This assignment can be done individually or in pairs. The purpose of this assignment is for you to demonstrate your knowledge of Incident investigation and Reports. Take the time to demonstrate your knowledge.
You will be given the name of a video that can be accessed from the Workplace Health and Safety Course Moodle site.
You are to complete the incident investigation summary report using the format provided. Remember this is a professional document and it will form the basis for the permanent record of this incident. Appropriate care must be taken when completing the document.
The video provides the factual basis for your summary report, for all other information needed to complete the report; you are to provide a reasonable assumption/hypothesis as to that information.
The grading rubric is attached.
Assignment #3 Rubric
Incident Investigation and Report
WORKPLACE SAFETY AND HEALTH COMMITTEE
INCIDENT INVESTIGATION SUMMARY REPORT
INJURY: YES ⃝ NO ⃝
DATE and TIME of INCIDENT: ______________________________________________________
INVESTIGATING COMMITTEE MEMBERS:
PART I – PARTICULARS
Did the incident involve injury?
If yes,
Injury
⃝ Lost Time ⃝ Medical Aid ⃝ First aid ⃝ Hazardous condition, no injury
Causes (check all that apply)
⃝ unsafe act ⃝ unsafe condition ⃝ poor/damaged equipment ⃝ no/poor training
⃝ no/poor procedures ⃝ other
Accident type: ⃝ overexertion/strain ⃝ caught in/between ⃝ slip/fall ⃝ struck by/against ⃝ exposed to ⃝ motor vehicle ⃝ contact with/by ⃝ other
Injury type
⃝ bruise ⃝ burn (heat) ⃝ burn (chemical) ⃝ cut ⃝ crush ⃝ strain ⃝ twist
⃝ lift ⃝ electric shock ⃝ inhalation ⃝ occupational illness ⃝ rash ⃝ other
Part of body injured ⃝ left ⃝ right
⃝ head ⃝ face ⃝ eye ⃝ ear ⃝ neck ⃝ chest
⃝ lung ⃝ abdomen ⃝ groin ⃝ back-upper ⃝ back middle ⃝ back lower
⃝ buttock ⃝ shoulder ⃝ arm ⃝ wrist ⃝ hand ⃝ finger th 2 3 4 5
⃝ leg ⃝ knee ⃝ ankle ⃝ foot ⃝ toe big 2 3 4 5 ⃝ other
Did the incident involve property damage? YES ⃝ No ⃝
Was first aid rendered? YES ⃝ No ⃝
If yes, by whom?
External Medical Assistance
Shift information ⃝ Day ⃝ Afternoon ⃝ Midnight
PART II – DESCRIPTION OF THE INCIDENT
PART III – EVIDENCE
Sketch of incident scene:
PART III – EVIDENCE (CONTINUED)
Persons with information – Statement Summary:
Does the witness have knowledge of the accident/incident or injury? YES ⃝ No ⃝
Did the witness see the accident/incident or injury? YES ⃝ No ⃝
Knowledge of accident/incident/injury: Explain what you know about the accident/incident/injury (e.g. what type of work was being done at the time of the accident/incident/injury, what happened to cause the accident/incident/injury, how serious was the injured worker hurt).
What the witness actually saw: Please identify what you saw before the accident/incident/injury, during and immediately after.
Give your opinion as to how this accident/incident/injury could have been prevented.
PART III – EVIDENCE (CONTINUED)
Persons with information – Statement Summary:
Does the witness have knowledge of the accident/incident or injury? YES ⃝ No ⃝
Did the witness see the accident/incident or injury? YES ⃝ No ⃝
Knowledge of accident/incident/injury: Explain what you know about the accident/incident/injury (e.g. what type of work was being done at the time of the accident/incident/injury, what happened to cause the accident/incident/injury, how serious was the injured worker hurt).
What the witness actually saw: Please identify what you saw before the accident/incident/injury, during and immediately after.
Give your opinion as to how this accident/incident/injury could have been prevented.
PART IV – INCIDENT CAUSATION
PART V – CORRECTIVE ACTION:
PART VI – REPORT REVIEW
This assignment can be done individually or in pairs. The purpose of this assignment is for you to demonstrate your knowledge of Incident investigation and Reports. Take the time to demonstrate your knowledge.
You will be given the name of a video that can be accessed from the Workplace Health and Safety Course Moodle site.
You are to complete the incident investigation summary report using the format provided. Remember this is a professional document and it will form the basis for the permanent record of this incident. Appropriate care must be taken when completing the document.
The video provides the factual basis for your summary report, for all other information needed to complete the report; you are to provide a reasonable assumption/hypothesis as to that information.
The grading rubric is attached.
Assignment #3 Rubric
Incident Investigation and Report
WORKPLACE SAFETY AND HEALTH COMMITTEE
INCIDENT INVESTIGATION SUMMARY REPORT
Industrial ⃝ Construction ⃝ Service Sector ⃝
Employer Name: ______________________________________________________________________
Department/Location:__________________________________________________________________
Address:_____________________________________________________________________________
____________________________________________________________________________________
INJURY: YES ⃝ NO ⃝
DATE and TIME of INCIDENT: ______________________________________________________
INVESTIGATING COMMITTEE MEMBERS:
__________________________________________________________
__________________________________________________________
___________________________________________________________
PART I – PARTICULARS
Did the incident involve injury?
