incident investigation workshop - iirsm investigation... · accident causation theories ......

Incident Investigation Workshop29 September 2017 Workshop

Introduction and welcome

Mark Kenyon & Lamis Al-Kaisi

LM H&S Consultants

Enable delegates to adopt a systematic approach in determining why an incident has occurred and the steps to be taken to prevent a recurrence.

ObjectivesGive a brief history to incident investigation;

Principles of accident causation theories;

Immediate vs Root Causes;

Explain human failures in accident causation;

How to utilise fact/evidence gathering techniques.

Definitions

• An accident is an unexpected (or unplanned/unwanted) event which results in some kind of loss.

What is an “accident”?

• A near miss is an unexpected (or unplanned/unwanted) workplace event that has the potential to cause loss.

What is a near miss?

Class Exercise – Case Scenario

• A Simple Car Accident

• A young man takes a car out desert driving for the day. Once his day in the sand is over, he starts on his way back home. As he joins the road, he comes to a junction and turns right.

• After 200 yards, he realizes he’s going the wrong way. Just as he does a U turn, a car hits him…….

Class Exercise – Case Scenario

Immediate Cause:A car hits his vehicle…

And the Root Causes?Group Work

Class Exercise – Case Scenario

WHY?

YOU HAVE NOT INVESTIGATED!!

ALL OF YOUR ANSWERS

ARE WRONG !!!

Brief History – Accident Triangle

600

30

10

1For every serious injury

there are minor injuries

and

and

damage only

incidents

Common Slips, Trips & Falls

• One size fits all ERP’s;

• Poor Quality Training (Provider / Duration / Language);

• Training not supported by Proof of Learning Tests ;

• Drills ‘Go through the motions’;

• Flawed Investigations – No one likes bad news;

• Lessons NOT learned.

A New Dawn

ERP’s directly derived from HIRA;

Provide Quality Training;

Mandatory Proof of Learning Tests;

Run Meaningful Drills – Multiple Scenarios;

Demand Answers from Investigations;

Tangible, Value Adding Outputs.

Available Tools

• Mechanism 6.0 – ’OSH Performance Monitoring & Reporting’

• Mechanism 11.0 – ’Incident Notification, Investigation & Reporting‘

• Element 6 – Emergency Management

• Technical Guidelines

OSHAD SF

• Incident & Performance Reports

• Audit & Cost Reports

• Incident & Injury Dashboards

AL ADAA System

• Why do it?

• Prevent reoccurrence;

• Legal;

• Insurance;

• Trend analysis;

• Civil action.

Accident Investigation

What is the purpose of the Investigation?

• Identify both immediate and underlying causes;

• Put in place measures to prevent a recurrence;

• Review existing risk assessments;

• Review control standards;

• Identify activities causing the greatest number of incidents;

• Satisfy legal reporting duties;

• Obtain details which might be needed subject to a civil claim.

• All incidents that either result or have the potential to result in loss;

• All injuries, dangerous occurrences and cases of occupational ill-health;

• Fires and spillages;

• Nears misses and property damage.

• The more serious the event or greater its potential, the greater is the effort to be applied.

Which incidents need investigation?

Accident Causation Theories

Accident causation models were developed to assist people investigating occupational accidents.

01Knowing the cause of accidents allows us to identify what types of failures or errors generally cause accidents, and

02Action can be taken to address these failures before they have the chance to occur.

03

• Heinrich’s domino theory postulates that accidents result from a chain of sequential events, metaphorically like a line of dominos falling over.

• When one of the dominos falls, it triggers the next one, and the next and so on.

Domino Theory

Domino Theory

• Removing a key factor (such as an unsafe condition or unsafe act) prevents the injury by interrupting the chain of events.

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• Injury is caused by an accident, due to an unsafe act and/or mechanical or physical hazard, due to the fault of the person, caused by their ancestry and Social Environment

Domino Theory

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FAULT OF

• The accident is avoided by removing one of the dominos.

Domino Theory

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Loss Causation Model

• Bird and Loftus came up with the first update to the Domino Theory, which introduced the following new concepts:

• The influence of management and management error;

• Loss, as the result of an accident could be production losses, property damage, or wastage of other assets, as well as injuries

