INCIDENT INVESTIGATION AND REPORTING

1. INCIDENT INVESTIGATIONAND REPORTING Omid Namvar & Martin Ordonez University of British Columbia Vancouver, BC, Canada

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

3. Importance to the Graduate Engineer • All workplace parties have a shared responsibility for the Occupational Health & Safety (OH&S) program • Integral parts of OH&S program: • Incident Investigation • Strengthens the internal responsibility system • Essential to building a positive OOH&S culture in workplace • Important to prevent similar occurrences in future through learning of root causes • Incident Reporting • Regulatory requirement • Can be shared to help prevent future occurrences • Systematic issues can be identified via incident trend analysis using data in the reports from past incidents

4. Module Basics • Goal • Maintain a safe and healthy work environment by learning from and correcting unsafe acts/conditions that causes or could potentially cause injury/damage in a timely manner • Objective • Learning procedures essential to an effective incident investigation and proper documentation “Those that do not learn from their mistakes are bound to repeat them”

5. Module Learning Objectives • Understanding the terms • Incident, near miss, unsafe act, unsafe condition • Principles of effective incident investigation • Intent of an investigation • What should be investigated? • Who should do the investigation? • How to report an incident? • Identifying root causes • Incident trend analysis • Understanding the Benefits • Identifies systematic issues • Prevents reoccurrence • safety awareness and culture

6. Module Learning Objectives (Continued) • Investigation and reporting procedure: • Manage the scene • Respond promptly to the emergency, eliminate immediate hazards while preserving the scene • Investigation • Gather information and identify direct causes of the incident via collecting physical evidence and conducting interviews • Identify root causes, otherwise known as management system causes

7. Module Learning Objectives (Continued) • Investigation and reporting procedure (continued): • Reporting • Communicate the investigation info and document recommendations for corrective actions • Follow-up • Ensure implementation and evaluate effectiveness of the recommended corrective actions • Recommendations must address root causes

8. Why incidents occur today?

9. Why incidents occur today? (Continued)

10. Why incidents occur today? (Continued)

11. Why incidents occur today? (Continued)

12. Understanding the Terms 12

13. Understanding the Terms • What is an incident? • An unplanned event that disrupts the orderly flow of the work process and results in some form of injury or damage. • E.g. an oil refinery explosion (incident, i.e. unplanned event), resulting in a fatality and property damage (consequences) • What is a near miss? • An unexpected event that did not cause injury or damage this time but had the potential. • Also known asdangerous occurrence • E.g. worker slipping on a patch of ice, not resulting in an injury • What is incident investigation? • The analysis and account of an incident based on information gathered by a thorough and conscientious examination of all factors involved, to learn what the root causes were, in order to prevent recurrence using corrective recommendations.

14. Understanding the Terms (Continued) • Incident Direct Causes • Unsafe act (Cause 88% of all incidents*) • Unsafe condition (Cause 12% of all incidents*) • What is an unsafe act? • An activity conducted in a manner that may threaten the health and/or safety of workers. • Using defective equipment • Operating machinery without qualification • Use of tools for other than their intended purpose • Bypass or removal of safety devices • Improper repair of equipment * C. R. Asfahl, and D. W. Rieske, ”Industrial Safety and Health Management,” Prentice Hall, 2009.

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

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

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

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

19. Incident Investigation

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

21. Conducting Investigation • Effective incident investigation procedure

22. Step 1: Manage the Incident Scene • Eliminate immediate hazards to minimize risk of further injury/damage • E.g. slippery surface, energized equipment, stop the leak and put out the fire, shutdown the process or equipment • Respond promptly to the emergency • Provide first-aid treatment to injured • Activate the facility emergency alarm • Response by emergency first responders; e.g. fire fighters, paramedics • Secure the incident site • Restrict access and limit disturbance until all information is collected • However, an authority may have jurisdiction at the scene; e.g. police • Meet regulatory requirements for notification

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

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

25. Step 2: Gather Information • Physical evidence • Examine incident scene and make accurate record • photos, measurements, sketches, etc. • Take notes • Should answer who, what, when, where, why, how • Be careful not to speculate on events before facts are established • Should include • Observations of environmental conditions • Reference to physical evidence • Information from interviews • View documentation • Training and maintenance records, inspection reports

26. Step 2: Gather Information (Continued) • Conducting Interviews • Who to interview? • Injured worker, supervisor, witness, anyone with info • Interview Tips • Maintain privacy and put the person at ease • Interview individuals separately • Explain main purpose is fact finding, not fault finding • Do NOT lead the witness • Repeat what is reported to verify your understanding • Ask specific questions to fill in the gaps

27. Step 2: Gather Information (Continued) • Information sought in Interview: • Identity of people involved in the incident • Events occurred before, during, and after the incident • Timing and sequence of events • Use created timeline to figure out where gaps in knowledge are • Location and direction of actions and events • Possible causes of each action and event • Witness’s suggestions for preventing similar incidents • Sample questions: • Are the workers trained for the standard procedure? • Was this the first time that the task was done? • What failed or malfunctioned? • What could have prevented the incident?