If yes,
Name of the injured: ____________________________________________________________
First Name Middle Last Name
Injured Worker’s Home Address: __________________________________________________________
___________________________________________________________
___________________________________Postal Code______________
Telephone:_________________________________________________
Cellular Land line
Supervisor’s Name:_____________________________________________________________________
First Name Middle Last Name
Physical Location of Incident:_____________________________________________________________
Injury
⃝ Lost Time ⃝ Medical Aid ⃝ First aid ⃝ Hazardous condition, no injury
Causes (check all that apply)
⃝ unsafe act ⃝ unsafe condition ⃝ poor/damaged equipment ⃝ no/poor training
⃝ no/poor procedures ⃝ other
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Explain the Nature of the Injury: __________________________________________________________
_____________________________________________________________________________________
Accident type
⃝ overexertion/strain ⃝ caught in/between ⃝ slip/fall ⃝ struck by/against ⃝ exposed to ⃝ motor vehicle ⃝ contact with/by ⃝ other
Explain
Injury type
⃝ bruise ⃝ burn (heat) ⃝ burn (chemical) ⃝ cut ⃝ crush ⃝ strain ⃝ twist
⃝ lift ⃝ electric shock ⃝ inhalation ⃝ occupational illness ⃝ rash ⃝ other
Explain
Part of body injured ⃝ left ⃝ right
⃝ head ⃝ face ⃝ eye ⃝ ear ⃝ neck ⃝ chest
⃝ lung ⃝ abdomen ⃝ groin ⃝ back-upper ⃝ back middle ⃝ back lower
⃝ buttock ⃝ shoulder ⃝ arm ⃝ wrist ⃝ hand ⃝ finger th 2 3 4 5
⃝ leg ⃝ knee ⃝ ankle ⃝ foot ⃝ toe big 2 3 4 5 ⃝ other
Explain
Did the incident involve property damage? YES ⃝ No ⃝
If yes, describe:
Was first aid rendered? YES ⃝ No ⃝
If yes, by whom?
External Medical Assistance
Name & address of hospital or clinic
Name of attending doctor
Name of family doctor
Address
Date and hour last worked
Shift information ⃝ Day ⃝ Afternoon ⃝ Midnight
PART II – DESCRIPTION OF THE INCIDENT
PART III – EVIDENCE
Sketch of incident scene:
Describe physical evidence collected:
Photo/Video Evidence: (List and describe the photos and videos)
PART III – EVIDENCE (CONTINUED)
Persons with information – Statement Summary:
Witness Name:
Does the witness have knowledge of the accident/incident or injury? YES ⃝ No ⃝
Did the witness see the accident/incident or injury? YES ⃝ No ⃝
Knowledge of accident/incident/injury: Explain what you know about the accident/incident/injury (e.g. what type of work was being done at the time of the accident/incident/injury, what happened to cause the accident/incident/injury, how serious was the injured worker hurt).
What the witness actually saw: Please identify what you saw before the accident/incident/injury, during and immediately after.
Give your opinion as to how this accident/incident/injury could have been prevented.
Witness Signature: Date:
PART III – EVIDENCE (CONTINUED)
Persons with information – Statement Summary:
Witness Name:
Does the witness have knowledge of the accident/incident or injury? YES ⃝ No ⃝
Did the witness see the accident/incident or injury? YES ⃝ No ⃝
Knowledge of accident/incident/injury: Explain what you know about the accident/incident/injury (e.g. what type of work was being done at the time of the accident/incident/injury, what happened to cause the accident/incident/injury, how serious was the injured worker hurt).
What the witness actually saw: Please identify what you saw before the accident/incident/injury, during and immediately after.
Give your opinion as to how this accident/incident/injury could have been prevented.
Witness Signature: Date:
PART IV – INCIDENT CAUSATION
What was the DIRECT CAUSE of the incident? (What caused injury or damage?)
What are the INDIRECT CAUSES? (What caused the incident?)
Task:
Worker(s):
Material/Equipment:
Management:
Environment:
PART V – CORRECTIVE ACTION:
Immediate corrective actions to prevent recurrence:
Target Date for corrective action:
dd/mm/yy
Long term solutions:
Target Date for corrective action:
dd/mm/yy
PART VI – REPORT REVIEW
Signature of Investigator(s):
Date report completed:
dd/mm/yy
Distribute report to:
Signatures of Co-Chairpersons – Safety and Health Committee:
_________________________________ __________________________________________
WHAT IS AN INCIDENT?
An incident is any unplanned
event that causes injury. A dangerous occurrence is any event that could have
caused injury, but did not. The term “incident” will be used to describe both
incidents and dangerous occurrences.
WHAT IS AN INCIDENT
INVESTIGATION?
An incident investigation is
the account and analysis of an incident based on information gathered by a
thorough examination of all contributing factors and causes involved.
