Incident Investigation

AMEC Earth & EnvironmentalMonthly Safety Training Program

March 2009

Expectations• This incident investigation presentation provides guidance and

awareness.

• Generally, Safety Professionals, Management, Supervisors (includes Project Managers), Unit SHE Coordinators, designated Safety committee members and safety representatives will perform investigations.

• Employees need to understand the process of incident investigation, in event that they are involved in an incident or asked to participate in an investigation.

• This training may also help to prevent incidents through the analysis of factors, leading to incidents, and their control, elimination or avoidance.

Introduction

An incident investigation is an after the fact reaction to an unfortunate event. By determining the Root Cause and contributing factors, steps

can be implemented through use of policy, procedures, and training to avoid future

occurrences.

The goal of the investigation is prevention and learning, not to place blame!

Incident or Accident?

• An incident is any unexpected event that may or may not have caused personal injury or damage

• An accident is an unexpected or unplanned event that results in injury to persons, property damage or loss

• A near miss or dangerous occurrence are terms for an event that could have caused injury to persons, property damage or loss.

Is it an accident or incident?

The term incident is sometimes used to describe either an accident or a near miss. It is argued that accident implies that the event was related to fate or chance. When the root cause is determined, it is usually found that many events were predictable and could have been prevented if the right actions were taken – making the event not one of chance or fate, thus the term incident often preferred.

CausationRemember these three basic facts:

1. Accidents are caused.

1. Accidents can be prevented if the causes are eliminated.

1. Unless the causes are eliminated, the same accidents will happen again.

Usually there are four or five root causes or factors that contribute to an accident. Often there are even more - your task is to identify as many as possible.

Accidents

• There is some correlation between the numbers of no injury, light injury, serious injury and fatality events of similar causation.

• By investigating all ‘Incidents’ we learn how to prevent more serious accidents

• Remember: Rare or exotic incident that may have catastrophic consequences, are not be identified by use of this model alone.

Investigation Objectives:

ACCIDENT & INCIDENT INVESTIGATION OBJECTIVESThe objectives of effective accident and incident investigations are to:

identify the root and basic causes and determine how these resulted in injury, property damage or loss.

identify means to prevent similar accidents or incidents from occurring.

utilize the investigation findings to develop and/or revise policies and procedures and determine if training is necessary to prevent reoccurrence.

ensure compliance with legislation as defined by OSHA, EPA, WCB/WSIB, Departments of Labour or Environment, etc.

provide awareness for all workplace parties. determine financial implications and process compensation claims.

Domino Accident Causation Model

Sub StandardActs

PersonalFactors

Struck byFell Off

InjuryDamageLoss

Lack of Control -

Management Systems Job

Factors

SubStandardConditions

Caught In

UnderlyingCausal factors

ImmediateCausalfactors

Incident Loss Direct cause

Lack of control - Management Systems

• Inadequate safety program.

• Inadequate program standards.

• Inadequate procedures.

• Inadequate compliance with the standards.

• Inadequate resources and commitment to above.

These failures permit the Underlying (Basic System) Causes to exist

Underlying (Basic System) Causal Factors : Personal

• Inadequate psychological capability. • Inadequate physical capability.• Physical stress or illness.• Improper motivation.• Lack of knowledge.• Lack of skill.

These are Preconditions for Immediate Causes

Underlying (Basic System) Causal Factors : Job

• Poor leadership or supervision.• Poor purchasing.• Poor engineering.• Poor maintenance.• Inadequate tools or equipment.• Poor working standards and systems.• Negative peer pressure.• Abuse or misuse.• Not taking the time to talk (safety meeting, JSA development etc.)

Preconditions for Immediate Causes Continued

Immediate Causes - Unsafe Acts

• Operating equipment without authority.• Operating at improper speed.• Making safety devices inoperable.• Using defective equipment.• Using equipment improperly.• Failure to follow procedures.• Failure to intervene.• Failure to recognize change.

Unsafe Acts may be Passive or Active!!

See Human factors

Human Factors in Accident Causation

Most Accidents have a human factor.

The skilled Accident Investigator looks beyond human errors & mistakes.

Rule-breaking: Deliberate or Habitual.

Lack of knowledge/training.

New task, inexperience = action causing accident.

Errors following rules - typically misinterpretation.

Lapses, errors & mistakes.

Unavoidable rule-breaking.

Immediate Causes - Unsafe Conditions

• Inadequate barriers or guards.• Defective tools or equipment.• Poor housekeeping.• Hazardous environment e.g. noise, gas, fume, high temp, low

temp.• Inadequate warning systems.• Inadequate ventilation.• Inadequate PPE.

Underlying (Basic System) Causal factors are the fundamental reason why Accidents happen. They are an inevitable outcome of

lack of management control!

Pressure vessel ruptures

below swp

Why?

