1. INCIDENT INVESTIGATION AND REPORTING
Omid Namvar & Martin Ordonez
University of British Columbia
Vancouver, BC, Canada
This educational module explains the incident investigation and reporting process in work place. Despite its pivotal role in preventing future incidents in any work place, this topic has not been well emphasized in the curriculum in various disciplines and many universities across the country. The goal of this educational module is to familiarize the engineers and practitioners with the steps involved in an effective investigation of an incident and its proper documentation.
The material in this module have been developed by PhD candidate, Omid Namvar, under supervision of Mr. Mark Rigolo and Prof. Martin Ordonez at the Electrical and Computer Engineering Department of the University of British Columbia with the industrial mentorship of Ms. Ryanne Metcalf at BC Hydro. The funding for this project was provided by Minerva Safety Management Education under a Mitacs grant.

2. Understanding the Terms Incident Investigation Incident Trend Analysis
Table of Contents
Introduction
Module Basics
Learning Objectives
Why incidents occur today?
Understanding the Terms
Incident Investigation
Conducting Investigation
Step 1: Manage the Incident Scene
Step 2: Gather Information
Step 3: Analyze Information
Step 4: Corrective Actions
Sample Incident Investigation Form
Step 5: Incident Investigation Report
Step 6: Follow-up
Role of OH&S Committees
Canadian Standards for OH&S
Other Types of Incident Reporting
Incident Trend Analysis
What Is Trend Analysis?
Types of Trends
Industry Example
Safety Strategy & Culture
Incident Investigation Process
Effective Risk Management
Incident Management System (IMS)
Incident Classification in IMS
Case Study
Step 1: Manage the Scene
Step 2: Gather Information
Step 3: Determine Causes
Step 4: Corrective Actions
Summary of Incident Causal Analysis
References
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

3. Importance to the Graduate Engineer
All workplace parties have a shared responsibility for the Occupational Health & Safety (OH&S) program
Integral parts of OH&S program:
Incident Investigation
Strengthens the internal responsibility system
Essential to building a positive OOH&S culture in workplace
Important to prevent similar occurrences in future through learning of root causes
Incident Reporting
Regulatory requirement
Can be shared to help prevent future occurrences
Systematic issues can be identified via incident trend analysis using data in the reports from past incidents
As part of the internal responsibility system, all workplace parties–employers, workers, including managers and supervisors, and occupational health and safety (OH&S) committees–have a shared responsibility for the OH&S program to the extent of each party’s authority and ability to be involved. This means everyone works co-operatively, shows ownership for the program and is committed to preventing injury, illness and property damage in the workplace.
Incidents have the potential to cause serious harm, injury or damage to people, equipment or the environment. Incident investigations are an important part of an OH&S program. By investigating why incidents occur, we can minimise the risk of the same or similar incidents from happening again. The involvement of all workplace parties in incident investigation strengthens the internal responsibility system, and is essential to building a positive health and safety culture in workplaces.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

4. Module Basics Goal Objective
Maintain a safe and healthy work environment by learning from and correcting unsafe acts/conditions that causes or could potentially cause injury/damage in a timely manner
Objective
Learning procedures essential to an effective incident investigation and proper documentation
“Those that do not learn from their mistakes are bound to repeat them”
The module provides the general knowledge about the procedures essential to an effective investigation of incidents and their proper documentation. The main objective of incident investigation is prevention. Finding the causes and taking steps to control or eliminate them can help to prevent similar or more serious incidents from happening in the future. The main learning objectives will be elaborated in the next two slides.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

5. Module Learning Objectives
Understanding the terms
Incident, near miss, unsafe act, unsafe condition
Principles of effective incident investigation
Intent of an investigation
What should be investigated?
Who should do the investigation?
How to report an incident?
Identifying root causes
Incident trend analysis
Understanding the Benefits
Identifies systematic issues
Prevents reoccurrence
safety awareness and culture
This module elaborates on the procedures involved in a systematic investigation of both potential and actual workplace incidents. Incident investigations are a mandatory part of an Occupational Health & Safety (OH&S) program and should have procedures to ensure their effectiveness. The motivation for this module is to outline an incident investigation procedure that is objective and satisfies most regulatory requirements. Many incident investigations and reports are done with prejudice. That is, conclusions and recommendations are often predetermined to suit the goals of the investigators. The main purpose of this module is to provide the knowledge and means to minimize the bias that can enter an investigation.
A prime objective of incident investigation is prevention. By finding the causes of an injury and taking steps to control or eliminate them, we can prevent similar incidents, as well as increase safety awareness and culture within workplace.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

6. Module Learning Objectives (Continued)
Investigation and reporting procedure:
Manage the scene
Respond promptly to the emergency, eliminate immediate hazards while preserving the scene
Investigation
Gather information and identify direct causes of the incident via collecting physical evidence and conducting interviews
Identify root causes, otherwise known as management system causes
This module covers the incident investigation process from start to finish including understanding the terms, how to gather evidence, interview witnesses, analyze facts, determine root causes, write reports and recommend corrective actions. The main purpose of writing an incident investigation report is to communicate the investigation information and document recommendations for corrective action. Investigation reports may be used as evidence during legal proceedings; therefore, it is important that it all aspects of investigation is fully documented. They can further be used for incident trend analysis, which analyzes data from past incidents to find regularities or patterns in the time, location, or causal factors of incidents.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

