Joint Occupational Health and Safety Committee Foundation course Facilitator guide

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1 Joint Occupational Health and Safety Committee Foundation course Module: Interim guide: August 1 to December 31, 2015 This is a health and safety related document. It is not copyrighted and you are encouraged to copy the document as necessary. For more information contact the WorkSafeBC Information Line at or toll free at

2 Guidelines This facilitator s guide discusses concepts and methods that may be useful when instructing joint health and safety committee members on ways to develop and conduct an accident or incident investigation process at a workplace. The guide includes a variety of forms, checklists and other documents. The process presented in this guide, and in the student guide and workbook is one approach. Employers, joint health and safety committees and worker representatives may develop another method or format that works for their workplace. Another method and additional training on accident investigation is available on supervisingforsafety.com under incident analysis. This is a free e-learning course. The course was developed for training supervisors, and may be helpful for joint committee members wishing additional information. The e-learning course contains videos, interactive exercises and additional occupational health and safety (OH&S) topics. It is recommended that anyone planning on teaching this module become familiar with the e-learning course material. Disclaimer This instructional guide has been developed by WorkSafeBC. The material is designed for use by Joint Health and Safety Committees. WorkSafeBC is not responsible for the results or interpretations when the material is presented through other sources. If there is any conflict between information in this material and the current Workers Compensation Act, Occupational Health and Safety Regulation and related policies, the Act, the Regulation and policies shall take precedence. 2

3 Contents Joint Occupational Health and Safety Committee Foundation course... 1 Notes to facilitator Components Why does this guide expire on December 31, 2015?... 4 Introduction Objectives and agenda Investigation purpose The Workers Compensation Act Investigation concepts What to investigate? What to report? What the investigation must establish Incident causation Incident causation - case study Investigation procedures Visit the scene Interviews Evaluation Report Writing Reporting timelines Summary

4 Notes to facilitator 1. Encourage participants to ask questions and engage in discussions. 2. The total time required to facilitate this module will vary according to the number of examples provided, the depth of the discussions and the number of participants. This module will take approximately 6.5 hours to complete if all exercises and case studies are used. 3. In this module, the Act refers to the Workers Compensation Act and the Regulation refers to the Occupational Health and Safety Regulation. 4. This module was designed to be used in conjunction with the Investigation of accidents and incidents Reference guide and workbook, which is available online at WorkSafeBC.com, under the Safety At Work tab, select Joint Committee Training. 5. Periodic updates to this module facilitator guide will be made and posted on WorkSafeBC.com. However, if you wish to update the statistics in this module independently, you may do so by going to worksafebc.com to obtain the most current injuries and claims information from the annual WorkSafeBC statistics report, under the Publications tab, select Statistics reports. 6. Review emergency evacuation procedures and housekeeping matters with the participants before proceeding with the main presentation. 1.1 Components The facilitator should encourage active participation in this participant-oriented workshop. The module begins with a brief review of the key points of the accident investigation and reporting requirements, and the general process of accident investigation. Let the participants know that a joint health and safety committee member has the duty to participate in investigations in according to section 130 of the Act. An optional accident scenario with role-play and analysis is available online at WorkSafeBC.com. The preliminary incident investigation role play considers how to identify unsafe conditions, acts and procedures that significantly contribute to the accident or incident. Students will analyze the facts and make recommendations for corrective actions. 1.2 Why does this guide expire on December 31, 2015? On May 27, 2015 WorkSafeBC introduced two new interim occupational health and safety policies on the topic of employer incident investigations. The policies and amendments apply to incidents that occur between May 27, 2015 and December 31, These interim policies will be replaced by final policies following public consultation. 4

5 Consultation regarding proposed policy changes specific to employer incident investigations will take place between June and October Public hearings regarding regulation changes are planned for the fall of Policy and regulation changes are expected to be made by the end of WorkSafeBC will also take this opportunity to revise the Investigation of accidents and incidents - Reference guide and workbook, as well as the facilitator s guide and optional workshop material, to incorporate current incident investigation best practices. A revised version of these training documents will likely be released in early 2016, after the new policies have been released. More information about policy consultation and public hearings is available on WorkSafeBC.com, under the Regulation & Policy tab. You can also go to WorkSafeBC.com to find more information about how you can provide feedback on proposed policy and regulation changes. 5