Corroded vessel

Why?Corrosion

undetected

Corrosive Conditions, not corrosion proof

WHY? Why?

Lack ofMaintenance/

Inspection prog

Inadequate design/specification

ROOTCAUSES

REMEMBER…

Accident Investigations are not just a good idea…they are required by law!

Quiz

What is the purpose of an Accident Investigation?

• To determine Root Cause or causes

• To prevent reoccurrence

• Learning

Notification

In an EMERGENCY provide first aid to the injured then the supervisor immediately calls:

• 9-1-1 to summon medical aid if necessary.• WorkCare’s 24/7 hotline: (800) 455-6155.• One of the following Incident Team Members:

• Regional SHE Manager or SHE Director• Local/Unit SHE Coordinator • Human Resources

• Project Manager, Unit Manager/Group Leader.• Member of Safety Committee, if applicable.• Media Crisis, if necessary.

AMEC First Alerts• An internal Notification process.

• Responsibility of an Incident Team Member to complete and submit the First Alert form to senior management.

Criteria for First Alert Notification:

1. Accident occurs which results in serious injury or death;

2. A reportable dangerous occurrence occurs;

3. An incident occurs which could lead to enforcement action;

4. An enforcement notice is issued;

5. An incident occurs which results in injury to a member of the public/visitor;

6. An incident occurs that is classified as high potential severity;

7. An incident that results in environmental damage.

Notification continued…

• In the case of immediately reportable incidents such as those requiring an AMEC First Alert, the notification of external agencies may be required to be performed by AMEC SHE Department, Management, or designee.

• Local regulations vary for agency reporting obligations – review your local requirements or contact the SHE Department.

• Management also needs to be notified immediately so they can contact the family of the injured worker.

The Investigation Process

Stage 1Preparation

ProceduresTrainingToolkits

Incident

Stage 2 Active Investigation

Preserving & Documenting Scene.

Mobilizing TeamCollecting,preserving

& controlling evidenceFirst Alert Reporting.

Interviewing witnesses.

Stage 3Research, Analysis Corrective Actions

and Communication

Review documentationTests/simulations/

calculations.

Analyze findingsidentify direct and underlying causes.

Communicate lessonslearned and prevent

re-occurrence

Continuous Critical Review of Process

Accident Investigations

Active Investigation

The Team will gather their information from:

ObservationDocumentary Evidence

Interviews

Investigation KitBE PREPARED! Have a kit ready that includes:

• Appropriate forms or checklists and applicable regulations.• Floor plans, diagrams, or maps of the workplace.• Camera (with film or digital capacity)* and voice recorder.• Flashlight, batteries.• Emergency phone numbers and other useful contacts.• Tape measure.• Required PPE for investigators.• Pencils, papers, pens and clipboard.• Barricade tape, paint.

*It is of crucial importance to ensure that digital images have not been modified. Do not change file names, and store securely.

QUIZ

List 3 other items that you would include in an Accident Investigation kit:

• Checklists.• An extra disposable camera.• Measuring wheel.

First on the scene - InvestigatorFirst on Scene• Summon emergency response / First Aid Hazard Assessment

- Check the area for any hazards (no fire, no wire, no gas, no glass, no confined space, don gloves and get CPR mask)

• Secure the scene and address risk of any further injury. • Keep the accident scene as undisturbed as possible.

Supervisors and Investigators actions continue. . .• Cooperate with Emergency Response Providers / Police /

Labour• Document the accident scene by photographs, drawings and

measurements.• Identify and interview all witnesses separately and individually.• Record all information accurately.

The Physical Investigation

Start by:1. Identify witnesses to interview.2. Record the accident scene and evidence:a) Photograph several angles of the scene and close-up

details of equipment/material or property damage.b) Prepare drawings of the scene to clarify written reports

and prompt witnesses during interviews. Note the locations (and viewing angles) of all witnesses, equipment, and materials.

c) include measurements of objects and locations of witnesses.

Collecting Information

Documentary Evidence

Information from:

• Written instructions - JSA

• Safe Operating Procedures

• Risk assessments

• Permits-to-work

• Inspection results

• Specifications

• Health & Safety Plan

• Method statements

Information from:

• Written instructions - JSA

• Safe Operating Procedures

• Risk assessments

• Permits-to-work

• Inspection results

• Specifications

• Health & Safety Plan

• Method statements

Gather Documentary Evidence

Examine training records

• Was appropriate training provided?

When was training provided?

Examine equipment maintenance records

• Is regular service provided?Has it been inspected?

Is there a recurring type of

failure?

Examine accident records

• Have there been similar incidents or injuries involving other employees?

The Interview

Interview anyone present at the scene and consider others who may not have been present, but who have special knowledge of the job, task, or equipment involved in the accident (e.g. project manager or site maintenance personnel).

