Incident Investigation

Topics
Establish an effective incident investigation program Learn effective analysis tools relating to incident investigations Learn how to conduct an incident investigation that identifies the contributing factors to the incident Minimize the recurrence of workplace incidents that are contributing to injuries and illnesses

Why Should We Investigate?

To prevent or decrease the likelihood of future injury or illness To identify and correct unsafe behaviors and conditions To identify training needs

When Do You Conduct an Accident Investigation?

All incidents All injuries, even very minor ones All incidents with the potential for injury Property damage, product damage, and near miss situations

Steps to Assure a Good Investigation

Emphasize that safety is a value, not just a priority Remind employees to report incidents immediately Explain how accident investigations are critical to the organization Ensure quality forms exist to guide your efforts and provide necessary reminders. Fix the cause, not the blame The 2nd, 3rd and 4th items are part of groundwork that needs to be laid before an incident occurs. These can also be reiterated as part of the investigation.

Steps to Assure a Good Investigation

Emphasize that safety is a value, not just a priority
Values do not readily change and remain unaffected by the competing, daily fluctuation of other factors in the work environment. Priorities can change daily in response to situational demands. When safety is a basic value, it becomes the natural way of performing a job, anything less is unacceptable.
Making Safety a Basic Value; R.E. Earnest; Professional Safety, August 2000; American Society of Safety Engineers

Unsafe Acts and Conditions

Unsafe Act Violation of established safety policies/procedures which could result in an incident. Unsafe Condition A mechanical or physical condition which if not eliminated, guarded or altered could result in and incident.

Unsafe Acts:
Cause 90% of ALL incidents *

Unsafe Conditions:
Cause 10% of ALL incidents

*Industrial Safety and Health Management; Liberty Mutual , 1995

Unsafe Acts Vs Unsafe Conditions

*Industrial Safety and Health Management by C. Ray Asfahl cites H.W. Heinrich, whose research concluded that 88% of all industrial incidents are from unsafe acts. A 1995 survey completed by Liberty Mutual of 400 Risk Managers and Safety Consultants found that, excluding acts of God, 92% of all workplace incidents result from performance deficit (unsafe behavior).

*Industrial Safety and Health Management; Liberty Mutual , 1995

Before an Incident
Establish Who should conduct the investigation Supervisor, foreman, safety committee, safety director/Coordinator. Why? Supervisors know the job. When incident investigations are to be completed ASAP after the incident How the investigation will be conducted Forms used Procedures

Before an Incident
Establish

What will be done with findings

Reviewed by senior management Safety committee discussion Follow up on corrective actions Incident trend analysis

After an Incident
Conduct investigation ASAP Control & preserve the scene Interview injured worker promptly while information is clear Interview witnesses individually Ask open ended questions Who, What, When, Where, Why, and How?

Compile background information

Seek facts not fault

After an Incident
Document investigation Determine cause(s) of incident Determine what can be done to prevent a similar incident from happening again Implement corrective actions Follow-up

Incident Causes
Immediate Cause A sequence of unsafe acts that led to the incident Example: Water on the floor Basic Cause The reasons why the immediate cause was allowed to occur or failed to occur Example: Why is the water on the floor?

General Causal Categories

Materials/equipment Environment Personnel Management Task

Incident Scene
Where did the incident occur?

What was the employee doing when the incident

occurred? What steps did the employee take while performing the task? What equipment/tools were being used? How were the equipment/tools used?

Incident Description
What task was being performed?

What were nearby employees (if any) doing?

What happened with the equipment/tools being used?

What was the injury or damage?

What steps should be taken to perform this task safely?

Identify Unsafe Conditions & Unsafe Acts

Work environment and equipment Was work environment safe? Housekeeping?

Additional factors?
Noise, heat, lighting, fatigue, height Were equipment/tools in good condition?

Defective?
Missing guards?