7. Module Learning Objectives (Continued)
Investigation and reporting procedure (continued):
Reporting
Communicate the investigation info and document recommendations for corrective actions
Follow-up
Ensure implementation and evaluate effectiveness of the recommended corrective actions
Recommendations must address root causes
This module covers the incident investigation process from start to finish including understanding the terms, how to gather evidence, interview witnesses, analyze facts, determine root causes, write reports and recommend corrective actions. The main purpose of writing an incident investigation report is to communicate the investigation information and document recommendations for corrective action. Investigation reports may be used as evidence during legal proceedings; therefore, it is important that it all aspects of investigation is fully documented. They can further be used for incident trend analysis, which analyzes data from past incidents to find regularities or patterns in the time, location, or causal factors of incidents.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

8. Why incidents occur today?
Item
Direct Cause (Equipment failure, human failure)
Management System Failure (Root Cause) (Controlled by Human Beings) 1
Fatigue Being pushed beyond reasonable limits to stay on top of workload
None or Inadequate Fatigue Countermeasures Program
None or Inadequate Resource Planning 2
Stress Job Security, finances, health issues, and personal relationships
None or Inadequate Employee Wellness Program
None or Inadequate Employee Assistance Program
None or Inadequate Supervision 3
Slips Wet linoleum, hardwood, and tile floorings or inappropriate type of footwear provided to workers
None or Inadequate housekeeping (for incidental spill)
None or Inadequate maintenance program (equipment)
None or Inadequate workplace inspection program
None or Inadequate policy on providing proper footwear 4
Trips Items left out in high traffic corridors, improperly taped extension cords, loose carpeting, poorly lit hallways and stairs
None or Inadequate housekeeping
None or Inadequate practices or procedures and/ or training on these practices or procedures
None or Inadequate maintenance program
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

9. Why incidents occur today? (Continued)
Item
Direct Cause (Equipment failure, human failure)
Management System Failure (Root Cause) (Controlled by Human Beings)
 5 
Toppling Objects Tall furniture not securely anchored or heavy objects stacked on high shelves
None or inadequate practices or procedures and/ or training on these practices or procedures
None or Inadequate workplace hazard assessment program
None or Inadequate workplace inspection program 6
Hazardous Material Improper use of gloves, protective clothing and eyewear
None or Inadequate practices or procedures and/ or training on these practices or procedures
None or Inadequate Behavioural Safety Observation program
None or Inadequate Supervision 7
Repetitive Motion Carpal Tunnel Syndrome is common among workers in repetitive activities that put pressure on the median nerve, causing numbness in fingers, wrists, and hands
None or Inadequate policy or program to encourage workers to take appropriate frequent breaks with flexing exercises to prevent Repetitive Motion Injuries
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

10. Why incidents occur today? (Continued)
Item
Direct Cause (Equipment failure, human failure)
Management System Failure (Root Cause) (Controlled by Human Beings) 8
Lifting Back injuries and pulled muscles as the result of lifting heaving objects
None or Inadequate practices or procedures and/ or training on these practices or procedures involving lifting objects
None or Inadequate assessments to evaluate where equipment are required over manual work
None or Inadequate Job Task Analysis 9
Workplace Violence Assaults by members or the public/clients/patients, estranged spouses, disgruntled former employees, tension among employees, suspicious mail, phone threats, security violations
None or Inadequate physical security systems (e.g., controlled access using registration with security, controlled access cards and card readers)
None or Inadequate bomb or threat response procedure
None or Inadequate security personnel
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

11. Why incidents occur today? (Continued)
Item
Direct Cause (Equipment failure, human failure)
Management System Failure (Root Cause) (Controlled by Human Beings) 10
Operational Procedures Lack of workers experience, use of shortcuts, not following the manufacturer’s suggested usage, insufficient training
None or Inadequate worker training and recertification program
None or Inadequate worker performance evaluation program
None or Inadequate worker accountability policy (e.g., deliberate acts of not following proper procedures can be grounds for immediate dismissal) 11
 Other
Lack of, or ineffective, Health, Safety and Environmental (HSE) Management Systems.
This includes lack of leadership, monitoring, accountability and/or providing appropriate resources.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

12. Understanding the Terms12
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

13. Understanding the Terms
What is an incident?
An unplanned event that disrupts the orderly flow of the work process and results in some form of injury or damage.
E.g. an oil refinery explosion (incident, i.e. unplanned event), resulting in a fatality and property damage (consequences)
What is a near miss?
An unexpected event that did not cause injury or damage this time but had the potential.
Also known as dangerous occurrence
E.g. worker slipping on a patch of ice, not resulting in an injury
What is incident investigation?
The analysis and account of an incident based on information gathered by a thorough and conscientious examination of all factors involved, to learn what the root causes were, in order to prevent recurrence using corrective recommendations.
The next three slides are devoted to defining the terms that are central to understanding incident investigation and reporting, and will be encountered frequently in the rest of this presentation.
An incident investigation is a well-planned analysis of an incident that identifies the root causes and recommends corrective action to prevent the incident from happening again.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

