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Incident Investigation Procedure

Incident Investigation Procedure. Overview. Guidelines. Plan. Investigation. Incident Investigation. Purpose. Incident Investigation. Purpose. Incident Investigation. Purpose. Incident Investigation. Terms. Incident Investigation Incident Occurred Close Calls.

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Incident Investigation Procedure

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  1. Incident InvestigationProcedure

  2. Overview Guidelines Plan Investigation

  3. Incident Investigation Purpose

  4. Incident Investigation • Purpose

  5. Incident Investigation Purpose

  6. Incident Investigation Terms

  7. Incident InvestigationIncident OccurredClose Calls

  8. Incident InvestigationIncident OccurredNow what?

  9. Incident InvestigationIncident OccurredApproaches Systems Approach: Concludes that carelessness or failure to follow a procedure alone was NOT the cause of an incident. Behavioral Safety Approach: Incorrectly assumes that the majority of workplace incidents are simply the result of “human error” or “behavioral” failures.

  10. When a shortcoming is identified, it is important to ask why it exists and why it was not previously addressed. Otherwise, you may fail to discover the underlying or root causes of the incident, and therefore fail to identify the systemic changes and measures needed to prevent future incidents. Incident Investigation Incident OccurredApproaches

  11. Incident InvestigationInvestigate Programs, Not BehaviorsExamples 3. Was the procedure out-of-date or safety training inadequate? 2. Did production pressures play a role? 1. Was the procedure or safety rule followed?

  12. The GOAL is to change the conditions under which people work by eliminating or reducing the factors (program deficiencies, root causes) that create unsafe conditions. This is typically done by implementing adequate barriers and safeguards against the factors that cause unsafe conditions or actions. Incident InvestigationIdentifying Root Causes

  13. Root causes often involve multiple deficiencies in the safety and health management programs. These deficiencies may exist in areas such as workplace design, cultural and organizational factors, equipment maintenance and other technical matters, operating systems and procedures, staffing, supervision, training, and others. Eliminating the immediate cause(s) is like cutting weeds, while eliminating the root cause(s) is equivalent to pulling out the roots of the weed. Incident Investigation Identifying Root Causes

  14. Incident Investigation • Establish an Incident Investigation Program Guidelines

  15. Incident Investigation • Establish an Incident Investigation Program Guidelines

  16. Incident InvestigationEstablish an Incident Investigation ProgramA Four-Step Systems Approach

  17. Incident InvestigationEstablish an Incident Investigation ProgramSTEP 1: Preserve & Document the Scene

  18. Incident information is collected through interviews, document reviews, and other means. Incident InvestigationEstablish an Incident Investigation ProgramSTEP 2: Collect Information

  19. Incident InvestigationEstablish an Incident Investigation ProgramSTEP 2: Collect Information, cont’d

  20. Investigation Procedure • Establish an Incident Investigation Program STEP 2: Collect Information: INTERVIEWING

  21. Investigation Procedure • Establish an Incident Investigation Program STEP 2: Collect Information: INTERVIEWING, cont’d

  22. ACTIVITY Investigation Procedure • Establish an Incident Investigation Program STEP 2: Collect Information: INTERVIEWING, cont’d

  23. Investigation Procedure • Establish an Incident Investigation Program STEP 3: Determine the Root Cause

  24. Investigation Procedure • Establish an Incident Investigation Program STEP 3: Determine the Root Cause, cont'd

  25. Investigation Procedure • Establish an Incident Investigation Program STEP 3: Determine the Root Cause, cont'd

  26. ACTIVITY Investigation Procedure • Establish an Incident Investigation Program STEP 3: Determine the Root Cause, cont'd

  27. Investigation Procedure • Establish an Incident Investigation Program STEP 4: Implement Corrective Action

  28. Investigation Procedure • Establish an Incident Investigation Program STEP 4: Implement Corrective Action, cont'd

  29. Investigation Procedure • Establish an Incident Investigation Program STEP 4: Implement Corrective Action, cont'd In planning corrective actions and how best to implement them, employers may find that some root causes will take time and perseverance to fix. Persisting in implementing substantive corrective actions, however, will not only reduce the risk of future incidents but also improve the company’s safety, morale and its bottom line.

  30. Questions ? ? ? ? ? ?

  31. OSHA Disclaimer • This material was produced under grant SH29640SH6 from the Occupational Safety and Health Administration, U.S. Department of Labor. It does not necessarily reflect the views or policies of the U.S. Department of Labor, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

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