Incident Investigation

Incident Investigation
Workshop

Welcome Your instructor for this workshop is: About the CCSA
Safety First! Instructor’s Notes: About the CCSA Provide a brief overview of the CCSA Safety First! Emergency procedure: If the course is onsite at one of our member facilities: Ask what the emergency procedure is should there be one during the course: Who will take the lead for the group? Where does the group go in the event of an emergency? If the course is off-site at a non-member facility: As part of the pre-course preparation obtain the emergency procedures for the building, including: Where the emergency exits are Where the muster point is Who the lead is in an emergency Provide this information to the participants Review any administrative stuff…….. Ensure all participants know where the washrooms are located Don’t assume everyone knows! sometimes the course may be held in a part of the building that not all participants are familiar with or it may be held in another building or location. And ensure they know they don’t have to wait for the breaks to go to the washrooms Course Materials Participant’s Manual, Hand outs (TBD) NOTE: introductions will be part of Exercise 1: Warm Up

Workshop Agenda 15 minutes Welcome & Workshop Introduction
Unit 3: Step 3: Gather Evidence 10 minutes Exercise 1 Exercise 5 20 minutes Unit 1: Introduction to Incident Investigation Unit 3: Step 4: Analyze Information Unit 2: Incident Investigation Process 5 minutes Exercise 6 Exercise 2 Unit 3: Step 5: Identify Corrective Actions Unit 2 Continued Exercise 7 Exercise 3 Unit 3: Step 6: Prepare the Incident Investigation Report Unit 3: Step 1: Emergency Response & Step 2: Secure the Scene Exercise 8 Exercise 4 Unit 3: Step 7: Make Decisions & Implement Corrective Actions Break Incident investigation Case Studies Wrap Up Speaker’s notes: The agenda is not in the manual This agenda should be used as a guideline for the workshop

Workshop Introduction
Speaker’s notes: Ask participants what the typical reaction to an incident like this is in their organization Hint: the end of the video may provide a typical reaction – put the bucket away before it’s an injury – which is a fault-finding reaction instead of a fact-finding reaction An effective incident investigation should answer questions such as “Why was the bucket left in the hallway in the first place?” to help organizations learn from incidents and prevent future incidents from happening.

Incident Investigation Management Leadership and Organizational Commitment Hazard Identification and Assessment Hazard Control Workplace Inspections Qualification, Orientation and Training Program Administration Speaker’s notes: P. 3 in the participant’s manual Proactive safety program activities (such as Hazard Identification, Assessment and Control and Workplace Inspections) are preferable to reactive activities, such as incident investigations. However when an incident happens, an effective occupational health and safety program also ensures it can learn from incidents and potential incidents by determining the factors that lead to the incident and correcting them.

What is an incident? An incident is an undesired, unplanned, unexpected event that results, or has the potential to result, in physical harm to a person or damage to property (loss or no loss). Speaker’s notes: P. 4 in the participant’s manual Incidents are not a preferred learning source as the outcome of an incident may be major or even catastrophic, to the individual, the organization or to society. So what happens when an incident occurs? Is there something to learn from incident investigations that can prevent future incidents from happening? Is there a way to turn reactive activities into proactive safety program actions? The objective of this workshop is to equip those individuals involved in conducting incident investigations and analyzing incident trends with the information, practical tools and resources to complete effective investigations and to use the results to learn from incidents and prevent recurrence.

Learning Objectives Explain the purpose and benefits of an incident investigation (Intro and Unit 1) Describe the incident investigation legal requirements for employers and workers (Unit 1) Explain which incidents should be investigated (Unit 2) Explain how to prepare for and respond to an incident (Unit 3) Conduct an effective incident investigation (Unit 3) Speaker’s notes: P. 7 in the participant’s manual

Learning Objectives Identify the direct and indirect causes of incidents using the evidence gathered (Unit 3) Determine the root cause(s) of incidents (Unit 3) Recommend corrective actions to prevent recurrence (Unit 3) Compile an Incident Investigation Report (Unit 3) Summarize and analyze incident statistics to identify trends (Unit 3) Speaker’s notes: P. 7 in the participant’s manual

Exercise 1: Warm Up Instructor’s Notes: Participant’s manual p. 7
The purpose of the warm up exercise is to: Get to know each other; ‘Break the ice’ – the CCSA courses are designed to include a lot of participation and interaction; breaking the ice early helps to create a safe & comfortable learning environment. Depending on the amount of time available for this workshop or in-service, conduct one of the following introduction activities to get the participants warmed up and allow you to get to know them a little bit. Option 1: Simple Intro with a short answer, get-to-know-you question The following icebreakers are best for medium – large groups; or for groups with participants who already know each other or at least have a working knowledge of one another. Round table introduction – approx. 30 sec. per participant: Ask each participant to introduce themselves by telling the group: Their name Their position/what they do How long they’ve been with the organization And one of the following: If you were stuck on a deserted island, like Survivor, what one thing would you have with you? One thing about you that may be surprising to us? One thing about you that no one knows? What would you have as your last meal? What is your favourite radio station? What is your favourite TV show or movie? What was the last concert or play you went to? Have you ever had an injury? Was it work related? What is your favourite book? What is the last vacation you went on? What is your favourite sports team? What is your favourite band or artist? Although you have previously introduced yourself, don’t forget to answer the question you chose yourself as an example of what you are looking for! Option 2: What motivates you?

Unit 1: Introduction to Incident Investigations
Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence Step 4. Analyze Information / Identify Causes Step 5. Identify Corrective Actions Step 6. Prepare Report and Provide Feedback Step 7. Make Decisions and Implement Corrective Actions What is an incident investigation? An incident investigation is a process used to determine the causes of an incident so you can take steps to prevent a similar event. Speaker’s notes: P. 9 in the participant’s manual

Unit 1: Introduction to Incident Investigations
Benefits of an effective incident investigation employers demonstrate their commitment to health and safety to their workers and the public; workers on the investigation team are trained in investigation techniques; workers are trained in the importance of reporting incidents; incidents are promptly and consistently reported; incidents are immediately investigated; root causes are identified; corrective actions are implemented, monitored and evaluated; workers are trained in how to prevent similar incidents; reduce worker pain and suffering; use findings to identify incident trends; and reduce the associated costs of incidents and property damage. Speaker’s notes: P. 9 in the participant’s manual Tell the participants behind the black box is a picture Ask the participants to tell you what the picture is under the box is by just looking at what they see through the small whole. They make a guess but most can’t tell you. That’s when you say that often we can’t tell what the whole story is by looking on the surface and what we think we see isn’t always what we uncover. This leads into the need for effective incident investigations. Benefits of an effective incident investigation The emphasis is always on understanding the causes in order to prevent a re-occurrence. An effective incident investigation is an opportunity to learn from an incident to uncover gaps, ask why these gaps exist and to correct them. An effective investigation will: describe what happened determine all of the causes of the incident – direct, indirect and root causes develop corrective action recommendations define trends demonstrate concern It’s easy to find fault with individuals, but workers’ decisions make sense to them at the time of an incident; no one consciously decides to become injured. An effective investigation not only determines whether certain conditions exist, but also questions if there is a better way to do things.