Identify Unsafe Conditions & Unsafe Acts

Procedures
Are there inspection procedures to detect hazard? Rushed job? Were task procedures followed? Were correct equipment/tools used?

Was employee authorized to perform task?

Contributing Factors Human Behavior Notes:

Common to all accidents Not limited to the person involved in the accident Highly probable that the behavior had occurred previously Risk behavior that occurs regularly becomes part of the system Behavior has been observed, condoned and encouraged, at least indirectly by management

Behavior

Identify Unsafe Conditions & Unsafe Acts

Was employee supposed to be in vicinity of

incident area? Was PPE worn?

Does employee know PPE is required?

Did employee know where PPE is stored? Was PPE adequate? Were safety rules broken? Were shortcuts taken?

Find the Root Causes

When you have determined the contributing factors, dig deeper! If employee error, what caused that behavior? If defective machine, why wasnt it fixed? If poor lighting, why not corrected? If no training, why not?

Find the Root Causes

A man falls off an unstable step ladder with a damaged rung Unsafe Act Climbing a defective ladder Unsafe Condition A defective ladder The Correction Get rid of the defective ladder

Have the root causes been identified?

Find the Root Causes

What are some of the contributing factors? Why was the defective ladder not found in normal inspections? Why did the supervisor allow its use? Did the employee involved know not to use it? Was the employee properly trained? Did the supervisor examine the job first?
Have the root causes been identified?

Find the Root Causes

Ask yourself, What was the Root Cause of the Injury?

Find the Root Causes

Initial information: An employee is using the grinder and is not wearing safety glasses. The glasses are on the workbench near the grinder. The supervisor walks by and sees it, but has other things to take care of. The Plant Manager, who happens to be passing through the plant on his way to the regularly scheduled Operations meeting with senior management, notices both the employee and supervisor, but is in a hurry to get to the meeting.

Find the Root Causes

Additional information: Senior management is having the regularly scheduled Operations meeting. Safety is not on the agenda.

Find the Root Causes

Result: A piece of metal becomes imbedded in the eye of the employee using the grinder.

Ask yourself, What were the Root Causes of the Injury?

Identify Possible Corrective Actions

Engineering controls Administrative controls Personal protective equipment

Do not stop at familiar or favorite corrective actions Lets look at a few

Engineering Controls
Automate hazardous process/use machine

Change the job task or equipment

Substitute high hazard materials for ones of lower hazard Specify correct equipment for job tasks

Modify work station

Change layout, location or position of equipment Change position of employee

Provide barriers, warning signs or guardrails

Increase visibility in workspace

Administrative Controls
Modify employee functions
Clearly define expectations Designate employees authorized to operate equipment Enforce disciplinary policy for violation of safety rules

Provide training for employees

Equipment, job procedures, reporting procedures

Review hazards and controls

Perform job safety analysis and change job procedures Review hazards and controls of infrequent tasks Change frequency & depth of hazard inspections

Personal Protective Equipment

Review/specify PPE requirements
Provide personal protective equipment Train employees on purpose and use Ensure employees wear adequate protective equipment.

Corrective Action Plan

Develop corrective action plan Assign responsibility for corrective action Follow-up Ensure corrective actions are taken Prevent similar incidents from occurring

Managing Recommendations for Corrective Action

Should a policy be revised or developed? Should the monthly self-inspection checklist be modified? Should training be conducted and will retraining on that topic be needed/provided? Should a work practice be modified or eliminated? Should the supervisor monitor the work practice and if so, how will this be accomplished?

Conclusion
Incident Investigation is both a reactive and proactive process in that it uncovers the root cause and other contributory factors as well as providing valuable information to prevent similar incidents from occurring in the future. We cannot afford, nor is it acceptable to wait for hazards to identify themselves through someones accident

Questions

Zenith Insurance Company Corporate Office: 21255 Califa Street Woodland Hills, CA 91367 2009 Zenith Insurance Company. All Rights Reserved. Zenith and TheZenith are registered U.S. service marks.