REPORTING SERIOUS INCIDENTS
When a serious incident
occurs at a workplace, the employer is required to notify Manitoba Labour and
Immigration – Workplace Safety and Health Division. Under Manitoba Regulation
108/88R, Section 8, such notification must take place immediately after a
serious incident, using the “fastest” means of communication available. A
Safety and Health Officer is on duty 24 hours each day of the week to respond
to emergency calls.
The question often asked of the Workplace Safety and Health Division is:
How do you define a serious
incident?
Workplace Safety and Health Division considers an incident to be serious
if it results in:
•
death, or serious injury (as defined below),
•
collapse or structural failure of a building,
tower, crane, hoist, temporary construction support system or excavation,
•
an uncontrolled spill or escape of a toxic,
corrosive or explosive substance
•
explosion, fire or flooding.
Serious injuries are defined
as:
fracture of a major bone
amputation
loss of sight
internal hemorrhage
third degree burns
unconsciousness resulting from concussion,
electrical contact, asphyxiation poisoning
cuts requiring hospitalization or time off work
any injury resulting in paralysis
any other injury likely to endanger life or
cause permanent disability.
The Regulation also stipulates that equipment or materials involved in a
serious incident shall not be moved, unless it is necessary to release an
injured person or to avoid creating additional hazards.
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INVESTIGATION CONCEPTS
WHY DO WE INVESTIGATE
INCIDENTS?
Prevention is the purpose of
an investigation. An
incident investigation should:
•
determine what actually happened,
•
determine the cause or causes of the incident,
•
identify any unsafe conditions, acts or
procedures,
•
help management to identify practical corrective
actions,
•
determines whether due diligence
was observed,
•
show the commitment of management that an
adequate investigation system is in place.
The purpose of these
activities is not to find fault or lay blame, but rather to identify the basic
causes of incidents so that controls can be put in place to prevent further
occurrences. Information from the investigation should be put on the record,
but not used to discipline anyone. This policy encourages witnesses to tell
investigators everything they know.
What is Due Diligence?
As a result of the 1978 court
case of R. vs. Sault Ste. Marie, due
diligence can be defined as: “…whether the accused exercised all reasonable
care by establishing a proper system to prevent commission of the offence and
by taking reasonable steps to ensure the effective operation of the system.”
Simply put, due diligence means taking all reasonable care in the circumstances
to protect the safety and health of all workers. It must be expressed in
behaviour and attitudes in the workplace, it can not be made up “after the
fact.” The employer must be able to demonstrate their due diligence in an
objective manner. A defense cannot succeed if the employer states that they
intended to provide a safe and healthy workplace. The employer must give actual
proof of real attempts to do so. The measures that will be necessary to prove
due diligence in court will depend on the particular circumstances of each
case.
UNDERLYING PRINCIPLES
Incidents don’t just
happened. They are caused. Incidents can be prevented if causes are eliminated
Causes can be eliminated if all incidents are investigated
properly.
Unless the causes are eliminated, the same
situation will reoccur.
Develop a procedure to
investigate incidents
Section 7.4(5)(I) of the
Workplace Safety and Health Act requires…a procedure for the investigation of
incidents, dangerous occurrences and refusals to work pursuant to Section 43 of
the Act. Investigation of incidents provide valuable information needed to
prevent similar incidents in the future.
There are many good reasons
why supervisors and managers should investigate incidents and near misses. One
of the most important reasons is that supervisors and managers are responsible
for making sure any problems are corrected. In addition, Section 40(10)(I) of
the Act requires the workplace safety and health committee to participate in
investigations of incidents.
3
What should be included in
incident investigation procedures?
Investigation procedures for incidents must fit your needs. Ideally,
they should state:
♦ the objective of
your investigations (find and correct root causes)
♦ who investigates
what incidents
♦ what training
investigators and incident responders will receive
♦ who receives the
written investigation reports
♦ who must fix
defects found during an investigation
♦ who follows-up on
corrective action
♦ what investigation
reports and follow-up records will be kept
♦ who keeps what
documents and records
♦ what
summary and statistics reports are to be developed and how often these reports
will be prepared.
THE SUPERVISOR’S ROLE
The supervisor of the area
where the incident takes place should be extensively involved in conducting the
investigation. Since supervisors are responsible for worker training and
activities on-the-job, they know the work assignments and have issued the work
instructions. The supervisor will be responsible for ensuring that appropriate
preventative measures are taken and that those actions are effective in
reducing or eliminating the possibility of recurrence.
SAFETY AND HEALTH
COMMITTEE/REPRESENTATIVE
Manitoba’s Workplace Safety
and Health Act describes the duties of the safety and health committee under
Section 40(10). One of the primary duties of a committee is noted under
40(10)(i) to participate in investigation of incidents and dangerous
occurrences.
An effective
committee/representative should have a good working knowledge of the work site,
the equipment, hazards present and the people involved. Members will know the
questions to ask and the information to consider as well as who to contact for
technical advice.
Both committee co-chairpersons,
or other members of the committee, or the worker representative should be on
the investigation team. Involving the committee/representative improves the
credibility of the investigation in the eyes of many workers. It also keeps
lines of communication open. The recommendations contained in the report are
likely to be accepted by workers if their representatives on the safety and
health committee participate.