14. Understanding the Terms (Continued)
Incident Direct Causes
Unsafe act (Cause 88% of all incidents*)
Unsafe condition (Cause 12% of all incidents*)
What is an unsafe act?
An activity conducted in a manner that may threaten the health and/or safety of workers.
Using defective equipment
Operating machinery without qualification
Use of tools for other than their intended purpose
Bypass or removal of safety devices
Improper repair of equipment
Despite what many people think, workplace incidents do not just happen; they result from a series of events that are categorized into “unsafe acts” and “unsafe conditions.”
* C. R. Asfahl, and D. W. Rieske, ”Industrial Safety and Health Management,” Prentice Hall, 2009.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

15. Understanding the Terms (Continued)
What is an unsafe condition?
A condition in the work place that is likely to cause injury or structural/property damage
Defective tools and equipment
Congestion in the workplace
Inadequate guards and warning systems
Unnoticed or disregarded hazardous releases or spills of hydrocarbons having the potential to create fire or explosions upon ignition
Poor Ventilation
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

16. Understanding the Terms (Continued)
What is a direct cause?
An immediate cause of an event. The first cause in a causal chain.
E.g. improper use of personal protective equipment
What is a programmatic cause?
A contributing cause to an event that, by itself, would not have caused the event. The causes after the direct cause.
E.g. deficiencies in health and safety programs.
What is a root cause?
The fundamental reason for an event, which if corrected, would prevent recurrence.
E.g. low management standards of performance.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

17. Understanding the Terms (Questions)
Multiple selection – choose all that apply:
Which of the following are examples of unsafe conditions?
i. Defective tools and equipment
ii. Bypass or removal of safety devices
iii. Congestion in the workplace
iv. Inadequate guards and warning systems
v. Operating machinery without qualification
vi. Unnoticed or disregarded hazardous releases or spills
vii. Poor ventilation
Which of the following are examples of an unsafe act?
i. Using defective equipment
ii. Operating machinery without qualification
iii. Congestion in the workplace
iv. Use of tools for other than their intended purpose
v. Bypass or removal of safety devices
vi. Poor management style
vii. Improper repair of equipment
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

18. Understanding the Terms (Questions)
Match the following terms with the correct description:
1. Direct Cause 2. Programmatic Cause 3. Root Cause
A. The fundamental reason for an event, which if corrected, would prevent recurrence.
B. An immediate cause of an event. The first cause in a causal chain.
C. An intermediate cause of an event, which if corrected, would prevent any unsafe acts.
D. A contributing cause to an event that, by itself, would not have caused the event.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

19. Incident Investigation
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

20. Incident Investigation
“Investigation of serious incidents often reveal earlier incidents that have been disregarded.”
What to investigate?
All (even very minor) injuries
All incidents with a potential for injury
Property/product damage & near miss situations
Intent of investigation
Determine the direct and root causes of the incident
Identify the contributed unsafe acts or conditions
Recommend corrective actions to prevent similar incidents in the future by addressing direct/contributory causes and root causes (the latter being fundamental management system causes).
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

21. Conducting Investigation
Effective incident investigation procedure
Manage Incident Scene
Gather Information
Analyze Information & Determine Causes
Determine Corrective Actions
Write Incident Investigation Report
Follow-up
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

22. Step 1: Manage the Incident Scene
Eliminate immediate hazards to minimize risk of further injury/damage
E.g. slippery surface, energized equipment, stop the leak and put out the fire, shutdown the process or equipment
Respond promptly to the emergency
Provide first-aid treatment to injured
Activate the facility emergency alarm
Response by emergency first responders; e.g. fire fighters, paramedics
Secure the incident site
Restrict access and limit disturbance until all information is collected
However, an authority may have jurisdiction at the scene; e.g. police
Meet regulatory requirements for notification
When an incident occurs, potential danger is not limited to those directly involved. When there is a gas leak or a fire, for instance, other workers on site and the general public may also be threatened. Managing the incident scene can help the investigation procedure. It prevents the present situation from getting worse and, therefore, protects workers and general public from further danger/injury. It could further protect the equipment and material from further damage.
Securing the incident scene keeps the situation under control and prevents further disturbance until the investigation is concluded. Injuries typically attract a crowd. Evidence can be easily disturbed by people or vehicles. If the site is not secured immediately, fact-gathering can be difficult. Securing the incident scene could be done using ropes, barrier tape, cones or human guards if required. Nothing has to be removed from or replaced in the incident scene without permission until all necessary information is collected. The amount of information gathered and the resources needed depend on the specific incident.
When there has been a critical injury, when a worker has lost consciousness, or following any other situation as defined by legislation, the regulatory requirements has to be met for notifying the governmental agencies. For example, in British Columbia, the worker, employer, and the worker's physician must report the injury/illness to WorkSafeBC. In Newfoundland, any injury in the workplace that leads to medical treatment has to be reported in writing to Workplace Health, Safety and Compensation Commission within three days.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