Loss Control Model

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Loss

PEOPLE

PROPERTY

PROCESS

ENVIRONMENT

SERVICE

Bruise to fatality

From a dented package to destroyed refinery

Brief air emission to major oil spill

Few minutes lost, to a month’s delay

LOSS

6

Contact

CONTACT LOSS

5 6

• STRUCK BY• STRUCK AGAINST• FALL TO• FALL ON• CAUGHT IN• CAUGHT BETWEEN• CONTACT WITH• OVER STRESS

Immediate Causes

IMMEDIATE CAUSES

CONTACT LOSS

4 5 6

UNSAFE ACTS

• WORKING AT UNSAFE SPEED• FAILURE TO WEAR PPE• USING DEFECTIVE TOOLS• SERVICING EQUIPMENT WHEN IN

OPERATION• WORKING WITHOUT A PERMIT• RENDERING SAFETY DEVICES

INOPERABLE

UNSAFE CONDITIONS

• INADEQUATE GUARDS/BARRIER• INADEQUATE PPE• DEFECTIVE TOOLS/EQUIPMENT• INADEQUATE WARNING SYSTEM• EXCESSIVE EXPOSURE• INADEQUATE VENTILATION

Basic Causes

BASIC CAUSES

IMMEDIATE CAUSES

CONTACT LOSS

3 4 5 6

JOB FACTORS

• INADEQUATE LEADERSHIP• INADEQUATE ENGINEERING• INEFFECTIVE PURCHASING• INADEQUATE TOOLS AND EQUIPMENT• INADEQUATE MAINTENANCE• INADEQUATE WORK STANDARDS• WEAR AND TEAR

PERSONAL FACTORS

• INADEQUATE CAPABILITY• LACK OF KNOWLEDGE• LACK OF SKILL• STRESS• IMPROPER MOTIVATION

NATURAL FACTORS

• EARTHQUAKES• FLOODS• LIGHTNING• WEATHER

Lack of Control

LACK OF CONTROL

BASIC CAUSES

IMMEDIATE CAUSES

CONTACT LOSS

2 3 4 5 6

• INADEQUATE PROGRAM/PROCEDURE/WI

• INADEQUATE PROGRAM STANDARDS

• INADEQUATE COMPLIANCE WITH STANDARDS

• INADEQUATE MANAGEMENT SYSTEM

Failure to Assess Risk

FAILURE TO ADDRESS

RISKS

LACK OF CONTROL

BASIC CAUSES

IMMEDIATE CAUSES

CONTACT LOSS

1 2 3 4 5 6

• NO HAZARD IDENTIFICATION• RISKS NOT ANALYSED• RISK NOT REASSESSED AND ELEVATED• NO RISK CONTROLS

If you don’t analyse risks, you can’t control them!

Three Stages of Control

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PRE-CONTACT CONTROL CONTACT CONTROL

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Underlying CausesManagement and Organizational Factors

Including:

- The adequacy of health and safety policy;

- How work is controlled, coordinated and supervised;

- How the co-operation and involvement of employers is achieved;

- The adequacy of the communication of health and safety information;

- How competency is achieved and tested (including the provision of health and safety assistance);

- The adequacy of planning, risk assessment and the design of RC’s;

- The adequacy of measuring and monitoring activity;

- The adequacy of review and audit arrangement.

A Framework for Analyzing

Causation

Human Factors

• Physical and Psychological Stressors;

• Environmental Stressors;

• Lack of Alertness;

• Lack of individual control over situations;

• Unsafe Acts and Conditions;

• Lack of managements supervision and control;

• Personal Factors;

• Job related factors;

• Perceived benefits of their actions.

A Framework for Analyzing

Causation

Time line after an incident

Review Review the process.

Recommend Make recommendations;

Conclude Draw conclusions;

Analyse Analyse the facts;

Gather and record Gather and record the facts;

Select Select level of investigation;

Deal Deal with the emergency first;

Make Make the area safe;

• Open questions to ask:

• What happened?

• Why did it happen?

• When did it happen?

• How did it happen?

• Where did it happen?

• Who was involved?

Gathering information

Excellent source of first hand knowledge;

Get preliminary statements as soon as possible from all witnesses;

Locate the position of each witness on a master chart (including the direction of view);

Explain the purpose of the investigation (accident prevention) and put each witness at ease;

Identify the qualifications of each witness (name, address, occupation, years of experience, etc.).

Supply each witness with a copy of their statements (signed statements are desirable).

Interviewing

Let

Let each witness speak freely and take notes without distracting the witness (use a tape recorder only with consent of the witness);

Word

Word each question carefully and be sure the witness understands;

Use

Use sketches and diagrams to help the witness;

Emphasise

Emphasise areas of direct observation and label hearsay accordingly;

Record

Record the exact words used by the witness to describe each observation.

Interviewing

• What did you see?

• What did you hear?

• Where were you standing/sitting?

• What do you think caused the accident?

• Was there anything different today?

• What is normal procedure for activities involved in the accident?

• What type of training persons involved in accident have had?

• What, if anything was different today?

• What they think caused the accident?