EXPERTS
Depending on the
circumstances, persons with expertise may be called upon to be involved or
actually conduct the investigation. The determining factor for involving an
expert relates to the severity and complexity of the incident. For example, in
the case of a fire, outside experts in fire investigation will be utilized. If
the investigator is not familiar with machinery involved in an incident, he or
she should consult someone who has experience and skill in a particular
situation.
4
WHAT INCIDENTS SHOULD BE
INVESTIGATED?
Incidents where injuries have
occurred or have the potential for injury or loss should be investigated. The
degree to which an incident is investigated is dependent on its severity and
the potential for it to reoccur.
Incidents to investigate:
All time-loss injuries should
be reviewed by the employer and all information provided to the Safety and
Health Committee. In addition, the employer must ensure that the committee is
involved in investigations of incidents involving:
a) Death
or serious injury (serious incidents include: fracture of a major bone;
amputation; loss of sight; internal hemorrhage; third degree burns;
unconsciousness resulting from concussion, electrical contact, asphyxiation;
poisoning; cuts requiring hospitalization or time off work; any injury
resulting in paralysis; any other injury likely to endanger life or cause
permanent diability).
b) Collapse
or structural failure of building, tower, crane, hoist, temporary construction
support system or excavation.
c) An uncontrolled
spill or escape of a toxic, corrosive or explosive substance
d) Explosion, fire
or flooding.
INTERNAL RESPONSIBILITY
The employer and the workers
share an equal concern in preventing incidents and ill-health arising out of
conditions in the workplace. The intent of the safety and health
committee/representative is to enhance the ability of workers and employers to
resolve safety and health concerns reasonably and co-operatively. They should
do so on their own, with a minimum of government involvement. The Safety and
Health Officer may conduct an incident investigation to determine if due
diligence was practiced. The Safety and Health Officer may require the employer
to conduct their own investigation, depending if there is a safety and health
committee or representative with the firm.
INCIDENT CAUSATION
Incidents usually result from
unsafe acts and conditions. These unsafe acts and conditions often arise
because of defects in the safety and health program. A safety and health
program by way of policies and procedures for organizing and performing work
defines the safe standards. Without a safety and health program or with a
non-functional program, workers and supervisors must devise their own safety
and health standards. Much is then dependent on an individual’s experience,
training, knowledge and will to apply safety and health standards on the job.
Incident causes are usually broken down into:
The direct cause
What was the direct cause of the incident? (What caused the injury?)
The indirect cause
What were the root or hidden
causes that led to the incident? (What caused the incident?)
5
FIVE FACTORS TO DETERMINE
INDIRECT CAUSES
To identify the indirect
causes of an incident, the investigator will need to examine the obvious and
underlying factors in the chain of events which took place prior to and during
the incident. The model suggested here, outlines a process where the
investigator examines the indirect causes within each of the following five
categories:
TASK,
MATERIAL/EQUIPMENT,
WORKER(S),
MANAGEMENT and
ENVIRONMENT.
The Task
The actual work
procedure being used at the time of the incident. Review the steps of the job;
method of performing the task; any change to the normal method of performing
the task; limitations; and how and why it is performed that way.
The Material/Equipment
Review the design of
machinery, tools and equipment and how they are used by the workers in terms of
machine guarding, emergency stop devices, lock-out, pinch points, design of
equipment for use by workers, body positions to work and demands such as
repetitive work. Also consider the condition of materials used in the work
process.
The Worker(s)
Consider the factors that affect the worker(s)
when performing the task such as: job requirements, experience and training,
physical capabilities, emotional status at the time of the incident (tired,
stressed, pressures to produce, rushing, interactions with other workers,
labour management issues, hours of work).
The Management
Management is legally
responsible for the safety and health of workers and therefore the role of
management must always be considered in an incident investigation. Review such
factors as: the safety and health rules (standards) in effect, how were they
enforced, type of supervision provided, maintenance procedures for
equipment/tools, safety and health inspections carried out, work processes and
procedures in place, hazard recognition and control methods, incident reporting
policies and first aid policies.
The Environment
The physical workplace
environment as well as sudden change to that environment are factors that need
to be identified. Keep in mind to assess the environmental factors at the
time of the incident. Factors to consider include: weather conditions, housekeeping, the layout of machinery
and storage areas, lighting, visibility, ventilation, temperature, noise,
vibration, gases, dusts and fumes.
6
INVESTIGATION STEPS
The process of investigating
an incident involves gathering evidence, analyzing it then making
recommendations in a written report.
Steps include:
Preparation
Visiting the Scene
Conducting Interviews
Examination of Physical
Evidence
Analyzing the Evidence
Preparing the Report
We will examine each of the above steps in detail.
♦ PREPARATION
As little time as possible
should be lost between the incident event and the beginning of the
investigation. The ideal situation would be to have all the necessary resources
available before the incident so that the investigator(s) can attend
immediately to their tasks. Some interim factors to consider include:
DETERMINE THE SCOPE OF THE
INVESTIGATION
As discussed previously,
under who should conduct an incident investigation, it is recommended that a
plan be developed which identifies who will conduct investigations and under
which circumstances investigations are performed. A plan of this nature will
aid greatly in determining the scope.