Why conduct Incident Investigations?
1. It's the Law In Alberta, we need to understand both the legal requirements under the Alberta Occupational Health and Safety: Act, Regulation and Code and the reporting requirements under WCB Regulation. 2. Prevent Recurrence Incident investigations are an important part of any workplace health and safety program. If an incident has occurred, the most positive impact we can make is to prevent a recurrence. Speaker’s notes: P. 11 in the participant’s manual NOTE: we’ll review the AB OHS requirements and WCB reporting requirements on the next two slides

Alberta Occupational Health and Safety Requirements Alberta OHS Act Section 18: Serious injuries and accidents Section 19: Investigation of accident Alberta OHS Code Part 11: First Aid Instructor’s Notes P in the participant’s manual Briefly review the summarized AB OHS Act and Codes that apply to Incident Investigation NOTE: we have summarized the codes in an effort to remove as much legalese as possible, since it is important for all participants to be aware of the legal requirements. If participants want to read the actual AB OHS Act and Code they should be referred to Appendix 7. Before moving to the next slide – ask participants to come up with their own definition of what an incident is. Two options: Option 1: There is space in the participant’s manual for them to write down their definition; Ask 2-3 participants to read their definition to the class; or Option 2: Ask participants to write their definition on a post-it note and place it on the flip chart or white board. You can read 2-3 of the definitions written. Regardless of the option chosen: discuss each of the definitions with the group; then ask one of the participants to read out loud the definition of an incident provided in the participant’s manual in Appendix 1 on p. 50.

WCB Act and Regulation Requirements WCB policy states that: Recording and reporting accidents is a joint responsibility of workers, employers and physicians. Workers must report all accidents to their employers and employers must keep a record of the accident. Workers, employers and physicians must report any accident to the WCB if it disables or is likely to disable the worker beyond the day of accident. Employers must also notify WCB if the worker is entitled to medical aid due to the accident. Speaker’s notes: P in the participant’s manual The Act differentiates between first aid, which does not require reporting to WCB, and all other medical aid, which requires reporting to WCB. Reportable accidents must submit the completed WCB Worker’s and Employer’s Report forms within 72 hours. If participant’s would like more information, refer them to WCB:

COR Audit Requirements Incident Reporting Procedure Awareness of Incident Reporting Responsibilities Incident Investigation Procedure Manager and Supervisor Accountability Incident Investigation Training Incident Investigation Report form Worker Involvement Identify root cause and recommend corrective actions Management review and sign off Communicate investigation results Implement corrective actions Speaker’s notes: P. 16 in the participant’s manual Briefly review – this course is not focused on COR, however for participants that are interested the above is a summary of the COR audit requirements for Incident Investigations If participant’s would like to know more about COR, advise them to visit the Government of Alberta website:

Why do incidents happen?
What is an incident? Definition: An incident is an undesired, unplanned, unexpected event that results, or has the potential to result, in physical harm to a person or damage to property (loss or no loss). Example 1: A staff member injures their back while transferring a resident from their bed to their chair. Example 2: A laundry cart is damaged when a staff member hits the door to the laundry room. Speaker’s notes: P. 17 in the participant’s manual Ask participant’s to write their definition of an incident; then, give a couple of examples to support their definition.

Loss Causation Model Instructor’s Notes: P in the participant’s manual The Loss Causation Model by Bird and Germain (The International Loss Control Institute Loss Causation Model (modified from Bird and Germaine, 1985)) is an example of a simple, linear incident causation model that illustrates the factors that lead to an incident. For the purposes of this workshop, we will explain the incident investigation process based on a simple, linear incident causation model similar to the one above. However, as an incident investigator for your organization, you should be aware of the range of models of causation and be able to critically evaluate the model for application to your practice. Regardless of the incident causation model you or your organization subscribes to, it is important to remember three basic facts: Incidents are caused. Incidents can be prevented if the causes are eliminated. Unless the causes are eliminated, the same incidents will happen again. Source: The International Loss Control Institute Loss Causation Model (modified from Bird and Germaine, 1985)

Define root cause, indirect cause and direct cause Root Cause Definition: The underlying or basic factors that contribute to the direct cause of an incident. Indirect Cause Definition: The reason for the existence of lack of recognition of unsafe acts and/or unsafe conditions. Direct Cause Definition: Unsafe acts and unsafe conditions which contribute in a chain of events leading to an incident. Inadequate Programs Inadequate Program Standards Inadequate Compliance to Standard Hazard identification and assessment not completed for all jobs and tasks Workers are not trained on proper use of hazard controls. Use of hazard controls not enforced No preventative maintenance program The preventative maintenance program is not tracked or reviewed by the OHS Committee. Preventative maintenance program not enforced Personal Factors Job Factors Workers are unsure who to report to and how to report hazards. The safe work procedure did not explain how to adequately control for the hazards associated with mowing the lawn. The supervisor noticed the broken equipment was not removed from service, but did not follow up with the worker to show them where to put broken equipment that is tagged out of service. Broken equipment is not replaced in a timely manner. Substandard Acts Substandard Conditions Worker used the lawn mower even though the automatic shut off was modified. The automatic shut off on the lawn mower was modified to prevent it from shutting down. reported and tagged the broken equipment but did not remove it from service. There is not enough space to store broken equipment on the floor. Speaker’s notes: P In order to understand the key elements of an loss/incident causation model, we should first establish basic definitions of key terms and identify examples of each based on your experience. Ask participant’s to write their definitions of root causes, indirect causes and direct causes; and, give examples to support their definition based on their experience. Two options: Option 1: There is space in the participant’s manual for them to write down their definition; Ask 2-3 participants to read their definition to the class; or Option 2: Ask participants to write their definition on a post-it note and place it on the flip chart or white board. You can read 2-3 of the definitions written. Regardless of the option chosen: discuss each of the definitions with the group.

Unit 2: Incident Investigation Process
Reflection and Discussion Do you think staff report every incident (even when there is no injury or damage) in your organization? If not, why do you think incidents are unreported? What does your organization do to encourage reporting or what would you suggest your organization could do? Speaker’s notes: P. 21 in the participant’s manual Before we look at the incident investigation process considerations, we must consider the fact that an investigation cannot take place unless you know an incident has occurred. Therefore, organizations should consider some of the reasons why staff do not report all incidents when developing their incident investigation process, then include procedures for incident reporting when implementing the investigation process. Activity: Ask participant’s to come up with 2-3 reasons why incidents are not reported in their facility; They should write each reason on a post-it note (1 reason per post-it note); When they’re done, ask the participants to bring their post-its up to white board or flip chart to post them; As they are posting their reasons, they should read them aloud to the rest of the participants; As each participant finishes posting their reasons, discuss as a group what they think they could do to ensure that incidents are reported in their facilities. You may get some ideas re: what is currently being done in their facilities But also ask them to think outside the box; and, Ask them to think about what they as workers could do vs. just things that the facility or management could do. Important Reminder! OHS Code (Part 11: First Aid) indicates that workers are required to report all incidents to their employer.

Before You Get Started Before you can begin to conduct incident investigations, consider: Review Safety Program An investigation is only as effective as the safety program that supports it. Incident Investigation Team Consider who is on the team and provide appropriate training. Prioritize Incidents Consider identifying which incidents require immediate investigation and a process for prioritizing incidents. Speaker’s notes: P. 21 in the participant’s manual Before you or your organization can begin to conduct incident investigations, there are number of things to consider such as First, you should recognize that an investigation is only as effective as the safety program that supports it. Therefore, the safety program must include safety activities to implement and support the incident investigation element. Second, your organization should consider who is on the incident investigation team and provide appropriate training. Third, your organization should consider identifying which incidents require immediate investigation and a process for prioritizing incidents.

