Incident Investigation and Analysis

1. Incident Investigation and Analysis Determining the True Root Cause(s) of Accidents and Safety Incidents

2. Training Goal Participants will be able to develop an incident investigation protocol at their respective institutions.

3. Objectives To meet the training goal, the following objectives will be covered: • Incident investigation overview • Desktop incident investigation exercise • Incident investigation protocol • Training investigation team

4. Purpose of Investigation • Determine sequence of events that led to consequence • Offer corrective action recommendations to prevent recurrence of the incident • Never to assign blame or assess liability

5. What should be investigated? • All incidents that cause • Injury • Illness • Lost time • Property damage • All near-miss incidents

6. Where should the investigation be conducted? The investigation must be conducted at the site of the incident

7. Who should conduct the investigation? • Team • Supervisor of the affected employee • Safety committee representative for area • Safety officer • Affected employee(s)

8. When should the investigation be conducted? Immediately after the incident occurred • Memories are fresh • Evidence is in place • Immediate corrective actions can be initiated

9. How to Conduct an Investigation Focus on finding fact, not fault • Investigate the facts • Review the facts to find the cause • Recommend corrective measures • Document findings and actions • Follow-up

10. Investigate the Facts • Look at the situation • Record general information • Collect evidence • Interview witnesses • Review records

11. Investigate the Facts Look at the situation • Examine the big picture • Think of the 5 W’s (who, what, why, when, where) • Outline your approach

12. Investigate the Facts Record General Information • Time and exact location • Injuries • Medical treatment or first aid • Anything unusual

13. Investigate the Facts Collect Evidence • Photographs of equipment • Samples of chemicals • Broken parts or pieces

14. Investigate the Facts Interview Witnesses • Individually • At the scene of the incident • Immediately after the incident, if possible • With an open mind

15. Investigate the Facts Review Records to Identify Trends • Inspection records • Previous incident reports • Maintenance records • Workers’ compensation insurance forms

16. Review the Facts to Find the Cause • Review all information • Clarify the facts • Analyze information • Examine contributing factors • List possible causes • Identify the cause Do not jump to conclusions

17. Examining Contributing Factors Employ a process called branching to find root causes Person slips on oil on floor Why? Oil was spilled on floor Person stepped in oil

18. Examining Contributing Factors Oil was spilled on floor Person stepped in oil Why? Why? Machine was being serviced and oil spilled Person walked through work area

19. Why? Why? Examining Contributing Factors Machine was being serviced and oil spilled Person walked through work area Spill not prevented Oil spill not cleaned Person worked in department

20. Recommend Corrective Actions • Look at each step in the chain of events • Suggest attainable actions • Assign responsibility for implementation • Coordinate a schedule for implementation • Start with simple solutions; move on to those that will be more complex

21. Recommend Corrective Actions Actions: Causes: ? Spill was not prevented ? Oil spill not cleaned Person worked in department ?

22. Document Findings and Actions Incident investigation reports usually contain • General information • Description of injury or illness • Description of the incident • Analysis • Corrective actions • Dates for completion and follow-up

23. Reporting According to the subsequent remedial measure rule, documented recommendations for corrective actions are not admissible as evidence in a court of law. Therefore, appropriate corrective actions can be documented and implemented without fear that they will be perceived as an admission of a previously unsafe condition.

24. Reporting • Do not assign blame, assess liability, or offer opinions in any written documentation • Forward report to university/agency administration

25. Follow-Up Ensure that recommended corrective actions • Have been implemented properly • Are effective in eliminating or reducing future incidents • Do not create an unforeseen hazard

26. Developing an incident investigation protocol Include the following elements: • Incident investigation procedures • Responsibilities for incident investigation • Reporting and record keeping procedures • Investigator training

27. Incident Investigation Procedures • Priority of incidents to be investigated • Notification of incident occurrence • First aid response • Securing the area • Gathering evidence • Interviewing witnesses • How program will be evaluated and updated

28. Reporting and Record Keeping ? • Who prepares the report • What will the report contain • To whom will the report be sent • How long will the reports be kept • Who keeps the reports

29. Investigator Training • Hand-on exercises • Retention exercises • Components of training • Training records

30. Training Topics How to • Conduct an incident investigation • Find the facts and not place blame • Find the cause of an incident • Complete an incident investigation report

31. Training Records Remember to complete a training record • Employee name • Job title • Employee signature • Date of training • Signature of trainer

32. Hands-On Exercises Suggestions • Set up a mock incident scene • Use experiences from your organization

33. Retention Exercises Commonly known as a QUIZ • Focus on important concepts, for example: True or False Every incident should be investigated immediately so that we can determine who was to blame.

34. Retention Exercises True or False A “near-miss” should be investigated in the same manner as an actual incident. True or False Most incidents have only one contributing factor.

35. Retention Exercises True or False The incident scene should be returned to normal as soon as the investigator arrives. True or False Corrective measure should address whatever hazards are uncovered in investigating the incident.

36. Resources • “Accident Investigation,” Comprehensive Loss Management, Inc. • “Investigating Accidents,” Business & Legal Reports • “Incident Investigation,” Safety Solutions • “Accident (Incident) Investigation,” National Safety Council

37. Responsibilities for Investigation Team • Supervisor • Safety officer • Safety committee representative for area

38. What We’ve Learned Today ... • The reasons for conducting thorough incident investigations • How to set up an incident investigation and analysis program

39. Conclusion When an organization reacts swiftly and positively to incidents, its actions reaffirms its commitment to the safety and well-being of its employees.