Every incident is unique and
requires an investigation tailored to the particular situation. Take the time
up front to determine the techniques that will be employed, sequence of events,
data to be analyzed, individuals involved and expected outcomes. Factors to
consider include:
♦ What
resources are needed to perform the investigation? (staff, equipment, budget
and time)
♦ Investigation
Kit:
investigation checklist, investigation form,
high visibility tape, pencils, pens, measuring tape, clipboard,
camera/video camera with
film/tape, graph paper, plastic bags & envelopes, notepaper, flashlight,
ruler
♦ Safety Equipment:
hard hat, eye protection,
hearing protection, protective clothing,
safety footwear
7
♦ 
What will be the deliverable (output)? internal
report to WSH/WCB,
communication to the media, workers, union,
associations, legal obligations
♦ What is your
attitude regarding the investigation?
The investigator(s) must be
seen as sincere, impartial and knowledgeable (in terms of the techniques of
conducting an incident investigation). It is important that the investigator
exhibit a behaviour of non-judgement and diplomacy. Much of the success of the
investigation depends on the investigator’s attitude, approach and
communication style.
Some tips to consider:
• Biases
(Individual, Team, Others?)
• Your experience
and skills (how it affects your perception)
• Avoid jumping to
conclusions
• Use appropriate
voice tone
• Minimize stress
wherever possible
• Be aware of your
non-verbal communication (e.g. facial expressions, gestures)
• Behave
professionally (representative of your company’s safety and health culture,
courteous, open, honest, candid, non-threatening)
♦ VISITING THE SCENE
Speed and thoroughness are
both necessary in incident investigations. Memories fade and evidence
disappears. Balancing the numerous activities to be undertaken when visiting
the scene is a great challenge for the investigator.
TAKE CONTROL of the situation and make the area safe for yourself and any others entering the scene. Consider any
imminent risk situations (e.g. moving equipment in order to secure the scene).
It is imperative that management be notified immediately of the incident,
injured parties, damaged material and equipment and any requests to shut down
operations to secure the area. Chaos may result from an incident and people may
be in a panic. The situation must be brought under control at once in order for
rescue work to proceed. Secondary incidents (such as fires, equipment or
structural failures) may result from the initial incident. These hazards should
be controlled as soon as possible.
CARE FOR THE INJURED. First aid or medical attendants should be called to care for the injured
immediatel y. If chemicals are involved, ensure that copies of the material safety data sheets (MSDS’s)
are provided to the hospital with the injured.
SECURE THE AREA. To protect evidence and to avoid further injuries or damage, people should be kept out of the
incident scene until the investigators arrive (except to relieve suffering).
One method is to rope off the area and notify management that the incident
scene is non-accessible.
8
CONTACT
APPROPRIATE PEOPLE. The employer should establish a procedure for notifying individuals concerned (e.g. investigation team,
management staff, family) If the incident is serious (see Reporting Serious
Incidents under the Definitions section), WSH must be notified immediately.
Also, the family of the injured worker should be contacted with care.
GATHER NAMES AND ADDRESSES OF EYE WITNESSES. Inquire with those at the incident scene and management staff as
to who witnessed the incident. Obtain the witnesses name, address, and phone
numbers and make a point of contacting them for an interview as soon as
possible.
SKETCH THE SCENE AND TAKE MEASUREMENTS. To improve the usefulness of field notes, sketch the scene and
measure the area. Note and map the positions and condition of the injured
workers, tools, equipment and materials involved, safety devices and personal
protective equipment, machinery and equipment controls and anything else of
value.
Tips on Sketching
Place the important
information in the center of the drawing and draw the rest around it. Include all measurements,
angles, and direction indicators taken at the site. Include the final positions
of casualties and debris. Do not worry about making drawings to scale or
creating artistically perfect drawings. Attempt to draw each item correctly
related to the other items present. Label items correctly. Cross reference your
sketches and photographs to applicable files and occupational safety and health
committee minute forms.
PHOTOGRAPHING. Photographs and video recording aid in preparing and delivering your report as well as in analyzing
conditions at the site of the incident. Photos/Video are also useful when
briefing the stakeholders such as the management team and Safety and Health
Committee. Photographs and video recordings should always be taken as soon as
possible. Below are some techniques useful in taking photographs at incident
scenes:
Start by
photographing the general area then move to the specific scene of the incident.
Take photos from all sides and several angles,
as well as close up and isolation shots.
Ask witnesses to direct where shots should be
taken and note their comments. Create a photo log which includes when the shot
was taken (date and time of day), by whom, location, under what lighting
conditions, what the shot contains, identifying number on a sketch of the area,
brief description of what the photograph is trying to identify.
Store the pictures in plastic photographic file
pages in a binder beside relevant notes and sketches. Cross reference photos
with the location of physical evidence and relevant notes.
When video recording, narrate the pertinent
points identified above.
9
COLLECTING EVIDENCE/SAMPLES. Depending on the incident, you may want to take one or more samples of evidence
found at the incident scene, which may require examination by qualified personnel.