23. Step 1: Manage the Scene (Continued)
Why report incidents?
Regulatory requirements
Worker’s Compensation Act, Division 10
WorkSafeBC, Occupational Health & Safety Regulations, Section 3.4
Ontario Occupational Health and Safety Act, Part VII Notices
Health Canada, Canada Consumer Product Safety Act, Section 14
Transport Canada, Transportation of Dangerous Goods Act, Section 18
Transportation Safety Board Regulations, Section 2.1
Canadian Nuclear Safety Commission, Nuclear Safety and Control Act
Company regulations
E.g. BC Hydro OHS Standard 130
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

24. Step 1: Manage the Scene (Continued)
In British Columbia, WorkSafeBC has to be notified of any incident that:
resulted in serious or time loss injury, illness, or death of a worker
involved a major structural failure or collapse of a building, bridge, crane, hoist, temporary construction support system or excavation
involved the major release of a hazardous substance
was a serious miss that could led to an incident involving fatality
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

25. Step 2: Gather Information
Physical evidence
Examine incident scene and make accurate record
photos, measurements, sketches, etc.
Take notes
Should answer who, what, when, where, why, how
Be careful not to speculate on events before facts are established
Should include
Observations of environmental conditions
Reference to physical evidence
Information from interviews
View documentation
Training and maintenance records, inspection reports
Of course, an investigation can be awkward for the people involved, but our culture is an open one and everyone understands that we investigate in order to learn from what went wrong. We have to separate emotions from facts, because it’s all about the facts when it comes to understanding the causes–whether they are mistakes or management failures–and learning to prevent them from happening in the future.
Keeping notes in a notebook throughout an investigation process keeps information together and organized. Notes should be neat and detailed, yet concise. They should answer who, what, when, where, why and how. Good notes help to recall facts and are useful when analyzing information to determine the root causes.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

26. Step 2: Gather Information (Continued)
Conducting Interviews
Who to interview?
Injured worker, supervisor, witness, anyone with info
Interview Tips
Maintain privacy and put the person at ease
Interview individuals separately
Explain main purpose is fact finding, not fault finding
Do NOT lead the witness
Repeat what is reported to verify your understanding
Ask specific questions to fill in the gaps
Witnesses can disperse quickly and never be seen again. This is especially true when passers-by have witnessed a construction incident. Some witnesses are eager to supply information. Others may be reluctant to speak and need coaxing. Some witnesses will not come forward because they are afraid of being blamed or do not want to get involved. A good witness can provide an accurate description of the incident. This helps investigators put the pieces of the puzzle together. It is important to identify and interview anyone who:
a) saw the incident and/or
b) was in the vicinity immediately before, during, or after the incident, including injured workers.
When conducting interview, put the person at ease. The interviewee may not see the bigger picture, and feel personally responsible. Interview people at the scene individually so as to make sure obtain different viewpoints to the sequence of events that led to the incident. Before starting the interview, make sure to explain that main purpose of investigation is identify the causes of the incidents so as to avoid its recurrence in the future. This will ensure the interviewees that they are not speculated. Always make sure to give witness feedback of your understanding, and go over your notes with the witness to confirm correctness and accuracy. At the end, thank the interviewees for their help, and end the interview on a positive note. This will ensure that the witnesses feel comfortable to add to their accounts should they remember something later on.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

27. Step 2: Gather Information (Continued)
Information sought in Interview:
Identity of people involved in the incident
Events occurred before, during, and after the incident
Timing and sequence of events
Use created timeline to figure out where gaps in knowledge are
Location and direction of actions and events
Possible causes of each action and event
Witness’s suggestions for preventing similar incidents
Sample questions:
Are the workers trained for the standard procedure?
Was this the first time that the task was done?
What failed or malfunctioned?
What could have prevented the incident?
At the conclusion of each interview, highlight new questions that need to be answered by listing information retrieved, what was accomplished, and what needs to be completed. This lets the investigator identify gaps in information and details that need to be confirmed from physical evidences or future interviews.
Some other questions that could be asked in Interviews include:
• Where were you when the incident happened?
• What did you see or hear?
• Is there a standard procedure for the task?
• Was the work being supervised?
• Who else was around when the incident happened?
Once all interviews are completed, the information should be sorted and analyzed to
• identify what has been found;
• identify what may be missing;
• determine next course of action;
• eliminate unnecessary duplication.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

28. Step 2: Gather Information (Continued)
Review documentation
Logbooks
Work schedules
HSE management systems, standards and management reports
Training records
Procedure manuals
Maintenance records
Manufacture’s specifications
Workplace inspection reports
Previous incident investigation reports
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

29. Step 3: Analyze Information
Determine the sequence of events that led to the incident
Identify and list possible causes:
Human
Management, workers, visitors
Age, experience, training, workload, stress
Health status, emotional status, physical capability
Equipment
Poor design/use, poor maintenance, manufacturer’s specs
Use of personal protective equipment
Materials
Use not in accordance with Manufacturer’s specs
Use of hazardous material
Once all information about the incident is collected, it should be organized into a logical sequence of events, working back from when the incident occurred. Many factors contribute to each incident; they can classified into four major categories: people, equipment, materials and the environment. All possible factors should be listed at each step and checked to see if they are supported by the evidence. If gaps in the evidence are discovered, there may be a need to re-interview witnesses, review the documentation again, or gather further information.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