Incident Reporting Policy and Procedure
The policy and procedure should include: Policy Statement Standard Definitions Procedure Instructor’s Notes: P. 22 in the participant’s manual To ensure that all incidents are reported, there should be a documented policy and procedure for incidents; and all workers must be trained on the policy and how to complete the procedures Review the high level components of an Incident Investigation policy on p. 22; If time allows, briefly review the Sample Incident Investigation policy in Appendix 6 (p )

Incident Record What should be included on the Incident Record?
Name of employer (site and department if applicable) Date and time the incident was reported Injured worker’s name, date of birth and job title Name and position of the individual who the incident was reported to (manager/supervisor/in-charge individual) Injured worker’s employment status (i.e. full-time, part-time or casual) Location of the incident Date and time of incident Description of the incident Name of witness/witnesses – if applicable Method of injury (e.g. body motion, caught in/between, contact by/with, etc.) Name and qualifications (including month & year of qualification expiry) of First Aider - if applicable Questions: Have you had a similar injury, illness or near miss? (No or Yes) Did the injury/illness result during a task that is part of your regular duties? (No or Yes) What do you think could have been done to prevent this incident from happening? (short answer) First aid provided – if applicable Worker’s signature; date signed Type and location of injury/illness Manager/Supervisor signature; date signed Instructor’s Notes: P. 23 in the participant’s manual P in the participant’s manual includes a Sample Incident Record P. 4-5 in the participants handout also includes a Sample Incident Record Review what should be included in the Incident Record Note: Participants can use the Incident Record that we’ve provided or they can use their own Incident Record (if their facility has one) If might be useful to have the participants compare their existing incident record against the one that we’ve provided to see whether or not their Incident Record should be revised to ensure that it includes the required information.

Exercise 2 Incident Reporting Instructor’s Notes:
P. 26 in the participant’s manual; p. 6 in the participant’s handout P in the participant’s manual includes the Case Studies that should be used for this exercise and the remaining exercises Exercise 2: Incident Reporting (10 min) Your instructor will advise whether you will be working in pairs or small groups. If you brought with you an example of an incident that recently occurred in your facility, use the incident to complete this exercise. NOTE: You will also use the incident to complete the remaining exercises for this workshop. Ensure any identifying information regarding the employee involved in the incident remains confidential. Otherwise, your instructor will assign your group one of the case studies on the following pages to use for this exercise, as well as the remaining exercises in this workshop. Using either the incident or the case study: complete the sample Incident Record (as much as possible); determine who the incident should be reported to (internally, Government of Alberta and/or WCB). Be prepared to discuss your answers.

Incident Investigation Report
What should be included on the Incident Investigation Report? Investigation Details Indirect/Basic Cause Analysis Hazard Assessment Root Cause Checklist (optional) Incident Details Root Cause Analysis Direct/Immediate Cause Checklist (optional) Corrective Action Checklist (optional) Direct/Immediate Cause Analysis Corrective Action Plan Indirect/Basic Cause Checklist (optional) Signatures and Reviews Speaker’s notes: P in the participant’s manual P in the participant’s manual includes a Sample Incident Investigation Report P in the participants handout also includes a Sample Incident Investigation Report Review what should be included in the Incident Investigation Report Note: Participants can use the Incident Investigation Report that we’ve provided or they can use their own Incident Investigation Report (if their facility has one) If might be useful to have the participants compare their existing report against the one that we’ve provided to see whether or not their Incident Record should be revised to ensure that it includes the required information

Incident Investigation Team
Incident Investigation Background Information Investigation Team Training Instructor’s Notes: P. 37 in the participant’s manual Investigation Team: Should the immediate supervisor be on the team? The advantage is that this person is likely to know most about the work and persons involved and the current conditions. Furthermore, the supervisor can usually take immediate remedial action. The counter argument is that there may be an attempt to gloss over the supervisors shortcomings in the incident. This situation should not arise if the incident is investigated by a team of people, and if the joint OHS committee review all incident investigation reports thoroughly.

Incident Investigation Process
When should incidents be investigated? Serious and Major Each incident must be automatically investigated. i.e. Fatality, Lost Time injury, etc. Minor and Near Miss Each incident does not necessarily need to be investigated. i.e. No Lost Time, First Aid Instructor’s Notes: P. 38 in the participant’s manual Important note regarding Minor or Near Miss incidents: However, indicators that point to a condition or practice that, if allowed to continue, could cause injury or equipment damage should be investigated.

Important Note: Fatal or serious injury Minor injuries Injuring involving property damage Near misses Investigations of serious incidents often reveal earlier incidents of a similar nature that were dismissed as insignificant because they were minor or did not involve loss. Speaker’s notes: P. 38 in the participant’s manual When determining which incidents require investigation, consider the following: Investigate all incidents with the potential for loss. Investigate when an individual worker suffers either: an acute health effect (like carbon monoxide poisoning); or a chronic effect (like hearing loss); or Investigate when a group of workers suffers the same symptoms or disease (such as patient care staff with repetitive strain injuries or cumulative trauma disorders such as: carpal tunnel syndrome). Serious incidents with a high potential of injury or damage will require an investigation; however, every incident is a signal that there are problems that require correction

Prioritizing incident investigations Speaker’s notes: P. 39 in the participant’s manual In many workplaces, if all incidents were reported or even if the majority of incidents were reported, there will be more incidents and near misses than can be thoroughly investigated. A thorough Incident investigation takes a lot of time and effort. This means as an organization there should be a process for establishing priority for incident investigation. Similar to Hazard Assessments, when assessing the incident, we want to consider these three things…. How often the task that was being performed when the incident occurred is performed by all workers? (Frequency) The type of injury that occurred? (Severity) The likelihood of the incident happening again? (Probability) Important Note: The seriousness of an incident should not only be based on the actual losses which occurred, but also on the potential losses. Don’t forget about Near Misses! Near misses (where no injuries occurred but very easily could have) are often not reported and investigated. However, as we discussed on the previous slide, useful information can be lost by ignoring these events. Near misses should be investigated on the basis of their most likely potential for harm. Rate the incident based on: How often the task is performed (frequency) Type of injury (severity) Likelihood of the incident recurring (probability)

Exercise 3 Is the incident in the case study a serious incident?
Incident Investigation Prioritization Is the incident in the case study a serious incident? If so, does the incident require investigation? If not, what priority would you give to the investigation? Instructor’s Notes: P. 40 in the participant’s manual P. 12 in the participant’s handout Exercise 3: Incident Investigation Prioritization (10 min) Advise participants they will continue working in the same pairing or small group. Using the same incident or case study, answer the following questions: Is the incident in the case study a serious incident? If so, does the incident require investigation? Note, participants will need to determine whether or not the incident automatically requires investigation. If not, what priority would you give to the investigation? Note, participants will need to complete the hazard assessment risk evaluation scale to determine the risk criticality ranking for their incident. Advise participants to be prepared to discuss why they felt their incident should have been investigated immediately or could be prioritized with other incidents. Bring the pairings or small groups back together and compare the hazard assessments against each other to determine the order to investigate each incident. Bonus question for participants: if there is an incident that required immediate investigation, ask the group who should be notified of the incident and how the notification would be completed.