(The decision to utilize experts to collect evidence should be exercised – e.g.
handling controlled products or analysis of engineered systems). An
investigator must ensure that s/he exercises caution when handling evidence for
two distinct reasons:
to protect
themselves against harm from handling evidence such as damaged equipment or
chemical substances, one should assess the need to wear personal protective
equipment.
to preserve the evidence, care should be taken
to maintain the original state of the evidence.
Since liquids can evaporate
quickly and other materials may be cleaned up before you can get a sample, it
is very important to take your samples as soon as possible. Examples of things
you might want to sample include:
♦
Any tools, materials, machinery part or
subassembly which is suspected of failure, malfunction, misfit or faulty
design.
♦
Air samples or other samples if the presence of
impurities or toxic substances may have contributed to the incident.
♦
Liquids or solids which are not normally present at the site of the
incident.
♦
Carefully wrap and label everything in clean,
dry and leak proof containers. Note where each specimen came from and what the
initial appearance was like. Avoid destroying or altering exhibits during
examination. Note the environment (e.g. noise, heat, cold, ventilation and
chemical contaminants). Find out what the weather conditions were at the time
of the incident, if applicable.
Note: If a serious incident
occurs at the workplace, a Safety and Health Officer may conduct an incident
investigation. The Officer will require that items involved in the incident
(e.g. equipment, materials) not be moved unless it is necessary to release an
injured person or to avoid creating additional hazards.
RETURN THE INCIDENT SCENE TO NORMAL USE. Once you have gathered all
the evidence and information needed,
ensure that the incident scene is returned to normal use. This may involve
disinfecting the area if blood was spilled, checking equipment and materials to
assess functionality, and ensuring that the incident will not be repeated. If a
process or piece of equipment needs to be stopped until further examination
proves its effectiveness, notify the management immediately to cease operation.
If in doubt about the functionality of equipment, materials or process, have it
checked by those who are technically qualified – preferably those external to
the organization.
♦ CONDUCTING INTERVIEWS
One of the main methods of
gathering information in an incident investigation is by interviewing people
who were at the incident scene. Interviews should also be conducted with anyone
who can give relevant information, even if they were not present. Examples
include: a supervisor who gave instructions at the start of the shift, a
trainer who instructed the worker, (even months earlier) or a worker who
performs the same job as the injured worker. Information presented here will
aid the interviewer in establishing a framework for the overall process. The
amount of openness that develops during an interview depends a great deal on
the rapport and atmosphere established during the initial contact.
10
CATEGORIZE WITNESSES There are several categories of witnesses who
could have information helpful to
determining the causes of an incident.
♦ Eyewitnesses
– those who actually saw the incident happen or were involved in the incident.
♦ Those who came on
the scene immediately after the incident.
♦ Those who saw
events leading to the incident.
♦ Those
who have information about the work tasks, processes, safety devices in use,
materials, equipment and other conditions involved in the incident.
Consider the expertise,
background and credibility of each witness. Consider where they were when the
incident occurred.
INTERVIEW
WITNESSES AS SOON AS POSSIBLE To obtain as untainted version of the story as possible, witnesses
should be interviewed as soon as practicable after the incident. If interviews
are not done quickly, memories of witnesses may fade and information become
distorted. If witnesses have an opportunity to discuss the event among
themselves, individual perceptions may be lost in the normal process of
accepting a consensus view where doubt exists about the facts. For this reason,
witnesses should be separated as soon as possible. Witnesses should be interviewed
individually rather than in a group, preferably at the scene of the incident
where it is easier to establish the positions of each person involved and
description of the events. If necessary, conduct more detail interviews later
as evidence, such as photographs, become available.
AN OPTION – WITNESSES OWN ACCOUNT OF WHAT HAPPENED. If witnesses are under stress or you cannot speak
to each one immediately, ask each to go into a separate room and write out what
they saw happen during the incident in their own words. Interview each witness
afterwards. Read each person’s statement back and clear up uncertainties. When
you are satisfied that you have all the necessary information, ask each witness
to review and sign their statement. Compare your interviews against those of
other investigators (such as the police or reporters from the media) if this
information is available. This method can serve as an effective means for
information gathering since individuals will jot down their own ideas in their
own words, without influence of an interviewer or other witnesses. It does
depend on how thorough one is when writing out their story, which will vary
from person to person.
CONSIDER THE EMOTIONAL STATE OF WITNESSES Witnesses may be feeling any number of emotions (e.g. anger,
sadness, stress, fear) which can hinder the investigation and may adversely
affect other persons involved. Be aware of each person’s physical and emotional
state and proceed with empathy and understanding to put each witness at ease.
Common causes for discomfort include:
Fear (e.g. of being blamed, punished, evaluated)
Past wrong doings – or perceptions thereof
Concern about releasing information
Interviewer not at ease
Incomplete knowledge of the topic
The interview location (e.g. privacy or lack
thereof)
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INTERVIEW QUESTIONING - THE W 5 METHOD The W5 method uses the
questions what, who, where, when,
and why/how to find out what happened and determine the causes of the incident.
Examples include: Can you tell me
WHAT happened?