6 Introduction Explain: In this module, we will be discussing the investigation of accidents and incidents, and the role of committee members or worker representatives in maintaining a safe and healthy workplace. Investigating workplace incidents and identifying corrective action to address any unsafe conditions, acts or procedures can help to prevent further workplace accidents and reduce the number of workers injured and killed on the job. 6

7 2.1 Objectives and agenda Ask participants to state their expectations for this module. Record participant expectations on a flipchart and review them at the end of the module. Explain the learning objectives of this module. Note how they match with participants expectations. Encourage the class to actively take part in discussions, ask questions and make notes. Let the participants know that it is OK to take pictures of each other s flip charts during the breaks with their cell phones or camera. Ask, how many in the class have participated in or have conducted an accident investigation. Take note of their responses as the information may become important when you start assigning roles in the case study exercises. You do not want one group with all the experienced participants in it. 7

8 Although the number of occupational injuries and diseases in B.C. has consistently declined in the past five years, serious injuries have not declined. Review the statistics on this slide. Ask participants to list some of the reasons why they think injuries and diseases occur in the workplace Record answers on the flipchart Explain that a serious injury is any injury that can reasonably be expected at the time of the incident to endanger life or cause permanent injury. Serious injuries include traumatic injuries that are life threatening, life altering or result in a loss of consciousness, as well as incidents such as chemical exposures, heat stress, and cold stress which are likely to result in a life threatening condition or cause permanent injury or significant physical impairment. 8

9 Ask, if a person is in a position that would allow him / her to prevent a workplace injury or occupational disease, do you think that person has a moral responsibility to do so? Note the general consensus of participants. Distribute the workbook - reference guide and workbook Note: Page references in this module refer to the workbook. Encourage participants to make notes in their workbook for future reference. Direct students to page 5 of the workbook Some basic definitions are required before proceeding with this module. Ask, what is an Accident? This slide is designed with animation. Answers: An accident is an unplanned, unwanted event that disrupts the orderly flow of the work process. It involves the motion of people, objects or substances. 9

10 Ask, what is an Incident? This slide is designed with animation. Answer: The term incident includes an accident or other occurrences which resulted in or had the potential for causing an injury or occupational disease. The term incident may be applied to any undesired or unwanted event that could (or does) degrade the efficiency of the business operation. This may include accidents, quality or production problems or security breaches such as theft. 10

11 Ask, what is an accident or incident investigation? This slide is designed with animation. Answer: An accident or incident investigation is the analysis and account of an incident based on information gathered by a thorough examination of all factors involved. 11

12 2.2 Investigation purpose Ask, why do we investigate accidents and incidents? Using a flipchart record participants answers for review at the end of this module. State the following: Remember these three basic facts: 1. Accidents and incidents are caused. 2. Accidents and incidents can be prevented if the causes are eliminated. 3. Unless the causes are eliminated, the same accidents and incidents will happen again. Usually there are four or five root causes or factors that contribute to an incident. Often there are even more. Your task is to identify as many as possible to establish the causes of a workplace incident, and to identify any unsafe conditions, acts or procedures that significantly contributed to the incident. 12

13 2.3 The Workers Compensation Act Ask participants to turn to page 7 of the Workbook. The legislative requirements for conducting incident investigations and preparing corrective action reports are contained in the Act Part 3, Division 10. These legislative requirements are outlined on pages 7 to 10. The Act also sets out the employer s responsibility to investigate incidents and prepare reports of those investigations. Excerpts from this legislation are included as Appendix 2 of the Workbook. The Prevention Manual contains WorkSafeBC policy with respect to matters under Part 3 of the Act. On May 27, 2015 WorkSafeBC introduced two new interim OHS policies regarding employer incident investigations. The policies and amendments apply to incidents that occur between May 27, 2015 and December 31, 2015 and will be replaced by final policies following public consultation. Excerpts from these policies are included as Appendix 3 of the Workbook. Remember that the requirements set out in the Act, Regulation and policy are the minimum standards. Your incident investigation procedures may go beyond these requirements. 13