Unit 3: Conducting an Incident Investigation
Preparation is key! Incident Investigation toolkit: Incident Investigation Report / WCB forms; Floor plans and basic layout plans; Information on possible toxic substances used; Inventory of equipment and materials; Personal Protective Equipment; Other equipment and resources. Speaker’s notes: P. 41 in the participant’s manual Suggested equipment includes: Notebook DO NOT ENTER tape Incident Investigation Checklist Straight edge Clipboard / pad of paper Tape measure Digital camera, with flash (if available) Tape recorder and batteries for dictating notes (if available). Pen / pencil / eraser Pen / Pencil / eraser And, something to carry it all in….some facilities use a backpack

Conducting an Incident Investigation
Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence Step 4. Analyze Information / Identify Causes Step 5. Identify Corrective Actions Step 6. Prepare Report and Provide Feedback Step 7. Make Decisions and Implement Corrective Action Set up steps Execution steps Speaker’s notes: P. 42 in the participant’s manual P. 13 in the participant’s handout Provide a short introduction regarding the overall process, each step will be discussed in detail so there is no need at this point to explain each step. Wrap up steps

Step1: Emergency Response
Arrange medical assistance; Stabilize the scene; Report the incident; and Lock out the equipment/machinery. Speaker’s notes: P. 43 in the participant’s manual

Step 1. Emergency Response
Step 2: Secure the Scene Ensure scene will not be disturbed; Capture all information possible; Collect appropriate evidences; Identify witnesses. Step 1. Emergency Response Step 2. Secure the Scene Speaker’s notes: P. 43 in the participant’s manual Important note: There are legal requirements that must be adhered to at this stage. For serious incidents, in particular, the scene cannot be disturbed until released by Occupational Health and Safety (refer to OHS Act, Section 18(6)).

Exercise 4 Determine Emergency Response & Scene Requirements
What emergency response is required? How should the incident investigation team secure the scene? Speaker’s notes: P. 44 in the participant’s manual P. 14 in the participant’s handout Exercise 4: Determine Emergency Response Requirements (10 min) Advise participants they will continue working in the same pairing or small group. Using the same incident or case study: determine what emergency response, if any, is required, and; how the scene should be secured. (i.e. do not enter tape, pictures, lock out equipment, witnesses, etc.) Advise participants to be prepared to discuss their answers.

Step 3: Gather Evidence Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence 4P’s of Evidence People Positions Parts Paper Speaker’s notes: P in the participant’s manual Note: an animation has been added to the SmartArt to emphasize each type of evidence as you discuss each, simply click your mouse each time you move to the next type of evidence People evidence: Ask the participants why they think People evidence is the most ‘fragile’ of the four types of evidence: From p : People evidence is most fragile because it is subject to: forgetfulness rationalization / justifying the worker’s actions / excusing influence by others personal conflicts / personal agendas or biases When collecting ‘People’ evidence: Choose a location for the interview and conduct the interview as soon as possible to get the most accurate information. Interview one person at a time. Establish a proper interview climate by explaining the purpose of the investigation, demonstrating concern, not rushing the witness and focusing on fact-finding, not on laying blame. Explain how you are going to record the interview (written, audio, audio/visual or combination thereof) and get the witnesses approval. Extract the facts. Get witnesses version, do not ask leading questions; let the witness do the talking. Keep questions simple, ask open-ended questions and move from general information to information that is more specific. Record facts and paraphrase what the witness told you to make sure you understand. End the session on a positive note. Let witness know if they have provided particularly useful information and ask for suggestions about the prevention of the incident that just happened. If needed, obtain a written statement from the witness. Thank the individual and invite them to contact you if they think of anything else. Review and organize your notes. We have also provided interview do’s and don’ts which participant’s can refer to, on p Positions P. 48 in the participant’s manual When collecting ‘Positions’ evidence: Document the positions of people, equipment, machinery, and other relevant items before, at the time of and after the incident. Look for and document the position of any items not belonging at the scene. Parts Ask the participants why they think parts evidence can be considered fragile (albeit not as fragile as people or positions) From p. 48 parts are subject to: pilferage / removal / walked off with, corrosion / deterioration, damage / ruin; and, misplacement. When collecting ‘Parts’ evidence: Look for and document the condition of any items not belonging at the scene. Improper items (i.e. tools) for the task involved, extent and pattern of damage, previously damaged parts, wear, safeguards, labels, signs and markings. Papers Paper evidence is the least fragile; however, it is often the most overlooked type of evidence From p. 49 We should always consider papers as a potential source of information; therefore, we should obtain any potentially relevant documents as quickly as possible to prevent potential misplacement or alteration. The investigator could collect paper evidence from the following sources: written job standards, policies and safe work procedures training records, operating instructions, maintenance records, Schedules for work or maintenance, log books, Material Safety Data Sheets (MSDS) Inspection reports, etc.

Step 3: Gather Evidence Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence Who? What? Where? When? How? Why? Speaker’s notes: P. 50 in the participant’s manual When collecting evidence, the investigator must answer six basic questions: Who? Collected from People, Positions and Papers Learn the names of all the people involved in the incident, not only the person or persons injured, but also any witnesses, others in the area, supervisors, others doing the same kind of work. What was their position relative to the incident? Did they see and/or hear what happened? Some factors will remain essentially constant while others may vary from day to day: Were workers experienced in the work being done? Had they been adequately trained? Can they physically do the work? What was the status of their health? Were they tired? Were they under stress (work or personal)? What? Collected from all 4 P’s: People, Positions, Parts and Papers The actual work procedure being used at the time of the incident should be explored. Members of the incident investigation team should look for answers to questions such as: Was a safe work procedure used? Had conditions changed to make the normal procedure unsafe? Were the appropriate tools and materials available? Were they used? Were safety devices working properly? Was lock out used when necessary? For most of these questions, an important follow-up question is "If not, why not?" Also include in your description details of any equipment or materials involved. Be sure you include the exact names of any chemicals. Check the equipment for defects. In your initial description, try to be clear about the sequence of events. To seek out possible causes resulting from the equipment and materials used, investigators might ask: Was there an equipment failure? What caused it to fail? Was the machinery poorly designed? Were hazardous substances involved? Were they clearly identified? Was a less hazardous alternative substance possible and available? Should personal protective equipment (PPE) have been used? Was the PPE used? Were users of PPE properly trained? Again, each time the answer reveals an unsafe condition, the investigator must ask why this situation was allowed to exist. Where? Collected from Positions When? Collected from People and Papers The physical environment, and especially sudden changes to that environment, are factors that need to be identified. The situation at the time of the incident is what is important, not what the "usual" conditions were. For example, incident investigators may want to know: What were the weather conditions? Was poor housekeeping a problem? Was it too hot or too cold? Was noise a problem? Was there adequate light? Were toxic or hazardous gases, dusts, or fumes present? How? When considering how the incident occurred (the sequence of events) the role or presence of management systems must always be considered in an incident investigation. Failures of management systems are often found to be direct or indirect factors in incidents. Ask questions such as: Were safety rules communicated to and understood by all employees? Were written procedures and orientation available? Were they being enforced? Was there adequate supervision? Were workers trained to do the work? Had hazards been previously identified? Had procedures been developed to overcome them? Were unsafe conditions corrected? Was regular maintenance of equipment carried out? Were regular safety inspections carried out? and most importantly, Why?