• What could have prevented the accident?

Interviewing – Sample Questions

• What is an immediate cause?

• Unsafe act(s)

• Unsafe condition(s)

Analysing the facts

Immediate CausesHuman Failures

Here is where we ask WHY?

• It is not enough to establish the immediate causes and prevent that happening again;

• What is the reason for the immediate cause?

• If there is an underlying cause it should be prevented from happening again.

Root or Underlying

cause

A pipe falls from height and the immediate cause is said to be corrosion. We can ask more questions:

• Was the material of construction specified correctly?

• Was the specified material used?

• Were the operating conditions the same as those assumed during design?

• What corrosion monitoring did they ask for?

• Was it carried out?

• Were the results ignored?

• And so on . . . .

Analysing the facts-Example

Make a list of the FACTS, just the FACTS that have been seen, heard, read etc. during the investigation stage

FACTS without interpretation and without value judgment

Each FACT must be written as a SINGLE, SIMPLE FACT

Avoid negatives!

Facts

• Talking about root cause analysis, and saying we do it is very different to actually doing it.

• There are many ways of doing it:

• Fault tree analysis;

• Why-because analysis;

• Causal tree analysis.

Root cause analysis

Start with the end result (the loss) and

ask 3 questions:

What is the immediate cause?

Was it necessary (to cause this fact)?

Was it sufficient (to cause this fact)?

Construction of the Causal Tree

Etc. Etc.Lights left

onFlat

batteryCar will

not start

Construction of the Causal Tree

1. Simple progression

Links between facts

Slipping Falling

2. Conjunction

(Two or more events leading to one)

Links between facts

Weight of load

Worn breaks

Not stopping in

time

3. Disjunction

(one event leading to two or more)

Links between facts

Tree branch broke

Phone wire brought

down

Storm

Alex was working by himself and using a utility knife to open a box of supplies. The exposed knife blade contacted his left forearm causing a 3" long laceration. Six stitches were required to close the wound. Alex states that he was cutting towards himself when the injury occurred. Forearm guards were available from the storeroom, however, Alex was not aware of them. It was raining and water had tracked inside the room.

Case Study 1

Not wearing forearm guards

The floor was wet

Using a knife

Blade was exposed

Working alone

Alex stated he didn't know about forearm guards

Alex stated was cutting towards himself

3" long cut on forearm

Case Study 1 - Facts

Not wearing forearm guards

The floor was wet Blade was

exposed

Working alone

Alex stated he didn't know about forearm guards

Using a knife

Alex stated was cutting towards himself

3" long cut on forearm

Facts that did not contribute to the incident

A Causal Tree

Using a knife

• In your groups

• Nominate a spokesperson

• Read through the illustrated scenario

1. List all the facts

2. The spokesperson will then present the facts to the group

Case study 2 – Part 1

The Facts

• The bike/scooter skidded

• The boxes and metal parts on the ground

• The speed of 15 mph

• The heavy load

• The tight bend

• The load falling

• Seeing the road blocked

• Entering the plant

• Coming to work

• Falling to the ground

• The injury

• The wet ground

• The sloping road

• The worn out forklift brakes

• The unsecured load

• Braking hard

• In your groups

• Nominate a spokesperson

• Construct a causal tree starting with the top event i.e. the injury

• All members of the group must agree on the tree!!

• Then present their tree with an explanation of the facts shown

Case Study 2 – Part 2

• Identify remedial actions

• Can be quite easy at times – especially for immediate causes:

• Replace guard on equipment

• For Root causes this can be:

• changes in company work practices;

• improving safety or skills training;

• improving management control;

• building a more positive safety culture.

Analysing the facts

• Having completed the report forms and preliminary investigation you should have;

• Personnel information;

• Accident information (location, events leading to accident, machines involved);

• Causes of the accident;

• Recommendation to prevent accident;

• Follow up information.

Accident Investigation

Reports

Timely

Accurate

Clear and unambiguous

Concise but with the right amount of detail

Establish a framework for improvement

Accident Investigation Reports

The Report

• From the accident investigation form and witness statements write an accident investigation report, the report should include:

• Executive Summary (sequence, extent, type, source);

• Background information (where, who);

• Introduction;

• Analysis (findings, observations, causes);

• Recommendations;

• Appendices (Witness Statements, Photographs, Sketches, Scientific Analysis/Reports).

Summary

Gather the facts as soon as possible after the incident

Do not stop the investigation after identifying the Immediate Causes

It is the Root/Underlying Causes that will ensure success

Do not look for someone to blame

Treat the witnesses with respect

Do not delay writing the report

And remember…. Better to put more effort to Prevent accidents than to deal with an investigation!