14 Division 10 - Accident reporting and investigation Immediate notice of certain accidents Section 172 (1) An employer must immediately notify the Board of the occurrence of any accident that (a) resulted in serious injury to or the death of a worker, (b) involved a major structural failure or collapse of a building, bridge, tower, crane, hoist, temporary construction support system, or excavation, (c) involved the major release of a hazardous substance, or (d) was an incident required by regulation to be reported. Notes: A serious injury is any injury that can reasonably be expected at the time of the incident to endanger life or cause permanent injury. Serious injuries include both traumatic injuries 14

15 that are life threatening or that result in a loss of consciousness, and incidents such as chemical exposures, heat stress, and cold stress which are likely to result in a life threatening condition or cause permanent injury or significant physical impairment. Guideline G-D sets out what WorkSafeBC considers to be a serious injury, which an employer is required to report to WorkSafeBC. A major release of a hazardous substance means not only a considerable quantity, or the peculiar nature of the release, such as a gas or volatile liquid, but, more importantly, the seriousness of the risk to the health of workers. Factors which determine the seriousness of the risk include the degree of preparedness of the employer to respond to the release, the necessity of working in close proximity to the release, the atmospheric conditions at the time of the release and the nature of the substance. Prevention Policy Item D provides additional guidance around what constitutes a major release of a hazardous substance. Explain that, as a general guideline, a report would be expected when: 1. The incident resulted in an injury which required immediate medical attention beyond the level of service (scope of practice or level of training) provided by a first aid attendant, or injuries to several workers which require first aid. 2. The incident resulted in a situation of continuing danger to workers, as when the release of a chemical cannot be readily or quickly cleaned up. 15

16 Preservation of evidence investigation process Review Section 172(2) of the Act on page 8 of the Workbook with participants, elaborate on the key points and give relevant examples regarding the preservation of evidence. Preservation of evidence Section 172 (2) Except as otherwise directed by an officer of the board or a peace officer, a person must not disturb the scene of an accident that is reportable under subsection (1) except so far as is necessary to (a) attend to persons injured or killed, (b) prevent further injuries or death, or (c) protect property that is endangered as a result of the accident. 16

17 Incidents that must be investigated Review Section 173 of the Act on page 8 of the Workbook with participants. Section 173 (1) An employer must conduct a preliminary investigation under section 175 and a full investigation under section 176 respecting any accident or other incident that (a) is required to be reported by section 172, (b) resulted in injury to a worker requiring medical treatment (c) did not involve injury to a worker, or involved only minor injury not requiring medical treatment, but had a potential for causing serious injury to a worker, or (d) was an incident required by regulation to be investigated. (2) Subsection (1) does not apply in the case of a vehicle accident occurring on a public street or highway. 17

18 Notes: Medical treatment means treatment by a registered medical practitioner. The Regulation sets out specific investigation and reporting requirements for blasting accidents and other dangerous incidents involving explosives (section 21.3) and for dangerous incidents that occur during a diving operation (section 24.34). Excerpts from these sections are included as Appendix 4 of the Workbook Elaborate on the points by giving examples from the participants industry. Try to use examples that have been recently highlighted in the media. 18

19 Investigation process Ask participants what kind of qualifications an investigator needs? Using a flipchart record participants answers for review at the end of this module. After the participants have come up with a list, go over the next slide with the material on page 9 and in Appendices 2 and 3 of the Workbook. Discuss the different purpose and intent of preliminary and full incident investigations. 19

20 Intent of the investigation Discuss the differences between a preliminary investigation and a full investigation o In the preliminary investigation, employers must identify any unsafe conditions, acts, or procedures as far as possible in order to ensure that work can be continued or resumed safely during the interim period between the incident and the conclusion of the full investigation. o In the full investigation, employers must determine the cause or causes of the incident. Determining the cause or causes means analyzing the facts and circumstances of the incident to identify the underlying factors that led to the incident. This includes identifying the underlying factors that made the unsafe conditions, acts, or procedures possible and identifying health and safety deficiencies. Elaborate on the points by giving examples from the participants industry. Try to use examples that have been recently highlighted in the media. 20