Step 3: Gather Evidence Step 1. Emergency Response
Indirect Causes Root Causes Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence Personal Adequacy of training, including new worker and refresher training Experience or knowledge to do the task safely Awareness of hazards associated with the work Job Level of physical effort Workload Adequacy of safe work procedures Equipment or workplace design Relevancy of resident assessment Organizational Awareness of roles and responsibilities Effectiveness of changes from previous incidents Communication Adequacy of resources (e.g. equipment) Speaker’s notes: P. 51 in the participant’s manual While collecting evidence it may help to divide the work environment into three factors related to indirect and root causes: the individual (personal), the job, and the organization. Since all three of these factors affect worker performance, an effective investigation should consider the effectiveness and interaction of all three while attempting to answer the six basic questions: who, what, where, when, how and why. NOTE: Indirect (basic) causes = personal/unsafe acts and job/unsafe conditions Root causes = organizational or program Remember! An effective incident investigation is an opportunity to learn from an incident to uncover gaps, ask why these gaps exist and to correct them. Therefore, investigations should not only determine whether certain conditions exist but also question if there is a better way to do things.

Exercise 5 Gather Evidence Who do you need to interview?
What interview questions would you ask? Where would you conduct the interviews? Document the parts & positions. What paper evidence do you need to look at? Speaker’s notes: Exercise 5: Gather Evidence (15 min) P. 52 in the participant’s manual P. 15 in the participant’s handout Advise participants they will continuing to work in the same pairings or small group. Advise participants to use the same incident or case study and gather the required evidence: Who do they need to interview? What interview questions would they ask? Where would they conduct the interviews? Document the parts & positions. What paper evidence do they need to look at? Advise participants to be prepared to discuss the evidence they gathered.

Step 4: Analyze Information
Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence Step 4. Analyze Information Analyze data Collect additional data, if necessary Speaker’s notes: P in the participant’s manual At this stage of the investigation, most of the facts about what happened and how it happened should be known. This has taken considerable effort to accomplish but it represents only the first half of the objective of an effective incident investigation. Now comes the key question -- why did it happen? To prevent recurrences of similar incidents, the investigators must find all possible answers to this question. Discuss: Why look for the root cause? Key point: Even in the most seemingly straightforward incidents, seldom, if ever, is there only a single cause. For example, an "investigation" which concludes that an incident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as: Was the worker distracted? If yes, why was the worker distracted? Was a safe work procedure being followed? If not, why not? Were safety devices in order? Was the worker trained?

Step 4: Analyze Information
Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence Step 4. Analyze Information Organize findings and recommendations Establish sequence of events Determine Direct, Indirect, & Root Causes Speaker’s notes: P. 55 in the participant’s manual You have kept an open mind to all possibilities and looked for all pertinent facts. There may still be gaps in your understanding of the sequence of events that resulted in the accident. You may need to re-interview some witnesses to fill these gaps in your knowledge. When your analysis is complete: write down a step-by-step account of what happened (your conclusions) working back from the moment of the accident, listing all possible causes at each step. This is not extra work; instead it is a draft for part of the final report. Each conclusion should be checked to see if: it is supported by evidence the evidence is direct (physical or documentary) or based on eyewitness accounts; or, the evidence is based on assumption. This list serves as a final check on discrepancies that should be explained or eliminated. NOTE: You may need to ask why, why, and why!

Exercise 6 Analyze Information
If not, what additional data/evidence do you need to gather, and how will you obtain the additional evidence? If yes, identify and describe the direct, indirect and root causes of the incident. Direct: Indirect: Root Causes: Speaker’s notes: P. 56 in the participant’s manual Exercise 6: Analyze Information (15 min) Advise participants they will continue working in the same pairing or small group. Using the same incident or case study and the evidence they would have gathered, participants should determine if they are able to answer the six questions (Who, What, When, Where, How and Why?). If not, what additional data do they need to gather and how would they obtain the additional data? If yes, identify and describe the direct, indirect and root causes of the incident. Advise participants to be prepared to discuss their answers.

Step 5: Identify Corrective Actions
Alberta OH & S Code, Part 2, Section 9 Hazard Elimination and Control Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence Step 4. Analyze Information Step 5. Identify Corrective Actions Speaker’s notes: P. 57 in the participant’s manual Once you have identified the root cause of the incident, develop well thought out recommended corrective actions as a means of preventing a similar event in the future. Corrective actions should: Provide recommendations to control the identified hazards and prevent recurrence. Identify whether the recommendations are temporary (often to address direct causes) or permanent (often to address indirect or root causes). Alberta OH & S Code, Part 2, Section 9 Hazard Elimination and Control Section 9 requires employers to eliminate hazards whenever it is reasonably practicable to do so. If elimination is not reasonably practicable, hazards must be controlled first by using engineering controls then administrative controls, and and finally, as a last option, by using personal protective equipment Therefore, when considering the corrective actions that are required, or possible, to control the hazards identified through the incident investigation and to prevent recurrence, we must consider the most effective method/methods for controlling the hazard/hazards.

1. Engineering controls They generally deal with installation or modification of equipment that control the hazard either at the source or along the path to the worker. 2. Administrative controls These controls do not eliminate the hazard, but dictate how to reduce worker exposure to the hazard (controlling the hazard along the path to the worker), or how workers deal with the hazard (controlling the hazard at the worker). 3. Personal Protective Equipment Personal protective equipment (PPE) is any device or item of apparel worn (controlling the hazard at the worker) to protect the health and safety of workers. 4. Combination of controls Employers are not restricted to a single approach if using a combination achieves a greater level of worker safety than if only one approach was used. Speaker’s notes: P. 58 in the participant’s manual The hierarchy of controls, required by Part 2, Section 9 of the OHS Code described on the previous slide, provides the framework for determining the most effective methods for controlling hazards

In determining the recommended corrective actions, consider: Where controls are needed Type of control required Priority Timing Speaker’s notes: P in the participant’s manual Where controls are needed: Include all tasks and locations that may be affected by the identified hazards and/or causes. The type of control required to effectively control the hazard: engineering, administrative, personal protective equipment or combination. Priorities: which controls are more urgent to implement than others. Timing: both short and long-term measures should be considered for potentially serious hazards as well as cost and feasibility. It might help to ask these questions when determining what corrective actions are required: What can management/senior management do to prevent the incident from recurring? What can the supervisor do to prevent recurrence? What can the worker do? NOTE: We have provided additional guidance for creating SMARTER corrective action recommendations on p. 59. Depending on the participant’s experience, briefly review or have participants review on their own.

Exercise 7 Identify Corrective Actions Speaker’s notes:
P. 60 in the participant’s manual Exercise 7: Identify Corrective Actions (10 min) Advise participants they will continue to work in the same pairing or small group. Using the same incident or case study and the analysis of the evidence completed in exercise 6: Advise participants to determine as many corrective actions that they would recommend as possible. Advise participants to be prepared to present their corrective actions. As a group discuss what the next steps would be.