30. Step 3: Analyze Information (Continued)
Environment
Lighting, noise, air quality, weather, cleaning
Toxic gases, dusts, or fumes
Task Control
Safety procedure
Availability and use of proper tools
deviation from normal task procedure
Organizational
Prior identification of hazards
Inadequate training and/or supervision
Irregular safety inspection
Improper communication of safety procedures
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

31. Step 3: Determine Causes (Continued)
Incident causes
Root causes
“Real” causes of incidents - not always immediately evident
Underlying causes related to management and organizational issues.
Examples:
Job Factors
Lack of resources provided to execute necessary programs
Poor knowledge of workplace parties
Lack of management monitoring
Human Factors
Lack of performance feedback
Low management standards of performance
The causes of incidents, briefly discussed in the last two slides, are usually grouped into two main categories:
Root causes;
Direct causes.
Root causes are the causes underlying the incident; however, they may not always be immediately evident. Root causes can be found by analyzing all direct causes and finding the gaps that completes the sequence of events that leads to the incident.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

32. Step 3: Determine Causes (Continued)
Programmatic causes
Events, conditions, or acts that contribute to the incident, which by themselves, would not have caused the incident
Symptoms of the root causes
Examples:
Deficiencies in health and safety programs
Communication of safe work practices
Deficiencies in management systems
Issues with task training and workload
Issues with inspections scheduled and conducted
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

33. Step 3: Determine Causes (Continued)
Direct causes
Events, conditions, or acts that immediately precede the incident and are usually related to uncontrolled hazards
Symptoms of the root causes
Examples:
Conditions
Unavailability of personal protective equipment
Not properly maintained machine guards
Poor housekeeping practices
Acts
Improper use of equipment
Shortcutting safe work procedures
Improper use of personal protective equipment
Direct causes are usually related to uncontrolled hazards arising from substandard conditions and/or actions. Analyzing direct causes increases the likelihood of finding the root causes. Finding the root causes and implementing corrective actions will in turn prevent similar incidents in the future.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

34. Step 3: Determine Causes (Continued)
Environment Issues
Task Control Issues
Human Errors & Equipment Failure
Management & Organizational Issues
Health and Safety Program Issues
Direct Causes
Increasing Depth of Analysis
Programmatic Causes
Root Causes
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

35. Step 4: Corrective Actions
Engineering Controls
Automate hazardous processes or use machines
Change the task/equipment:
Substitute high hazard with lower hazard materials
Specify the correct equipment/tool for each task
Modify workstation:
Change layout, location or position of equipment
Change position of employee
Provide barriers, warning signs, or guardrails
Increase visibility in workplace
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

36. Step 4: Corrective Actions (Continued)
Administrative Controls:
Modify employee function:
Clearly define expectations
Designate employees authorized to operate equipment
Enforce disciplinary policy for violation of safety rules
Provide employee training:
Equipment, task procedures, reporting procedures
Review hazards & controls:
Perform task safety analysis & change task procedures
Review hazards & controls of infrequent tasks
Change frequency & depth of hazard inspections
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

37. Step 4: Corrective Actions (Continued)
Personal Protective Equipment:
Specify personal protective equipment requirements
Which protective equipment(s) should be used with each machine or tool
Provide personal protective equipment
Train employees on their purpose and use
Raise awareness on the potential incidents and injuries
Enforce their use via supervisory procedures
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

38. Step 4: Corrective Actions (Continued)
Administrative Controls and Personal Protective Equipment are weaker than engineering controls and should only be used when engineering controls cannot be implemented
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

39. Step 4: Corrective Actions (continued)
Corrective actions should get at root causes
Should NOT be a collection of nice-to-have recommendations
Recommendations should
be as specific as possible
be determined with worker participation
determine the responsible parties for their implementation
identify contributing factors
identify target dates for implementation
identify follow-up date
list the required sources for implementation
e.g. human, material, equipment, financing
Once the root causes of the incident is identified, appropriate recommendations should be developed as a means of preventing a similar incident in the future. The incident investigation procedures should outline the criteria for writing recommendations.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

40. Sample Incident Investigation Form
Reference:
Workplace Health, Safety & Compensation Commission of Newfoundland and Labrador, Accident/Incident Investigation, May 2006.
URL:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

41. Step 5: Incident Investigation Report
Incident investigation reports should include
Place, date, and time of incident
Injured worker’s name and job title
Witnesses’ names
Concise description of the incident
Sequence of events preceding the incident
Analysis of root and direct causes
Recommendations for corrective actions
Outline of the follow-up procedure
Supporting documentation and evidence (summary of interviews, pictures of physical evidence)
Copies of the report shall be communicated to the OH&S Committee and the management team
Workers confidential information has to be removed before communication of findings
The purpose of the incident investigation report is to communicate the investigation information and document recommendations for corrective action. Incident investigation reports may be used as evidence during legal proceedings; therefore, it is important that it is fully completed. The incident investigation procedures should identify who is responsible for distributing the written report and who is responsible for communicating its findings to the appropriate workers.
The report should be distributed to senior management, the occupational health and safety committee, and the management in the appropriate work areas.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