21 Incident Investigation Report Go through the requirements of sections 175 and 176 of the Act, and the associated Prevention Policies. Refer the participants to Appendices 2 and 3 of the Workbook. Reports and forms WorkSafeBC has developed two methods of recording incident investigations that employers may use if they do not wish to develop their own form. The first option is to use the fourpart Incident Investigation Report form to complete all report types using one form. The second option is to use individual reports specifically tailored for each report type. These forms are available as Microsoft Word documents and as dynamic PDF forms, and can be found online at WorkSafeBC.com, under Forms. A copy of the four-part Incident Investigation Report form is included as Appendix 7 in the workbook (p. 45). A sample completed preliminary incident investigation report is included as Appendix 8 (p. 53). 21

22 Note: Employers wanting help in completing incident investigation reports may consult the Quick Guide to Incident Investigation and Reporting for Employers. This guide is available for free download on WorkSafeBC.com, under the Forms tab, select Incident investigation report form and resources. Section 175(2) Preliminary investigation Report The employer must ensure that a report of the preliminary investigation is (a) prepared in accordance with the policies of the board of directors, (b) completed within 48 hours of the occurrence of the incident,... Prevention policies On May 27, 2015 WorkSafeBC introduced two new provisional OHS policies regarding employer incident investigations. These are interim policies. The policies and amendments apply to incidents that occur between May 27, 2015 and December 31, 2015 and will be replaced by final policies following public consultation. Prevention Manual Item D (interim) An employer s preliminary investigation report of a section 173 incident must contain the following elements, as far as possible: (a) the place, date and time of the incident; (b) the names and job titles of persons injured in the incident; (c) the names and job titles of witnesses; (d) the names and job titles of any other persons whose presence might be necessary for a proper investigation of the incident; (e) a statement of the sequence of events that preceded the incident; (f) identification of any unsafe conditions, acts or procedures that significantly contributed to the incident; (g) a brief description of the incident; (h) the names and job titles of the persons who conducted the preliminary investigation of the incident; (i) interim corrective actions the employer has determined to prevent the recurrence of similar incidents, for the interim period between the occurrence of the incident and the submission of the full investigation report; (j)information about what interim corrective action has been taken and when any corrective actions not yet implemented will be taken; and (k) the circumstances of the accident or incident that preclude the employer from addressing a particular element of the above-listed elements during the preliminary investigation period. Section 176(2) Full investigation report preparation and distribution The employer must ensure that a report of the full investigation is (a) prepared in accordance with the policies of the board of directors, and (b) submitted to the Board within 30 days of the occurrence of the incident... 22

23 Prevention Manual Item D (interim) An employer s full investigation report of the section 173 incident must contain the following elements, as far as possible: (a) Elements (a) through (f) of Item D , Preliminary Incident Investigation, Report and Follow-Up Action, including any updates available following the preliminary investigation period; (b) determination of the cause or causes of the incident; (c) a full description of the incident; (d) the names and job titles of the persons who conducted the preliminary and full investigation of the incident; (e) all corrective actions the employer has determined are necessary to prevent the recurrence of similar incidents; and (f) information about what corrective action has been taken and when any corrective actions not yet implemented will be taken. 23

24 Investigation concepts In this section of the course we will discuss some of the basic concepts and theories of incident investigations (pages 11 and 12 of the Workbook). Before we proceed, consider the fact that an accident/incident cannot be investigated unless it is known that one has occurred. Ask, What are some of reasons why accidents/incidents are not reported and how would you ensure that they are reported? Using a flipchart, record participant answers. Encourage suggestions and discuss them. Go over the list of reasons why accidents/incidents are not reported with the participants and add any that you feel are missing. At the end of the above exercise, refer the participants to page 27 of their workbook and compare answers. Reasons for not reporting are important as a lot of incidents that should be reported are not reported or are under reported. Reasons why accidents/incidents may not be reported could include: Not wanting to spoil safety record Not wanting to go to first aid Afraid co-workers will give them a hard time Afraid of medical treatment Doesn t like the red tape involved with filling out forms Afraid foreman will get mad Not wanting to be central person in an incident investigation Not wanting to lose time. 24