Step 6: Prepare Report and Provide Feedback
Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence Step 4. Analyze Information Step 5. Identify Corrective Actions Step 6. Prepare Report and Provide Feedback The Incident Investigation Report should: be brief yet complete and limited to the subject of the report; include facts, conclusions and corrective action recommendations; include observations and interpretations; include appropriate attachments or references to any materials used as a basis for your report. Speaker’s notes: P. 61 in the participant’s manual

Complete the Incident Investigation Report Provide investigation details: Type of incident Employee’s name (optional) and position Incident date and time Report date Summary of incident Witness statements should be attached, if necessary Speaker’s notes: P. 61 in the participant’s manual Remember: This discussion is not about the form itself (the form was reviewed back in Unit 2), rather this is a discussion of how to present the investigation findings. NOTE: there are two ways to present & discuss how to complete the investigation report and exercise 8: discuss how to complete the entire incident investigation report using these slides & the information in the manual, then have the participants complete Exercise 8. Discuss how to complete each section of the incident investigation report using these slides & the information in the manual one section at a time and have participants complete exercise 8 as each section is discussed. Direct Cause Checklist & Analysis, examples for some of the checklist items: Operating equipment without authority: lack of training on equipment; use of wrong type / size of lift or other equipment; unnecessary use of equipment; Failure to warn / communicate: resident changes affecting safety; new environmental hazard; wear and tear/breakdown of equipment or fixtures; inadequacy of hazard controls; unsafe behaviours of staff Failure to secure: includes sling use, falling objects; residents in chairs/beds; tripping hazards; door and cabinet closures and locks; leaky containers; not securing shelving units to the wall, ceiling lift tracks; Operating at improper speed: maintenance tools/equipment; rushing with resident care or portering; auto accidents; moving carts; Making safety devices inoperable: railings, gates, guards, bed rails, door locks, switch plates, chemical dispensers, ice melt, signage, modifying guards so that can’t be positioned properly, modifying resident lifting equipment; Removing safety devices: guards on equipment, switch plates, door locks, signage, stair railings, gates, transfer belts, slings, bed rails; Improper loading/placement: sling use; resident positioning in chairs/ beds/ lifts/transfers; materials spills and drops; Improper position for task: body mechanics and ergonomics for resident and/or materials handling tasks Poor housekeeping: creating or not eliminating slipping/tripping hazards or falling object hazards or other hidden dangers

Complete the Incident Investigation Report Rate the potential frequency, severity and probability. The total of these three = the risk criticality ranking. The higher the total = the incidents that should be investigated on a priority basis. Speaker’s notes: P. 61 in the participant’s manual Remember: This discussion is not about the form itself (the form was reviewed back in Unit 2), rather this is a discussion of how to present the investigation findings. NOTE: there are two ways to present & discuss how to complete the investigation report and exercise 8: discuss how to complete the entire incident investigation report using these slides & the information in the manual, then have the participants complete Exercise 8. Discuss how to complete each section of the incident investigation report using these slides & the information in the manual one section at a time and have participants complete exercise 8 as each section is discussed. Direct Cause Checklist & Analysis, examples for some of the checklist items: Operating equipment without authority: lack of training on equipment; use of wrong type / size of lift or other equipment; unnecessary use of equipment; Failure to warn / communicate: resident changes affecting safety; new environmental hazard; wear and tear/breakdown of equipment or fixtures; inadequacy of hazard controls; unsafe behaviours of staff Failure to secure: includes sling use, falling objects; residents in chairs/beds; tripping hazards; door and cabinet closures and locks; leaky containers; not securing shelving units to the wall, ceiling lift tracks; Operating at improper speed: maintenance tools/equipment; rushing with resident care or portering; auto accidents; moving carts; Making safety devices inoperable: railings, gates, guards, bed rails, door locks, switch plates, chemical dispensers, ice melt, signage, modifying guards so that can’t be positioned properly, modifying resident lifting equipment; Removing safety devices: guards on equipment, switch plates, door locks, signage, stair railings, gates, transfer belts, slings, bed rails; Improper loading/placement: sling use; resident positioning in chairs/ beds/ lifts/transfers; materials spills and drops; Improper position for task: body mechanics and ergonomics for resident and/or materials handling tasks Poor housekeeping: creating or not eliminating slipping/tripping hazards or falling object hazards or other hidden dangers

Complete the Incident Investigation Report Provide details of the incident: Injured worker’s description Sketches or diagrams (or attach) Relevant details Include observations and interpretations Speaker’s notes: P. 62 in the participant’s manual Remember: This discussion is not about the form itself (the form was reviewed back in Unit 2), rather this is a discussion of how to present the investigation findings. NOTE: there are two ways to present & discuss how to complete the investigation report and exercise 8: discuss how to complete the entire incident investigation report using these slides & the information in the manual, then have the participants complete Exercise 8. Discuss how to complete each section of the incident investigation report using these slides & the information in the manual one section at a time and have participants complete exercise 8 as each section is discussed. Direct Cause Checklist & Analysis, examples for some of the checklist items: Operating equipment without authority: lack of training on equipment; use of wrong type / size of lift or other equipment; unnecessary use of equipment; Failure to warn / communicate: resident changes affecting safety; new environmental hazard; wear and tear/breakdown of equipment or fixtures; inadequacy of hazard controls; unsafe behaviours of staff Failure to secure: includes sling use, falling objects; residents in chairs/beds; tripping hazards; door and cabinet closures and locks; leaky containers; not securing shelving units to the wall, ceiling lift tracks; Operating at improper speed: maintenance tools/equipment; rushing with resident care or portering; auto accidents; moving carts; Making safety devices inoperable: railings, gates, guards, bed rails, door locks, switch plates, chemical dispensers, ice melt, signage, modifying guards so that can’t be positioned properly, modifying resident lifting equipment; Removing safety devices: guards on equipment, switch plates, door locks, signage, stair railings, gates, transfer belts, slings, bed rails; Improper loading/placement: sling use; resident positioning in chairs/ beds/ lifts/transfers; materials spills and drops; Improper position for task: body mechanics and ergonomics for resident and/or materials handling tasks Poor housekeeping: creating or not eliminating slipping/tripping hazards or falling object hazards or other hidden dangers

Complete the Incident Investigation Report Check off the substandard actions and/or conditions that existed immediately before the incident occurred. (optional) Then provide specific information about each of the substandard actions and/or conditions identified. Speaker’s notes: P. 63 in the participant’s manual Remember: This discussion is not about the form itself (the form was reviewed back in Unit 2), rather this is a discussion of how to present the investigation findings. NOTE: there are two ways to present & discuss how to complete the investigation report and exercise 8: discuss how to complete the entire incident investigation report using these slides & the information in the manual, then have the participants complete Exercise 8. Discuss how to complete each section of the incident investigation report using these slides & the information in the manual one section at a time and have participants complete exercise 8 as each section is discussed. Direct Cause Checklist & Analysis, examples for some of the checklist items: Operating equipment without authority: lack of training on equipment; use of wrong type / size of lift or other equipment; unnecessary use of equipment; Failure to warn / communicate: resident changes affecting safety; new environmental hazard; wear and tear/breakdown of equipment or fixtures; inadequacy of hazard controls; unsafe behaviours of staff Failure to secure: includes sling use, falling objects; residents in chairs/beds; tripping hazards; door and cabinet closures and locks; leaky containers; not securing shelving units to the wall, ceiling lift tracks; Operating at improper speed: maintenance tools/equipment; rushing with resident care or portering; auto accidents; moving carts; Making safety devices inoperable: railings, gates, guards, bed rails, door locks, switch plates, chemical dispensers, ice melt, signage, modifying guards so that can’t be positioned properly, modifying resident lifting equipment; Removing safety devices: guards on equipment, switch plates, door locks, signage, stair railings, gates, transfer belts, slings, bed rails; Improper loading/placement: sling use; resident positioning in chairs/ beds/ lifts/transfers; materials spills and drops; Improper position for task: body mechanics and ergonomics for resident and/or materials handling tasks Poor housekeeping: creating or not eliminating slipping/tripping hazards or falling object hazards or other hidden dangers