WHO was involved in the incident? (Victim,
Witnesses, Supervisor)
WHERE did the incident occur?
WHEN did the incident happen?
What + Who + Where + When = WHY/HOW WHY and HOW did the incident happened?
Use the W5 method to plan interviews as well as to collect and analyze
evidence.
THE OPENING OF THE INTERVIEW It is said that people make judgements within
the first few seconds of meeting
someone. Take the time at the beginning of the interview to put the witness at
ease, to begin slowly and to listen closely and carefully. This gives the
individual a chance to formulate the story in their own mind and gives you a
preview of what they know.
USE OPEN ENDED QUESTIONS While you may want to use “yes” and “no”
questions to break the ice at the
start of the interview, proceed with open-ended questions to obtain each person’s
version of the incident. A series of structured questions may also work, such
as:
♦ Tell me about…
♦ What did you see,
hear?
♦ Where were you at
the time?
♦ Explain how this
task is done?
Ask questions to get more
information as required. Use visual aids (photographs, sketches and
illustrations) to help witnesses recall information and clarify important
points. Consider asking witnesses to draw a sketch.
SOME PITFALLS TO AVOID:
Don’t:
♦ Ask leading questions
(e.g. “Didn’t you think that..”)
♦ Intimidate
the witness (e.g. Alarming or discouraging remarks such as “Well that was a
stupid thing to do..”)
♦ Interrupt the
witness
♦ Convey your
judgements
TAKING NOTES It is important that you document pertinent information from the witnesses for your own reference. You
can go over your notes with the witness to ensure they agree with your
interpretation. While it is important to take notes, it is equally as important
that the note taking process not interfere with the interview process. Bear in
mind that some people feel nervous whenever investigators take notes and they
may be reluctant to share information. If note taking distracts the witness,
attend to it after the interview. Use judgement if you are considering the use
of a tape recorder as it tends to impede rather than contribute to
information gathering. People are
inclined to withhold information for fear of saying the wrong thing,
particularly if they know it’s being captured word for word on a recording
device. If you must use a tape recorder, clarify why you need to use it and how
the information will be used.
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DEALING WITH CONFLICTING STATEMENTS It is normal for statements to conflict. People see things differently and may
remember events differently. Each witness likely saw the incident from a
slightly different angle. Opinions and perceptions differ. Avoid accepting
opinions as fact until you have all the evidence.
ENDING THE INTERVIEW End the interview on a positive note by
expressing appreciation to witnesses
and others who aided you in gathering information. Encourage the witness to
contact you at a later date should they think of something else. Give credit if
an individual’s ideas are used later. Reiterate the goal of the investigation
(prevention) and what will be done with the information you gather.
♦ EXAMINATION OF PHYSICAL EVIDENCE
As noted under the section “Visiting
the Scene” collecting evidence/samples will be one of the first steps in an
incident investigation. Once you have collected evidence, you will need to
examine it closely in order to draw conclusions about what happened. This may
involve sending the evidence to an expert for analysis (e.g. engineer, health
professional, manufacturer) Physical evidence found at the scene is usually
more reliable than evidence obtained from your witnesses. Ensure to:
Examine all physical evidence thoroughly (e.g.
condition of the equipment)
Have equipment tested for malfunction by
qualified personnel
Obtain the relevant specs for the equipment
Review written documentation
(e.g. MSDS, Manufacturer’s specs). Broken equipment, debris, and samples of
materials involved may be removed for further analysis by appropriate experts.
Make notes which will identify exactly where these items came from.
WRITTEN DOCUMENTATION
An often overlooked source of information can be
found in documents such as past incident reports, W.C.B. claim records,
maintenance reports, safety and health committee minutes, formalized safe work
procedures and training records. Any pertinent information should be studied to
consider how the information relates to the incident and ultimately, to prevent
recurrence.
♦ ANALYZING THE EVIDENCE
Once the evidence (witness
accounts, documentary or physical) has been gathered, you are ready to begin
analysis. By this stage, you should know how the incident happened and what the
immediate causes were. Use this information to determine why the incident
occurred. Usually the fundamental causes can be found by simply asking “why.”
To prevent recurrences of similar incidents you must find all possible answers
to this question.
All causes of an incident
must be considered for analysis. Be sure to keep an open mind to all
possibilities and seek out all pertinent facts. If there are gaps in your tracing
or sequence of events, you will need to fill these gaps by the necessary means
(e.g. re-interviewing witnesses). If this is not possible, you may need to
develop a “best guess” scenario that can be supported by the majority of facts
you gathered during your investigation.
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Write out the events of the
incident, step by step. Recall the five factors identified under “Incident
Causation:” Consider the sample questions within each of the following factors:
These are questions intended for the investigator to assess root causes.
They should not necessarily be used for witness interviews since they could
intimidate the witness.
Task – The work procedure
used at the time of the incident.
1. Was a safe work
procedure used?
2. Had conditions
changed to make the normal procedure unsafe?
3. Were the
appropriate tools, materials available?
4. Were they used?
5. Was all of the
required personal protective equipment available?
6. Were inherent
safety devices, alarms or other systems in place?