25 3.1 What to investigate? Types of accidents/incidents to investigate Serious and major incidents or accidents Usually investigated automatically, Must be investigated if specified in the Act, Regulation or policy. Prevention Policy Item D provides additional guidance around what constitutes a major release of a hazardous substance. Occupational Health and Safety Guideline G-D , WorkSafeBC Notification of Serious Injuries sets out what WorkSafeBC considers to be a serious injury, which must be reported to WorkSafeBC. Minor and near-miss incidents which had the potential to cause serious injury, illness or death. Indicators that point to a condition or practice that, if allowed to continue, could 25

26 cause injury or equipment damage. Investigations of serious incidents and accidents often reveal earlier incidents of a similar nature, but with less serious injury or damage, that have been dismissed as insignificant. Proper investigations of earlier less serious, minor or near miss incidents would likely have prevented the serious accident just experienced. To prevent that scenario from repeating itself in the future, if the accident or incident only caused minor injury or no injury, ask yourself: Had circumstances been a little bit different, could someone have been seriously injured? If the answer is Yes, then the incident or accident should be investigated. Be grateful that you were able to correct potential risks for serious injury before such an event occurred. Employers are required to immediately undertake an investigation into any accident or other incident that involves: Serious injury to or death to a worker Major structural failure or collapse Major release of hazardous substances Blasting accident causing personal injury Dangerous incident involving explosives, whether or not there is personal injury Diving incident, as defined by regulation Injury requiring medical treatment Minor injury or no injury but had potential for causing serious injury Note: The requirement to conduct an investigation does not apply in the case of a vehicle accident occurring on a public street or highway (section 173(2) of the Act). All accidents and incidents with the potential for loss should be investigated. 26

27 3.2 What to report? Depending on the nature of the incident or accident, and whether or not any corrective action is required, the employer may be required to complete four reports: 1. A preliminary investigation report (within 48 hours of the incident) 2. An interim corrective action report that addresses the findings of the preliminary investigation 3. A full investigation report (within 30 days of the incident) 4. A full corrective action report that addresses the findings of the full investigation The employer may provide a copy of the preliminary report or the full report to the joint committee or worker health and safety representative, as applicable. If doing so, the employer may need to remove some information from the investigation reports in order to protect personal information of individuals. 27

28 3.3 What the investigation must establish Review the bullets on the slide and provide examples. 1. What happened? Describe the incident or accident. 2. Who was involved or injured? Include the name and job title of the person or people injured, witnesses and anyone else whose participation might be necessary for a proper investigation. Who witnessed the incident or accident? Who else has information that would be beneficial to the investigation? Who conducted the preliminary investigation and the full investigation? 3. Where did the accident/incident happen? Include the place, name of the department, specific machine and location and any 28

29 other details. If the accident or incident occurred at a temporary work location or remote worksite, provide information about the exact location. This may include the name of the area (such as a lake or mountain), latitude and longitude, GPS coordinates, or other specific locators. 4. When did the accident/incident occur? Include the date, exact time of day, and shift. 5. What were the immediate and basic causes? Provide a statement of the sequence of events that occurred before the incident or accident. Also, identify any unsafe conditions, acts or procedures that may have significantly contributed to the incident. Include information about any special circumstances around the accident or incident that may have prevented the employer from gathering all the information during the preliminary or full investigation. 6. Why was the unsafe act, condition, or procedure permitted? (For example, lack of training, supervision, rule enforcement, maintenance). 7. How can a similar accident/incident be prevented? (Be specific). Provide information about the interim corrective action that has been taken immediately after the incident, about other corrective action that has been determined to be necessary but has not yet been implemented, and about final corrective action taken to prevent the recurrence of similar incidents. If there are circumstances that inhibit the employer s ability to identify unsafe conditions, acts or procedures that significantly contributed to the accident or incident, these should be included in the preliminary investigation report. If corrective action has been identified but not implemented, include information about why the employer has not taken the corrective action immediately and when it will be implemented. 29

