to notify

• A regulator must be notified of a ‘notifiable

incident’ immediately after the PCBU

becomes aware of the incident arising from

the business or undertaking.

• The notice must be given by the fastest

possible means which could be by telephone

or in writing, for example by facsimile, email

or other electronic means.

• If notifications are made by telephone follow-

up information may be requested either by

telephone or in writing. If you are asked to

follow-up in writing you must provide the

required information in writing within 48

hours of the request being made.

WHS REQUIREMENTS FOR INCIDENT REPORTINGCan work continue where the incident occurred?

• The person with management or control of a workplace at which a

notifiable incident has occurred must ensure, so far as is reasonably

practicable, that the site where the incident occurred is not disturbed

until an inspector arrives at the site or directs otherwise (whichever is

earlier).

• Requirements to preserve the incident site apply to any plant,

substance, structure or thing associated with the notifiable incident.

This means that any evidence that may assist an inspector to

determine the cause of the incident is preserved.

WHS REQUIREMENTS FOR INCIDENT REPORTING• An incident site may be disturbed:

• to assist an injured person

• to remove a deceased person

• to make the site safe or to minimise the risk of a further notifiable incident

• to facilitate a police investigation, or

• after an inspector has given a direction to do so either in person or by

telephone.

• The sooner the regulator is notified, the sooner the site can be released.

• If however after arriving at the incident site an inspector considers that it

should remain undisturbed in order to facilitate investigation of the incident

they may issue a non-disturbance notice. This notice must specify the period

for which the notice is to apply—no more than seven days.

• Penalties apply if an individual or body corporate fails to preserve a site.

WHS REQUIREMENTS FOR INCIDENT REPORTINGSite Preservation requirements only apply to the incident site

• Requirements to preserve a site only apply in relation to the immediate area where

the incident occurred— not the whole workplace.

• If you are unsure about what you need to do to preserve a site, ask the regulator

when you notify them of the incident.

• You can also ask the regulator to be relieved of your legal obligations to preserve the

incident site at this point—even if you don’t meet the strict criteria above.

WHS REQUIREMENTS FOR INCIDENT REPORTINGUpgrading Notifications

• If a notifiable incident escalates from a serious illness or injury to a death the

regulator must be separately notified of the death immediately after becoming aware

that the person has died.

Record keeping requirements

• The notifier must keep a record of the notifiable incident for at least five years from

the date of notification. Penalties apply for failing to do so.

• As a practical matter these records should include any directions or authorisations

given by an inspector at the time of notification (including authorisations to disturb

incident sites) and any confirmation you received from the regulator that you notified

them about the incident.

BREACHES UNDER THE HVNLThe HVNL contains three different types of penalties that can apply:

•  infringeable offences

• court imposed penalties

• demerit points.

Heavy Vehicle National Law Act 2012: Chapter 6 Vehicle operations—driver fatigue

222 Categories of breaches

(1) A contravention of a maximum work requirement or minimum rest requirement is a minor risk

breach if it is declared under the national regulations to be a breach in the minor risk category.

(2) A contravention of a maximum work requirement or minimum rest requirement is a substantial

risk breach if it is declared under the national regulations to be a breach in the substantial risk

category.

(3) A contravention of a maximum work requirement or minimum rest requirement is a severe risk

breach if it is declared under the national regulations to be a breach in the severe risk category.

(4) A contravention of a maximum work requirement or minimum rest requirement is a critical risk

breach if it is declared under the national regulations to be a breach in the critical risk category.