Complete the Incident Investigation Report Check off the personal and/or job factors that allowed the direct cause(s) to develop. Then provide specific information about each of the personal and/or job factors identified. Speaker’s notes: P. 63 in the participant’s manual Remember: This discussion is not about the form itself (the form was reviewed back in Unit 2), rather this is a discussion of how to present the investigation findings. NOTE: there are two ways to present & discuss how to complete the investigation report and exercise 8: discuss how to complete the entire incident investigation report using these slides & the information in the manual, then have the participants complete Exercise 8. Discuss how to complete each section of the incident investigation report using these slides & the information in the manual one section at a time and have participants complete exercise 8 as each section is discussed. Direct Cause Checklist & Analysis, examples for some of the checklist items: Operating equipment without authority: lack of training on equipment; use of wrong type / size of lift or other equipment; unnecessary use of equipment; Failure to warn / communicate: resident changes affecting safety; new environmental hazard; wear and tear/breakdown of equipment or fixtures; inadequacy of hazard controls; unsafe behaviours of staff Failure to secure: includes sling use, falling objects; residents in chairs/beds; tripping hazards; door and cabinet closures and locks; leaky containers; not securing shelving units to the wall, ceiling lift tracks; Operating at improper speed: maintenance tools/equipment; rushing with resident care or portering; auto accidents; moving carts; Making safety devices inoperable: railings, gates, guards, bed rails, door locks, switch plates, chemical dispensers, ice melt, signage, modifying guards so that can’t be positioned properly, modifying resident lifting equipment; Removing safety devices: guards on equipment, switch plates, door locks, signage, stair railings, gates, transfer belts, slings, bed rails; Improper loading/placement: sling use; resident positioning in chairs/ beds/ lifts/transfers; materials spills and drops; Improper position for task: body mechanics and ergonomics for resident and/or materials handling tasks Poor housekeeping: creating or not eliminating slipping/tripping hazards or falling object hazards or other hidden dangers

Complete the Incident Investigation Report Check off the Safety Program components/ elements that allowed the direct & indirect causes to develop. Then provide specific information about each of the root causes identified. Speaker’s notes: P. 64 in the participant’s manual Remember: This discussion is not about the form itself (the form was reviewed back in Unit 2), rather this is a discussion of how to present the investigation findings. NOTE: there are two ways to present & discuss how to complete the investigation report and exercise 8: discuss how to complete the entire incident investigation report using these slides & the information in the manual, then have the participants complete Exercise 8. Discuss how to complete each section of the incident investigation report using these slides & the information in the manual one section at a time and have participants complete exercise 8 as each section is discussed. Direct Cause Checklist & Analysis, examples for some of the checklist items: Operating equipment without authority: lack of training on equipment; use of wrong type / size of lift or other equipment; unnecessary use of equipment; Failure to warn / communicate: resident changes affecting safety; new environmental hazard; wear and tear/breakdown of equipment or fixtures; inadequacy of hazard controls; unsafe behaviours of staff Failure to secure: includes sling use, falling objects; residents in chairs/beds; tripping hazards; door and cabinet closures and locks; leaky containers; not securing shelving units to the wall, ceiling lift tracks; Operating at improper speed: maintenance tools/equipment; rushing with resident care or portering; auto accidents; moving carts; Making safety devices inoperable: railings, gates, guards, bed rails, door locks, switch plates, chemical dispensers, ice melt, signage, modifying guards so that can’t be positioned properly, modifying resident lifting equipment; Removing safety devices: guards on equipment, switch plates, door locks, signage, stair railings, gates, transfer belts, slings, bed rails; Improper loading/placement: sling use; resident positioning in chairs/ beds/ lifts/transfers; materials spills and drops; Improper position for task: body mechanics and ergonomics for resident and/or materials handling tasks Poor housekeeping: creating or not eliminating slipping/tripping hazards or falling object hazards or other hidden dangers

Complete the Incident Investigation Report Check off the Corrective Actions that are required to prevent recurrence. Then provide specific information about each of the Corrective Actions identified, including: Details: specific information regarding the corrective action including whether recommendations are temporary (often to address direct causes) or permanent (often to address indirect or root cause). Who’s responsible for implementation. Target date for implementation to be complete. Speaker’s notes: P. 64 in the participant’s manual Remember: This discussion is not about the form itself (the form was reviewed back in Unit 2), rather this is a discussion of how to present the investigation findings. NOTE: there are two ways to present & discuss how to complete the investigation report and exercise 8: discuss how to complete the entire incident investigation report using these slides & the information in the manual, then have the participants complete Exercise 8. Discuss how to complete each section of the incident investigation report using these slides & the information in the manual one section at a time and have participants complete exercise 8 as each section is discussed. Direct Cause Checklist & Analysis, examples for some of the checklist items: Operating equipment without authority: lack of training on equipment; use of wrong type / size of lift or other equipment; unnecessary use of equipment; Failure to warn / communicate: resident changes affecting safety; new environmental hazard; wear and tear/breakdown of equipment or fixtures; inadequacy of hazard controls; unsafe behaviours of staff Failure to secure: includes sling use, falling objects; residents in chairs/beds; tripping hazards; door and cabinet closures and locks; leaky containers; not securing shelving units to the wall, ceiling lift tracks; Operating at improper speed: maintenance tools/equipment; rushing with resident care or portering; auto accidents; moving carts; Making safety devices inoperable: railings, gates, guards, bed rails, door locks, switch plates, chemical dispensers, ice melt, signage, modifying guards so that can’t be positioned properly, modifying resident lifting equipment; Removing safety devices: guards on equipment, switch plates, door locks, signage, stair railings, gates, transfer belts, slings, bed rails; Improper loading/placement: sling use; resident positioning in chairs/ beds/ lifts/transfers; materials spills and drops; Improper position for task: body mechanics and ergonomics for resident and/or materials handling tasks Poor housekeeping: creating or not eliminating slipping/tripping hazards or falling object hazards or other hidden dangers

Complete the Incident Investigation Report Ensure the investigator or lead investigator’s name and signature is indicated on the report. List the names of the investigation team members who participated in the investigation. Indicate the name of the individual from the management team who reviewed the report along with the date they reviewed the report. Finally, indicate if the report was sent to the OHS Committee for review and the date the report was reviewed by the OHS Committee. Speaker’s notes: P. 65 in the participant’s manual Remember: This discussion is not about the form itself (the form was reviewed back in Unit 2), rather this is a discussion of how to present the investigation findings. NOTE: there are two ways to present & discuss how to complete the investigation report and exercise 8: discuss how to complete the entire incident investigation report using these slides & the information in the manual, then have the participants complete Exercise 8. Discuss how to complete each section of the incident investigation report using these slides & the information in the manual one section at a time and have participants complete exercise 8 as each section is discussed. Direct Cause Checklist & Analysis, examples for some of the checklist items: Operating equipment without authority: lack of training on equipment; use of wrong type / size of lift or other equipment; unnecessary use of equipment; Failure to warn / communicate: resident changes affecting safety; new environmental hazard; wear and tear/breakdown of equipment or fixtures; inadequacy of hazard controls; unsafe behaviours of staff Failure to secure: includes sling use, falling objects; residents in chairs/beds; tripping hazards; door and cabinet closures and locks; leaky containers; not securing shelving units to the wall, ceiling lift tracks; Operating at improper speed: maintenance tools/equipment; rushing with resident care or portering; auto accidents; moving carts; Making safety devices inoperable: railings, gates, guards, bed rails, door locks, switch plates, chemical dispensers, ice melt, signage, modifying guards so that can’t be positioned properly, modifying resident lifting equipment; Removing safety devices: guards on equipment, switch plates, door locks, signage, stair railings, gates, transfer belts, slings, bed rails; Improper loading/placement: sling use; resident positioning in chairs/ beds/ lifts/transfers; materials spills and drops; Improper position for task: body mechanics and ergonomics for resident and/or materials handling tasks Poor housekeeping: creating or not eliminating slipping/tripping hazards or falling object hazards or other hidden dangers