30 3.4 Incident causation Exercise Divide the participants into small groups and ask each group to choose a spokesperson. Get the groups to brainstorm and answer the following questions, have them record their answers on a flip chart. Post group answers at the front of the room. The spokesperson for each group explains their list to the other participants in the room. Ask, what are some contributing factors to Accidents and Incidents? When considering contributing factors, ask yourself the following questions at the same time. What can management do to prevent the incident from recurring? What can the supervisor do to prevent recurrence? What can the worker do? 30

31 3.4.1 Incident causation - case study Ask participants to turn to page 17 of the workbook. Explain that most incidents are the result of several causes happening in sequence and in combination. Ask participants to read through the case study on page 17 of the workbook and to identify and underline the various unsafe acts, conditions, procedures or personal factors which contributed to the incident. Ask them to be prepared to discuss the case study. Allow 5 to 10 minutes for participants to read through this case study and identify and underline the contributing factors. It all started in the afternoon. Bill had a violent argument with a co-worker shortly before quitting time, which almost came to blows. Bill left the plant still angry and emotionally upset. He stopped off at a bar for a drink and stayed longer than he had intended. Leaving the bar in an intoxicated state, Bill arrived home late for supper, which precipitated an argument with his wife. Stomping out of the house without supper, Bill returned to the bar and spent the rest of the evening there. Finally leaving the bar, he realized he had better sober up before returning home and decided to drive out to a highway restaurant to get something to eat. Outside, snow and freezing rain had been falling. The highway, which had not yet been sanded, was slick with ice and snow. Oblivious to hazards, Bill drove too fast for the road conditions. Rounding a sharp curve, he was blinded by the high beam lights of an oncoming car. Bill slammed on his brakes. That did it. His car went into a skid and crashed into a guardrail. The car sustained extensive damage. Bill, fortunately, received only minor cuts and bruises. Note: Answer key is in Appendix 1 of the workbook 31

32 Factors that contributed to the incident may include: Argument with a co-worker Angry and emotionally upset Goes to bar Drinks alcohol Stays longer than intended More upset Left the bar intoxicated Roads had not been sanded Late for supper Oblivious to hazards Argument with wife Drove too fast for conditions Goes back to bar Curve in road No supper High beams Drives intoxicated Over-compensated Snow and freezing rain Braked hard Slick roads By identifying and listing all possible contributing factors, no matter how trivial, the investigating team can isolate the factors most useful to them. Unsafe conditions, acts, procedures and personal factors The various contributing factors identified in the case study may be grouped as follows: Unsafe conditions or environment Icy road conditions Glare of oncoming headlights Sharp curve in the road Improper workplace activities or behaviour Unsafe acts by the individual Braking too abruptly Driving too fast for road conditions Driving while intoxicated Unsafe acts by others Failure of oncoming driver to dim the lights Failure to sand the road Personal factors Intoxication Emotional state of mind (arguments with co-worker and with wife) 32

33 Investigation procedures Explain that this portion of the module deals with the procedural aspects of conducting an investigation. Similar investigation procedures may be used for both preliminary and full investigation, though the elements of each may differ slightly. Review each point on the slide. Let the participants know that we will go over each of the points in detail in the next few slides and in their workbook. This section of the course starts on page 18 of the workbook. Remind participants that, to become proficient at conducting investigations, they will need to apply the skills acquired during this module on every accident and incident that occurs at the workplace. An optional accident scenario with role-play and analysis is available online at WorkSafeBC.com. The preliminary incident investigation role play will provide students with an opportunity to apply some of the skills learnt. 33

34 Basic investigation kit Review each point on the slide. Ask the participants if anything was left out of the list that that they think should be included in an Investigation Kit. You may get the following as answers: Water proof paper Voice or audio recorder Video camera Cell phone Numbered tent cards Remind the participants that the list contains the basics and that they are free to add to their own investigation kits and it may be a good idea to make it industry specific. For example, if they are dealing with cranes they may want to invest in getting some wire gauges and a wind meter. All the above items should be stored in a sturdy bag or plastic bucket that is easy to transport. 34