28. Step 2: Gather Information (Continued) • Review documentation • Logbooks • Work schedules • HSE management systems, standards and management reports • Training records • Procedure manuals • Maintenance records • Manufacture’s specifications • Workplace inspection reports • Previous incident investigation reports

29. Step 3: Analyze Information • Determine the sequence of events that led to the incident • Identify and list possible causes: • Human • Management, workers, visitors • Age, experience, training, workload, stress • Health status, emotional status, physical capability • Equipment • Poor design/use, poor maintenance, manufacturer’s specs • Use of personal protective equipment • Materials • Use not in accordance with Manufacturer’s specs • Use of hazardous material

30. Step 3: Analyze Information (Continued) • Environment • Lighting, noise, air quality, weather, cleaning • Toxic gases, dusts, or fumes • Task Control • Safety procedure • Availability and use of proper tools • deviation from normal task procedure • Organizational • Prior identification of hazards • Inadequate training and/or supervision • Irregular safety inspection • Improper communication of safety procedures

31. Step 3: Determine Causes (Continued) • Incident causes • Root causes • “Real” causes of incidents - not always immediately evident • Underlying causes related to management and organizational issues. • Examples: • Job Factors • Lack of resources provided to execute necessary programs • Poor knowledge of workplace parties • Lack of management monitoring • Human Factors • Lack of performance feedback • Low management standards of performance

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

33. Step 3: Determine Causes (Continued) • Direct causes • Events, conditions, or acts that immediately precede the incident and are usually related to uncontrolled hazards • Symptoms of the root causes • Examples: • Conditions • Unavailability of personal protective equipment • Not properly maintained machine guards • Poor housekeeping practices • Acts • Improper use of equipment • Shortcutting safe work procedures • Improper use of personal protective equipment

34. Step 3: Determine Causes (Continued) Human Errors&Equipment Failure DirectCauses Environment Issues Increasing Depth of Analysis Task Control Issues ProgrammaticCauses Health and Safety Program Issues RootCauses Management & Organizational Issues

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

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

37. Step 4: Corrective Actions (Continued) • Personal Protective Equipment: • Specify personal protective equipment requirements • Which protective equipment(s) should be used with each machine or tool • Provide personal protective equipment • Train employees on their purpose and use • Raise awareness on the potential incidents and injuries • Enforce their use via supervisory procedures

38. Step 4: Corrective Actions (Continued) Administrative Controls and Personal Protective Equipment are weaker than engineering controls and should only be used when engineering controls cannot be implemented

39. Step 4: Corrective Actions (continued) • Corrective actions should get at root causes • Should NOT be a collection of nice-to-have recommendations • Recommendations should • be as specific as possible • be determined with worker participation • determine the responsible parties for their implementation • identify contributing factors • identify target dates for implementation • identify follow-up date • list the required sources for implementation • e.g. human, material, equipment, financing

40. Sample Incident Investigation Form

41. Step 5: Incident Investigation Report • Incident investigation reports should include • Place, date, and time of incident • Injured worker’s name and job title • Witnesses’ names • Concise description of the incident • Sequence of events preceding the incident • Analysis of root and direct causes • Recommendations for corrective actions • Outline of the follow-up procedure • Supporting documentation and evidence (summary of interviews, pictures of physical evidence) • Copies of the report shall be communicated to the OH&S Committee and the management team Workers confidential information has to be removed before communication of findings

42. Step 5: Investigation Report (Continued) Sample Incident Investigation Report Form

43. Step 6: Follow-up • Assign responsibilities for • Implementing corrective actions • Procedures • Equipment • Training • Meeting time-lines for implementing corrective actions • Evaluating effectiveness of corrective actions • Communicating the effectiveness evaluations to management, occupational health & safety committee, and workers in the affected workplace area The follow-up procedures has to be documented.

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

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

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

47. Incident Investigation (Questions) Place the steps of an incident investigation in the correct order: ___ Gather Information ___ Determine Corrective Actions ___ Write Incident Investigation Report ___ Manage Incident Scene ___ Follow-up ___ Analyze Information & Determine Causes

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

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

50. Incident Trend Analysis