Determining the True Root Cause(s) of Accidents and Safety Incidents Incident Investigation and Analysis

Training Goal Participants will be able to develop an incident investigation protocol at their respective institutions.

Objectives To meet the training goal, the following objectives will be covered: Incident investigation overview Desktop incident investigation exercise Incident investigation protocol Training investigation team

Purpose of Investigation Determine sequence of events that led to consequence Offer corrective action recommendations to prevent recurrence of the incident Never to assign blame or assess liability

What should be investigated? All incidents that cause –Injury –Illness –Lost time –Property damage All near-miss incidents

Where should the investigation be conducted? The investigation must be conducted at the site of the incident

Who should conduct the investigation? Team –Supervisor of the affected employee –Safety committee representative for area –Safety officer –Affected employee(s)

When should the investigation be conducted? Immediately after the incident occurred Memories are fresh Evidence is in place Immediate corrective actions can be initiated

How to Conduct an Investigation fact Focus on finding fact, not fault Investigate the facts Review the facts to find the cause Recommend corrective measures Document findings and actions Follow-up

Investigate the Facts Look at the situation Record general information Collect evidence Interview witnesses Review records

Investigate the Facts Look at the situation Examine the big picture Think of the 5 W’s (who, what, why, when, where) Outline your approach

Investigate the Facts Record General Information Time and exact location Injuries Medical treatment or first aid Anything unusual

Investigate the Facts Collect Evidence Photographs of equipment Samples of chemicals Broken parts or pieces

Investigate the Facts Interview Witnesses Individually At the scene of the incident Immediately after the incident, if possible With an open mind

Investigate the Facts Review Records to Identify Trends Inspection records Previous incident reports Maintenance records Workers’ compensation insurance forms

Review the Facts to Find the Cause Review all information Clarify the facts Analyze information Examine contributing factors List possible causes Identify the cause Do not jump to conclusions

Examining Contributing Factors Employ a process called branching to find root causes Person slips on oil on floor Why? Oil was spilled on floorPerson stepped in oil

Examining Contributing Factors Oil was spilled on floorPerson stepped in oil Why? Machine was being serviced and oil spilled Person walked through work area Why?

Machine was being serviced and oil spilled Person walked through work area Examining Contributing Factors Why? Spill not prevented Oil spill not cleaned Person worked in department Why?

Recommend Corrective Actions Look at each step in the chain of events Suggest attainable actions Assign responsibility for implementation Coordinate a schedule for implementation Start with simple solutions; move on to those that will be more complex

Recommend Corrective Actions Causes: Actions: Spill was not prevented Oil spill not cleaned Person worked in department ? ? ?

Document Findings and Actions Incident investigation reports usually contain General information Description of injury or illness Description of the incident Analysis Corrective actions Dates for completion and follow-up

Reporting According to the subsequent remedial measure rule, documented recommendations for corrective actions are not admissible as evidence in a court of law. Therefore, appropriate corrective actions can be documented and implemented without fear that they will be perceived as an admission of a previously unsafe condition.

Reporting Do not assign blame, assess liability, or offer opinions in any written documentation Forward report to university/agency administration

Follow-Up Ensure that recommended corrective actions Have been implemented properly Are effective in eliminating or reducing future incidents Do not create an unforeseen hazard

Developing an incident investigation protocol Include the following elements: Incident investigation procedures Responsibilities for incident investigation Reporting and record keeping procedures Investigator training

Incident Investigation Procedures Priority of incidents to be investigated Notification of incident occurrence First aid response Securing the area Gathering evidence Interviewing witnesses How program will be evaluated and updated

Reporting and Record Keeping Who prepares the report What will the report contain To whom will the report be sent How long will the reports be kept Who keeps the reports

Investigator Training Components of training Training records Hand-on exercises Retention exercises

Training Topics How to Conduct an incident investigation Find the facts and not place blame Find the cause of an incident Complete an incident investigation report

Training Records Remember to complete a training record Employee name Job title Employee signature Date of training Signature of trainer

Hands-On Exercises Suggestions Set up a mock incident scene Use experiences from your organization

True or False Every incident should be investigated immediately so that we can determine who was to blame. Retention Exercises Commonly known as a QUIZ Focus on important concepts, for example:

Retention Exercises True or False A “near-miss” should be investigated in the same manner as an actual incident. True or False Most incidents have only one contributing factor.

Retention Exercises True or False The incident scene should be returned to normal as soon as the investigator arrives. True or False Corrective measure should address whatever hazards are uncovered in investigating the incident.

Resources “Accident Investigation,” Comprehensive Loss Management, Inc. “Investigating Accidents,” Business & Legal Reports “Incident Investigation,” Safety Solutions “Accident (Incident) Investigation,” National Safety Council

Responsibilities for Investigation Team Supervisor Safety officer Safety committee representative for area

What We’ve Learned Today... The reasons for conducting thorough incident investigations How to set up an incident investigation and analysis program

Conclusion When an organization reacts swiftly and positively to incidents, its actions reaffirms its commitment to the safety and well-being of its employees.