Exercise 8 Prepare the Incident Investigation Report Speaker’s notes:
P. 65 in the participant’s manual P. 19 in the participant’s handout NOTE: they can use their own incident investigation report or they can use the sample incident investigation report provided in the manual on p P in the participant’s handout also includes the sample incident investigation report Exercise 8: Prepare the Incident Investigation Report (10 min) Advise participants to continue working in the same pairing or small group. Depending on which presentation method chosen, the instructions for this exercise will be: Option 1: Advise participants to complete the Incident Investigation Report for the incident or case study they have been using based on the information gathered in each exercise. Advise participants to be prepared to present their completed Incident Investigation Report to the group. Option 2: Advise participants to complete the Incident Investigation Report after each section is discussed using the incident or case study they have been using and based on the information gathered in each exercise. Advise participants to be prepared to present & to discuss as a group what they filled in for each section of the report as each section of the report is completed.

Step 7: Make Decisions & Implement Corrective Actions
Step 1. Emergency Response Step 2. Secure the Scene Step 3. Gather Evidence Step 4. Analyze Information Step 5. Identify Corrective Actions Step 6. Prepare Report and Provide Feedback Step 7. Make Decisions and Implement Corrective Actions Decision Making Implementation Implementation Plan Description of Corrective Action Assign responsibility Target fate Resource Allocation Timelines Communication Plan Evaluate Speaker’s notes: P in the participant’s manual Decision making: Who has authority? Implementation: Communicate-Communicate-Communicate Always communicate your findings with workers, supervisors and management. Present your information 'in context' so everyone understands how the incident occurred and the actions in place to prevent it from happening again. Evaluate: Measure effectiveness of the corrective actions (reduced incidents?); Follow up! Management is responsible for acting on the recommendations in the accident investigation report. The health and safety committee, if you have one, can monitor the progress of these actions. Follow-up actions include: Respond to the recommendations in the report by explaining what can and cannot be done (and why or why not). Develop a timetable for corrective actions. Monitor that the scheduled actions have been completed. Check the condition of injured worker(s). Inform and train other workers at risk. Re-orient worker(s) on their return to work.

Exercise 9 Make Decisions & Implement Corrective Actions
Who approves and need to be involved in the corrective actions decisions making? How are corrective actions implemented? How are the results of incident investigations shared with workers? Speaker’s notes: P. 72 in the participants manual P. 25 in the participant’s handout Exercise 9: Make Decisions and Implement Corrective Actions (10 min) Based on the Incident Investigation Report you created, determine who in your organization or site would need to be involved in making the decisions regarding which corrective actions to implement. Discuss how the corrective actions would be implemented Discuss how the Incident Investigation Report and Corrective Action Plan would be communicated within your organization or site.

Incident Investigation Case Studies
Case example: Resident handling A care worker was assisting a resident to her wheelchair in the bathroom. The resident was following instructions to stand but her knees buckled. The worker tried to keep the resident from falling while also ringing the call bell for help. The worker sustained a low back injury. Speaker’s notes: Instructions are included on p. 73 in the participant’s manual Option 1: Assign one case study to each small group Ask each group to review the incident, the investigation questions and the two potential investigation outcomes Ask each group to answer the following questions: Are there other questions that you would like to ask? If so, what questions would you ask. Why do you think this first investigation is incomplete? What causes does the second investigation identify and attempt to control that the first one did not? In your own words, what is an effective incident investigation. Option 2: self reflection Assign one case study to each participant Ask each participant to review the incident, the investigation questions and the two potential investigation outcomes Ask each participant to reflect on the following questions: Regardless of how you group the participants, bring them back together and discuss the case studies and their conclusions together as a large group. This case study is on P in the participant’s manual

Case example: Violence A care worker was helping a male resident take a bath. It was mid-morning. After getting the resident from his room and helping him to the tub room, the worker moved to help him to disrobe. Suddenly, the resident shoved the worker, causing her to fall backward and hit her head. Speaker’s notes: Instructions are included on p. 73 in the participant’s manual Option 1: Assign one case study to each small group Ask each group to review the incident, the investigation questions and the two potential investigation outcomes Ask each group to answer the following questions: Are there other questions that you would like to ask? If so, what questions would you ask. Why do you think this first investigation is incomplete? What causes does the second investigation identify and attempt to control that the first one did not? In your own words, what is an effective incident investigation. Option 2: self reflection Assign one case study to each participant Ask each participant to review the incident, the investigation questions and the two potential investigation outcomes Ask each participant to reflect on the following questions: Regardless of how you group the participants, bring them back together and discuss the case studies and their conclusions together as a large group. This case study is on P in the participant’s manual

Case example: Slip and Fall A food services worker was walking past the entrance to the bathing/tub room. The worker slipped and fell, suffering a contusion to their elbow. Speaker’s notes: Instructions are included on p. 73 in the participant’s manual Option 1: Assign one case study to each small group Ask each group to review the incident, the investigation questions and the two potential investigation outcomes Ask each group to answer the following questions: Are there other questions that you would like to ask? If so, what questions would you ask. Why do you think this first investigation is incomplete? What causes does the second investigation identify and attempt to control that the first one did not? In your own words, what is an effective incident investigation. Option 2: self reflection Assign one case study to each participant Ask each participant to review the incident, the investigation questions and the two potential investigation outcomes Ask each participant to reflect on the following questions: Regardless of how you group the participants, bring them back together and discuss the case studies and their conclusions together as a large group. This case study is on P in the participant’s manual

Workshop Summary What have you learned today?
Explain the purpose and benefits of an incident investigation (Intro and Unit 1) Describe the incident investigation legal requirements for employers and workers (Unit 1) Explain which incidents should be investigated (Unit 2) Explain how to prepare for and respond to an incident (Unit 3) Conduct an effective incident investigation (Unit 3) Speaker’s notes: P. 81 in the participant’s manual

Workshop Summary What have you learned today?
Identify the direct and indirect causes of incidents using the evidence gathered (Unit 3) Determine the root cause(s) of incidents (Unit 3) Recommend corrective actions to prevent recurrence (Unit 3) Compile an Incident Investigation Report (Unit 3) Summarize and analyze incident statistics to identify trends (Unit 3) Speaker’s notes: P. 81 in the participant’s manual

Questions? Appendices Wrap-up Training Evaluation Speaker’s notes:
Appendix: The information in the Appendix is included as reference for the participants and should not be presented in detail. You should encourage participants to read and familiarize themselves with the material on their own time. Or if there is time, you can provide a high level overview. Appendix 1: Glossary of Terms Appendix 2: WCB Employer Fact Sheet Appendix 3: Checklist of the Most Common Direct, Indirect and Root Causes Appendix 4: Detailed Incident Investigation Report Appendix 5: Incident Investigation Checklist Appendix 6: Sample Incident Investigation Policy Appendix 7: Alberta Occupational Health and Safety Act, Regulation and Code Appendix 8: Common Root Cause Analysis Models Hand out a training evaluation to each participant Thank the participants for attending

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