1. Incident Investigations

2. Module Objectives Purpose of investigations Reporting requirements
Near miss investigations
Key points for preparation
Investigation steps
Reporting and follow-up

3. Investigation Terms Accident: Near Miss: Incident:
Loss to people, equipment, property and/or production
Event that could have resulted in loss
Describes both the above

4. Investigation Purpose
Recording facts
Determine direct and indirect causes and to identify possible trends
Substantiate personal injury claim
Demonstrates mgmt. commitment 4

5. Why Should Incidents be Investigated?
To Prevent Reoccurrence 5

6. Direct/Indirect Costs
Time Loss of
Injured Worker
Damage to Tools
Or Equipment
Direct Costs
4/5
below water
Time Damaged
Tool out of Service
Economic Loss to
Injured Family
Spoiled Work
Lost Time by
Fellow Workers
Loss of Production
Indirect
&
Hidden Costs
Loss of Efficiency
Crew Break-up
Spoilage -Fire,
water,explosion
Lost Time by
Supervisor
Failure to
fill orders
Cost of Breaking
In New Person
Overhead Costs
During disruption 6

7. Incident Reporting Serious Injuries Medical Aid All incidents
Workplace Safety and Health Division.
Medical Aid
Workers Compensation Board of Manitoba
All incidents
Reported to supervisor immediately (within 24 hours) 7

8. Incident Reporting - WSH
Death or permanent disability
Serious or significant body trauma
Structural Failure - collapse of:
Building
Tower
Crane
Support system
Excavation
Explosion, Fire or Flooding
Major release of toxic or hazardous substance
SAFE Work Bulletin #119
Fastest means possible 8

9. Incident Reporting - WCB
Any incident requiring treatment from a healthcare professional Employer report submitted within 5 business days of the incident being reported Inform board of worker return to work 9

10. Incident Reporting Supervisor
All incidents to be reported immediately to supervisor
Minor Injury
Medical Aid
First Aid
Property Damage
Near miss and close calls with the potential for injury or property damage 10

11. Why Investigate a Near Miss?
Investigations of serious accidents often reveal earlier incidents of a similar nature that were dismissed as insignificant
The near miss pyramid

12. Preparation
Policy
Investigation Kit
Attitude

13. Investigation Steps Overview Gather physical evidence
Who, what, where, when, why, how
Gather physical evidence
Positions of workers, tools, equipment, PPE, guards, housekeeping, lighting
Conduct interviews
Open-ended questions, conduct at the scene, as soon as possible
Check background information
Training, maintenance reports, previous incident reports

14. Investigation Steps Determine Causes Recommend corrective action
Direct, indirect
Recommend corrective action
Short term, long term
Determine Costs
Direct, indirect costs
Write the Investigation Report
As soon as possible

15. Overview Be objective - focus on the facts
Record events in chronological order
Consider all factors
Consider what evidence is direct, circumstantial or hearsay
Consider multiple causes

16. Physical Evidence Devices in / not in use PPE Noise levels Lighting
Awkward angles, positions

17. Interviews
Reassure the witness on investigation purpose (prevention, not blame)
In their own words, what happened before, during, after?
Who, what, where, when, why, how?
Ask the witness to contact you at a later date, should they think of something else
Thank individuals for their assistance

18. Background Information
SDSs
Maintenance
JHAs
Training records
Safety meeting
Safe work practices
Safe job procedures

19. Causation Model Causes are likely to fall into five categories: Task
Material
Environment
Personnel
Management

20. Recommend Corrections
Corrective action on both types of causes must be very specific
Each action to be assigned a target date
May be implemented in stages

21. Recommendations Communicate well Choose effective strategies
Present strategies persuasively
Point out actual costs, not just potential ones 21

22. Exercise
Case studies Groups of Exercises 1 and 2 (pages 23 – 28) 22

23. Written Report Brief history of events
chronological order
Be specific - include dates, times, places, and persons
Attach diagrams, photos, etc.
Make recommendations to prevent repetition
Review by senior management
Must sign off

24. Investigation - Follow Up
Establish a system of follow-up
Site visit
Phone call
Communicate investigation results
Toolbox talk
Safety meeting
Program/manual review will be required
Monitor corrective actions
Is it working?

25. Maintain Standards
Resist temptations and pressures to relax your safety standards
Always remember: the savings achieved by cutting safety corners are “phantom savings”
Your responsibility is to see work is done on time with no delay from incidents or accidents

26. Questions?