42. Step 5: Investigation Report (Continued)
Sample Incident Investigation Report Form
Examples of incident investigation report forms can be found in the following links:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

43. Step 6: Follow-up Assign responsibilities for
Implementing corrective actions
Procedures
Equipment
Training
Meeting time-lines for implementing corrective actions
Evaluating effectiveness of corrective actions
Communicating the effectiveness evaluations to management, occupational health & safety committee, and workers in the affected workplace area
The follow-up procedures has to be documented.
Incident investigation procedures should identify those responsible for:
implementing corrective actions within the assigned time frame;
meeting time-lines for implementing the corrective actions;
adding the corrective actions to the workplace inspection checklist as a means of evaluating them;
evaluating corrective actions to ensure they are effective;
sharing the investigation findings with workers;
communicating the effectiveness of the corrective actions to senior management, the OH&S committee, and the staff in the affected work area.
Every employer shall initiate corrective action without undue delay to prevent recurrence of similar incidents.
The responsible parties has to coordinate with management to ensure the required resources are provided in a timely manner, and all deadlines are met.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

44. Role of OH&S Committees
Under provincial legislation, the employer is required to establish and maintain an operational health and safety (OH&S) committee in workplaces with 10 or more workers
The OH&S committee
May participate as a members of the investigation team
Management
Receives and reviews incident investigation reports to ensure
Incident investigation procedure is followed
Root causes are identified
Trends in injury, illness, and property damage are identified
Recommendations for corrective actions are provided
Monitors implementation, follow up, and evaluation of corrective actions
Reviews requirements for improved management systems, procedures, training as a result of the incident investigation
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

45. Canadian Standards for OH&S
CSA Z1005: Incident Investigation and Prevention
Under development by Canadian Standards Association (CSA)
Incorporates the following elements:
Organization & assignment of responsibilities
Training & competency requirements for investigators & data analyzers
Incident reporting & communication, Incident response & control
Initial assessment, investigation preparation & resources
Conducting investigations
Worker participation in all aspects of the investigation program
Analyzing data (causal factors, control gaps, trends, etc.)
Corrective actions & implementations of controls
Modifications to management system (policies, procedures, training)
Ongoing integration into OH&S management system
Reference:
Standards Council of Canada:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

46. Other Types of Incident Reporting
Health Canada: Industry Guide on Mandatory Reporting
Under section 14 of the Canada Consumer Product Safety Act
Sets out mandatory reporting standards for people and companies who sell, distribute, import or manufacture consumer products in Canada
Canadian Nuclear Safety Commission: Reporting Requirements
Under section 3.1 of the Nuclear Safety and Control Act (NSCA)
Sets out reporting requirements and compliance monitoring for groups specified under the Act, such as:
Nuclear Power Plants
Uranium Mines and Processing Facilities
Transportation Safety Board: Mandatory Reporting
Under section 2 of the Transportation Safety Board Regulations
Sets out mandatory and voluntary reporting standards for aviation, marine, pipeline and railway incident occurrences
Reference:
Standards Council of Canada:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

47. Incident Investigation (Questions)
Place the steps of an incident investigation in the correct order:
___ Gather Information ___ Determine Corrective Actions
___ Write Incident Investigation Report
___ Manage Incident Scene
___ Follow-up
___ Analyze Information & Determine Causes
Reference:
Standards Council of Canada:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

48. Incident Investigation (Questions)
Multiple selection – choose all that apply:
In BC, WorkSafeBC has to be notified of any incident that:
i. resulted in serious or time loss injury, illness, or death of a worker
ii. resulted in financial losses of the company involved
iii. involved the major release of a hazardous substance
iv. was a serious miss that could led to an incident involving fatality
v. involved potential environmental damage
Recommendations for corrective actions should be:
i. be as specific as possible
ii. be determined by management
iii. determine the responsible parties for their implementation
iv. identify contributing factors
v. give a general timeline for action, without target dates
vi. list those responsible for the incident
vii. list the required sources for implementation
Reference:
Standards Council of Canada:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

49. Incident Investigation (Questions)
Match the following terms with the correct examples:
1. Engineering Control
2. Administrative Control
3. Personal Protective Equipment
A. Specify personal protective equipment requirements
B. Perform task safety analysis & change task procedures
C. Specify the correct equipment/tool for each task
D. Provide employee training on equipment, task procedures, and reporting procedures
E. Automate hazardous processes or use machines
Reference:
Standards Council of Canada:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

50. Incident Trend Analysis
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

51. Understanding the Terms Incident Investigation Incident Trend Analysis
What Is Trend Analysis?
Search for patterns over time in the incident data in order to identify the ways in which they develop
E.g. If several hand laceration incidents occur in various location of a production firm, it specifies a need for a hand protection program in the firm
Understanding trends is an important tool in the early detection of problems that may lead to future larger incidents
One should look for:
Recurring themes and motifs common across a range of cases at different times and locations
A particular design/distribution of events repeated regularly or representing an anomaly
A standard form of activity shifted over time and replaced by a hazardous form
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