Key Considerations• Recollection declines by 50-80% in the first 24 hours after an incident.• Influence of third party discussions.• Consider trauma and shock effects, counseling needs etc.

Advise witnesses who may be interviewed by HSE/Police/Labour under caution to seek assistance from AMEC prior to the interview.

Remember: It is desirable to interview witnesses ASAP after the event but in practice circumstances may prohibit this.

The Interview Process

When an accident occurs it is important to remember that witnesses have experienced a traumatic event and empathy should be expressed. A stressed or defensive witness can hinder the process.

Remember we are all working towards the same goal of preventing reoccurrences!

Interview Tips…

• Investigators should conduct separate interviews with each person.

• Put the interviewee at ease, remind them that the purpose of the investigation is prevention, not to place blame.

• Introduce the investigation team, and if using a tape recorder ask permission.

• Ask the witness to explain what happened in their own words.

• Ask for further detail if unsure of their explanation.• Follow-up with open-ended questions that require more

than a ‘yes’ or ‘no’ answer.

Tips Continued…

• Listen carefully and avoid interruptions.• Avoid asking ‘leading questions’.• Go over your notes with the witness and ask

them to verify their accuracy by signing.• Encourage them to contact you with any

information they may remember, and inform them you may need to speak with them again.

• Thank them for their help and cooperation.

Determining Causal Factors

While it is crucial to establish the immediate causes of the accident, these are generally the symptoms of higher level or management systems failures.

Management system failures have the largest potential to cause accidents and it is incumbent on the investigator/team to ensure that the investigation is not ended until the Root Causes are identified.

Causal AnalysisYou will now be presented with a tool that may be used to analyze the causes (acts, conditions, personal and job factors) of incidents/accidents.

When applied correctly it will comprehensively identify the incident/accident causes. (Note: legible on 11x17 paper)

A-Z of Accident Causes

For each immediate cause (act or condition) identify any and all applicable root causes (personal or job factors), or specify other. Every Root Cause is colour coded to associate with a System Cause. This is where corrective actions may be warranted.

Investigation Traps

Put your emotions aside! - Don’t let your feelings interfere - stick to the facts!

Do not pre-judge.- Find out the what really happened.- Do not let your beliefs cloud the facts.

Never assume anything.

Do not make any judgments.

The Investigation ReportAn accident investigation must determine certain facts

and the report must include them.

• WHO was involved or injured? Were there witnesses? (Names, job titles.) • WHERE did the accident happen? (Name of department, machine, location,

etc.) • WHEN did the accident occur? (Date, exact time of day, shift.) • WHAT happened? (A brief description of the accident.) • WHAT were the immediate causes? (Conditions, procedures, equipment,

acts, sequence of events that preceded the accident.) • WHY was the unsafe act or condition permitted? (Lack of training,

supervision, rule enforcement, maintenance.) • HOW can a similar accident be prevented? (Must be specific and provide

recommendations for specific action.)

Once the recommendations are made, the employer has an obligation to initiate corrective action, report the action to the health and safety committee and communicate to employees.

Remove CONFIDENTIAL personal/medical information

Recommendations

• Corrective actions should always consider the hierarchy of hazard controls from the most effective through to the least effective:

• Engineering Controls

• Administrative Controls

• Retraining and PPELess

Effective

Potential Actions

• It is worth reiterating that the goal of the investigation is not to place blame, but a potential outcome may result in disciplinary action, an agency order, occupational or criminal charges to an individual or corporation.

• The infraction of policies, safety rules, procedures, acts and regulations may be subject to disciplinary action, based on a weight of evidence.

• At AMEC, where necessary, disciplinary action would involve collaboration between the SHE Department, Human Resources, and Management.

Accident Investigation Summary

The provision of first aid or medical attention is always the first priority!

Secure and Manage Accident Scene

• Secure the scene immediately. Usually this is the responsibility of the first person on the scene. The employer or supervisor notified is responsible to preserve evidence and ensure that there is no further risk of injury or damage.

• Critical injury or fatality scenes must not be disturbed without permission from an Agency Inspector (or other regulatory authority).

• No one may disturb, alter, or remove anything at/or connected to the scene or occurrence.

• Exceptions may apply where lives are endangered, or where the interruption of essential services or further damage to equipment/property is possible. Security support should be considered.

Cost of Accidents

• Please review the safety video at the following link. This 12 min. video demonstrates clearly the distinction between incident types and outcomes.

• Link to Safety Video• Reference: Harsco Corporation is a diversified,

worldwide industrial services company.

Evaluation

• An online Quiz has been developed• Safety professionals, Management, Supervisors, Project

Managers, SHE Coordinators, designated Safety committee members and safety representatives are required to complete the Quiz.

• All employees are welcome to complete the online Quiz.