7. Were all backup
safety devices or systems in place?
8. Was the task
structured to encourage/discourage safe work practices or procedures?
Material/Equipment – Causes
brought about by the equipment or materials used.
1. Was there an
equipment malfunction or failure?
2. What caused it to
fail?
3. Was the material
or equipment substandard in some way?
4. Was personal
protective equipment used? Should it have been?
5. Were hazardous
substances involved?
6. Were tools,
machinery and equipment being used correctly? (Check manufacturers
specifications for operating tools, machinery and equipment as well as any
other applicable standards)
7. Were tools or
machinery modified in any way?
Worker(s) – The factors related to workers include individual
experience, skills and abilities as well as one’s physical capabilities, and
emotional state at the time of the incident.
Your inquiry of a worker is not to place blame, but to uncover the
factors they experienced at the time of the incident. Consider the following
questions:
1. Were
workers aware of the standards, practices, procedures or legislation governing
the activity?
2. Were workers
adequately trained to do the task in question according to standards, practices
and procedures prescribed?
3. What training had
the worker received?
4. What experience did
the worker have to do the task?
5. Was the worker
physically capable?
6. Was
judgement, health and/or ability impaired for any reason? (e.g. Were they
Tired? Rushed? Stressed? Using Medication?)
Management – The employer is responsible for ensuring the safety and
health of workers at the workplace and is therefore responsible for the
policies, procedures and rules on the job. This also includes enforcing the
policies, procedures and rules. Management staff (managers, supervisors, lead
hands, etc.) must always be considered in an incident investigation since they
are responsible for providing direction and supervision.
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1. Were the hazards
which led to this incident known to supervisors?
2. Were standards,
practices and procedures developed and implemented to overcome these hazards?
3. Were supervisors
aware of the standards, practices, procedures or legislation governing the
activity?
4. Were safety and
health rules in effect?
5. Were they being
enforced?
6. Was adequate
supervision given?
7. Was regular
maintenance of equipment carried out?
8. Were unsafe
conditions corrected?
Environment – The physical environment, and particularly sudden changes
to that environment, are factors which need to be identified. It is important
to note the situation at the time of the incident.
1. What were the
weather conditions?
2. Was it too hot or
too cold?
3. Was noise a
problem?
4. Was there
adequate light?
5. Were toxic gases,
dusts, fumes, present?
List all possible causes
within each category. It is important to remember that no one element in an
incident: Task, Materials/Equipment, Workers, Management or Environment stand
alone. Each of these elements must be analyzed in its relationship to the
others.
Use the W5 method as
described under “Conducting Interviews” to analyze the influence of everything
involved in the incident. Usually the fundamental causes can be found by simply
asking “why?” Use photographs and drawings to illustrate important points.
♦ PREPARING THE REPORT
The intent of the report is
to effect change. If after an investigation, there are no recommendations or
actions taken to improve the safety and health at the workplace, it is likely
incidents will continue to happen and workers will feel a sense of
irresponsibility on the part of the employer and safety and health committee. A
succinct report detailing specific recommendations is critical to the
effectiveness of prevention at the workplace. The report should be written with
consideration as to who is the target group that will be reading the report. If
your company has developed a form for reporting incidents, you will want to
complete such a form for each incident. Attached is a report format recommended
by WSH. It covers the following aspects:
REPORT FORMAT
Part I – Particulars
- Injured party
Information
- Where and when
the incident occurred
- Damaged
property/material information
-
First Aid response
Part II – Description of the
Incident
- Description of what happened in detail
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- Sketch of the
incident scene
- Photographs,
diagrams and physical evidence
- Persons with
information and statements
Part IV – Incident Causation
- Direct and
indirect causes of the incident
- Five factor
analysis
Part V – Corrective Action
- Immediate and
long term corrective actions
- Target completion
dates
Part VI – Report Review
- Who prepared the
report and when it was prepared
- Report
distribution list
- Signatures of the
Safety and Health Committee Co-Chairs
DISCUSS THE REPORT
Once the report is complete,
it should be discussed at the safety and health committee meeting. The causes
of the incident should be reviewed and each recommendation debated. Each
conclusion and recommendation must be supported with evidence. Where the
investigator has used the “best guess” scenario to fill in the gaps, be
prepared to offer reasons why those conclusions were drawn. Consider things the
committee can do. The incident may point to weaknesses in the activities of the
committee (such as it’s inspection program). These activities should be
reviewed in light of the evidence.
FINALIZE THE REPORT
If necessary, the report
should be reworked to deal with the concerns of committee members. When the
committee is satisfied with the final version of the report, both
co-chairpersons should sign it. It should then be sent to the employer for
corrective action. The committee should assign members to follow up.
WHAT ACTION SHOULD THE
EMPLOYER TAKE?
The employer has a duty to
promptly respond to the report and advise the committee in writing of the
remedial actions taken. The committee should list these corrective measures and
follow up on them. A summary of the incident report should be posted in the
workplace for the information of workers. A copy of the report should also be
kept in the committee’s files and available if requested by the Workplace
Safety and Health Division. Note: Names of individuals involved in the incident
should be omitted from this version.
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