52. Understanding the Terms Incident Investigation Incident Trend Analysis
Types of Trends
Temporal Trends
Regularities within the distribution of the events that led to incidents over time
Incidents during night shifts due to fatigue/sleepiness
Incidents in warmer months due to not using protective equipment
Spatial Trends
Regularities within the distribution of incidents over different sections of a company
Slipping incidents in the tiled areas of a laboratory
Hand laceration incidents using a particular machine
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

53. Types of Trends (Continued)
Associational Trends
Direct/causal factors that contributed to a large number of incidents in the past
Multiple incidents due to irregular maintenance of machines
Multiple incidents due to improper training of newly hired workers
Compound Trends
Patterns that combine two or more types of trends e.g. space and time
Hand laceration incidents in Summer using machines in a particular section of the company
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

54. Incident Trend Analysis
Management has to periodically review all incident investigation reports to identify trends in injuries, illnesses, and property damages – the OH&S Committee may assist
Incident Management Systems (IMS) facilitate trend analysis by providing statistical results related to the time, location, and causal factors related to past incidents
Trends in incidents reveals systematic issues in the task procedures
These systematic issues are the root causes of incidents that, when addressed, will prevent future incidents
Management is responsible to implement and evaluate corrective actions to address root causes that will eliminate future unsafe acts or conditions that were associated with trends in incidents
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

55. Incident Trend Analysis (Questions)
Match the following terms with the correct description:
1. Temporal Trends 2. Spatial Trends 3. Association Trends 4. Compound Trends
A. Patterns that combine two or more types of trends e.g. space and time.
B. Regularities within the distribution of incidents over different sections of a company.
C. Regularities within the distribution of incidents over different companies of an industry.
D. Regularities within the distribution of the events that led to incidents over time.
E. Direct/causal factors that contributed to a large number of incidents in the past.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

56. Understanding the Terms Incident Investigation Incident Trend Analysis
Industry Example
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

57. Safety Strategy & Culture
Identify hazards; design, implement, and verify barriers and controls
Culture Improvement through Safety Taskforce Recommendations
Process Improvement through SHE Management System
Focus on
Regulatory Compliance
Electrical Safety
References:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

58. Incident Investigation Process
References:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

59. Effective Risk Management Example
Complete & correct switching order to isolate hazardous energy
Effective isolation of work zone from hazardous energy
Effective bonding & grounding to de-energize & protect work zone
PIC develops correct switching order
PLT1 correctly executes switching order
PLT2 correctly applies bonding & grounding system
14.4 kV phase to ground hazardous energy
(Potential) PLT2 injured from electrical contact
Source of harm
Undesirable consequences
communicate
When people do their Critical Tasks correctly to make the Barriers work, PLT2 will be safe.
References:
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

60. Incident Management System (IMS)
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

61. Incident Classification in IMS
Level
Injury/Illness
Near Miss
Barriers In Place 1
Fatality/ Permanent Disability
Event that could have credibly resulted in a fatality or permanent disability
NO effective barrier.
In the case of a Near Miss, only luck or PPE avoided fatality/ permanent disability. 2
Injury
(required medical treatment and/or missed work shifts)
Event could have credibly resulted in a Level 2 Injury
At least ONE effective and planned barrier (not including PPE) was in place to prevent a fatality or permanent disability. 3
(required first aid)
Event worthy of sharing with others. If no one was at risk, it’s not a safety incident
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

62. Understanding the Terms Incident Investigation Incident Trend Analysis
Case Study*
* This case study is based on the following article:
R. Phifer. “Case study – Incident investigation Laboratory explosion.” Journal of Chemical Health and Safety, 21(5):2–5.
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

63. Understanding the Terms Incident Investigation Incident Trend Analysis
Incident Summary
A research associate was performing a synthesis of hydroxymethylfurfural (HMF) in a thick walled glass tube closed with a Teflon stopper when the tube exploded in a university lab at the Department of Chemistry. Subsequently, a fire was initiated involving the hotplate power wire and the silicone oil bath, which was placed on top of a hot plate for heating the reaction. At the time, the technician was at his desk which is located approximately 10 m from the hood and slightly around a corner. He could not have observed the reaction from this location. He indicated he heated the silicone oil bath to 150 °C prior to placing the apparatus in the bath, and checked on the temperature and the reaction “periodically” and did not notice a rise in temperature.
Step 1: Manage the Scene
Building alarm was pulled promptly
Building was evacuated
The county HazMat team was called
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

64. Step 2: Gather Information (Observations)
Physical Damages
The thick walled glass tube and beaker in which the tube was immersed were obliterated
The hotplate showed signs of severe downward depression, with the surface top compressed through two layers of insulation
The inside electronics of the hotplate showed little or no damage visible from the underside
There were 15 other containers of chemicals or waste in the hood at the time of the incident
No reported injuries
The following extract is taken from
R. Phifer. “Case study – Incident investigation Laboratory explosion.” Journal of Chemical Health and Safety, 21(5):2–5.
“The experiment apparatus was carefully inspected to attempt to determine the cause of the explosion. The thick walled glass tube and beaker in which the tube was immersed were obliterated; the Teflon stopper showed no specific defects, but the O-ring could not be located. The hotplate showed signs of severe downward depression, with the surface top compressed through two layers of insulation and an aluminum bottom. The inside electronics of the hotplate showed little or no damage visible from the underside. The hotplate model, Corning PC420D, like other similar models, has failed before to properly maintain temperature. At the University of California – Berkeley, the same model reportedly overheated while the heat control was in the “off” position. Hot plates tend to cycle on and off rather than outputting a constant temperature. This can result in drifting of the desired bath temperature by up to +/- 10 C. In addition, virtually no commercial laboratory hotplate is explosion proof, so if the bath material is heated above its flash point a fire and/or explosion could occur.
The hood itself was inspected; aside from the adjacent experiment, there were approximately 14 other containers of chemical or waste in the hood at the time of the incident.
Ultimately, the cause of the incident was failure to properly monitor the procedure. Based on inspection of the equipment in the aftermath of the explosion, it appears the temperature of the bath was allowed to rise well above the planned 150 C endpoint, resulting in an increase in pressure in the closed reaction above the threshold of the thick-walled tube. It is possible there was a defect in the tube that was not noticed prior to the experiment; it is also possible the temperature controller on the hotplate failed. That problem could have been avoided if an external temperature controller (an available option for the hotplate; there are numerous on the market) had been utilized to control the temperature of the oil bath. Instead, the temperature controller monitoring the hotplate surface was the only control device. While it is also possible that the rubber O-ring on the Teflon stopper failed, the release in pressure was sufficient to damage the hood sash, the top of the hood, and severely damaged the hotplate in a downward direction, indicating the system was overly pressurized. If either the O-ring or Teflon stopper had failed, the pressure release would likely have been up instead of in all directions. The cause
of the smoke and fire that melted the hotplate wiring was the silicone oil bath catching fire, indicating a strong likelihood that a temperature above 250 C was reached, as this is generally the flashpoint or decomposition point of silicone oil. The boiling point, though not provided by the manufacturer’s MSDS, is approximately 120 C.”
Photo documentation
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

65. Step 2: Gather Information (Interviews)
Department Head
Provided photos taken by county HazMat team who responded to the pulled alarm
Noted that the incident and chemicals were safely removed
Researcher
Has several publications and a patent related to the experiment that caused the incident
Reviewed the experiment procedure together
Indicated no laboratory safety training was provided by the university
Was unable to provide documentation related to risk/hazard assessment completed before or as a part of his current project
Principal Investigator
Believed that the experiment failed due to the hotplate malfunction
Believed that the researcher was competent and experienced
Director of Environmental Health & Safety
Answered questions related to general safety practices, chemical hygiene training, and other aspects of safety implementation
Stated that the EH&S office is not involved in the chemical hygiene and other safety trainings for the Department of Chemistry
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

66. Step 3: Determine Causes
Direct Causes
Rapid, uncontrolled increase in temperature resulting in the pressure buildup in excess of the procedure apparatus’s containment ability
The fire was caused by the silicone oil contacting either the hotplate electronic wiring or the experiment components after explosion
Failure to thoroughly inspect and/or test the hotplate before its use
Root Causes
Not using an external heat controller
Defect in the high density glass tube
Lack of effective preventive maintenance program for laboratory equipment
No documented laboratory safety program
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

67. Step 4: Corrective Actions
Closed system experiments involving heat buildup should be monitored with an external temperature controller to control the bath temperature instead of the hotplate surface
Risk assessments should be performed and documented for each research experiment prior to beginning work, with the Principal Investigator responsible for approving the procedure in writing
The policy against working alone, particularly during the use of “hazardous procedures or work with highly toxic materials,” should be strictly enforced.
Hoods used for experiments should not also be used for waste storage
Safety training should be completed within the first two weeks of employment
The Safety Committee needs to commit to performing regular safety inspections and documenting those inspections
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

68. Summary of Incident Causal Analysis
Direct Causes
Acts
1. Equipment Failure
2. Personal Protective Equipment
3. Materials
4.Behavioral
Conditions
1. Housekeeping
2. Noise
3. Lighting
4. Weather
5. Temperature
Root Causes
Personal
1. Experience
2. Health
3. Attitude
4. Capability
Management
1. Training
2. Supervision
3. Maintenance
4. Inspections
5. Work Procedures
Introduction
Understanding the Terms
Incident Investigation
Incident Trend Analysis
Industry Example
Case Study

69. References
WorkSafeBC, “Investigation of Accidents and Incidents,” Nov
Health & Safety Ontario, “Incident Investigations,” Nov
Safe Work Newfoundland & Labrador, “Accident/Incident Investigations,” May 2006.
Government of Saskatchewan, “Occupational Health & Safety: Committee Manual,” Queen’s Printer.
CSA Group, “OHS Standards,” Apr
Zenith Insurance Co., “Incident Investigation,” 2009.
R. Phifer, “Case Study – Incident Investigation Laboratory Explosion,” Journal Chemical Health & Safety, Vol. 21, No. 5, pp. 2-5.
F. A. Manuele, “On the Practice of Safety,” 4th Ed., Wiley.
Monash Univ. OHS System, “Procedures for Hazard and Incident Reporting, Investigation and Recording,” Mar
J. E. Spear, “Incident Investigation – A Problem-Solving Process,” Professional Safety, Apr