35 4.1 Visit the scene Review the following points on the slide. Recommended procedure Secure the scene to minimize the risk of any further injury. While approaching the accident scene, analyze the situation and take suitable action to prevent further deterioration. Ensure the injured are cared for. Make sure that the injured workers are properly cared for before starting the investigation. Keep the accident scene as undisturbed as possible. The Act provides that the scene of an accident must not be disturbed except to the extent necessary to attended to people who have been injured or killed, to prevent further injuries or death or to protect property endangered as a result of the accident. 35

36 Make an accurate record of the accident scene. Photographs of the accident scene should be taken, drawings made and measurements checked for reference in future discussions. Sample accident scene sketches are included as Appendix 5 of the workbook. Identify and interview all witnesses separately and individually as soon as possible. Interviewing skills will be reviewed in the next section. Record all information accurately. Start the incident investigation report. The basic information such as dates and times can be filled in on the incident investigation report at this point. It s a good idea to do a rough drawing in the field then go back to the office and design a computer drawing be sure to keep a copy of your original drawing in case it goes to court. Ask participants to turn to page 41 to 44 of their workbook. Review the sample accident scene sketches with them. Ask participants to turn to page 45 of the workbook for a copy of an accident/incident investigation check list. Remind participants that it is only a sample. Each employer may have their own list. You may have or you may want to develop your own list. Ask if anyone has any questions. 36

37 4.2 Interviews One of the main methods of gathering information in an incident investigation is interviews with people who were at the accident scene. Interviews should also be conducted with anyone who can give relevant information, even if they were not present. An example would be the supervisor who gave instructions at the start of the shift or a trainer who instructed the worker, even if the training occurred several months earlier. The following techniques may assist in conducting interviews: Put the witness at ease. o A hostile or defensive witness can hinder the investigation and may adversely affect other persons involved. Reassure each witness of the investigation s main purpose. o The investigation is to find the causes so they can be eliminated to prevent recurrence, not to pin blame. Responsibilities may be pointed out, but this is only to assist in preventing the same contributing factors that led to the incident in the first place. 37

38 Ask the witness to relate his or her account of the incident. Listen closely and carefully, and do not interrupt at this time. This gives the individual a chance to formulate the story in their own mind and gives you a preview of what they know. Do not take notes during this initial dissertation as it distracts the witness. Do not record the interview. Have the witness relate their story again. Take notes and ask questions to fill in the gaps. Do not take your notes in a secretive manner. Allow the individual to see your notes. Ask further specific questions if required. Avoid questions that lead the witness or imply answers. Go over your notes to ensure the witness agrees with your interpretation of their story. Ask the witness for their suggestions as to how the accident could have been avoided. Encourage the witness to contact you at a later date should they think of something else. Be sure to thank individuals for their assistance. 38

39 4.3 Evaluation We are now at the stage of evaluating the evidence you have gathered and are prepared to draw conclusions based on that evidence. (Page 21 of the workbook) Review each point on the slide and remind them to: Be objective don t start with a fixed opinion. Set out the events in chronological order. Be sure to consider all of the contributing factors. Use a checklist to ensure that you have covered all of the areas. Consider what evidence is direct, circumstantial or hearsay. Explain the meaning of each of the terms. o Direct one of your witnesses saw it happen; o Circumstantial indirect evidence- establishing a conclusion by inference from known facts; o Hearsay someone hears something said by someone else. Do not draw conclusions on the first basic cause found. 39

40 Common Investigation Errors and Pitfalls The following are common errors and pitfalls that arise in the incident investigation process: Elaborate on each point, Believing carelessness is a cause of accidents and incidents. Assuming contradictory evidence indicates falsehood. Conducting interviews as if in a courtroom. Asking for a signed statement from witnesses. Looking for only one basic cause. Forgetting about the personal feelings of others. Failing to keep information confidential. 40

41 4.4 Report Writing Show Slide Now we are at the point where the report can be written. There are a few points that should be kept in mind for writing incident investigation reports (page 22): Include a brief outline of the events leading up to and including the accident or incident. Describe the events in chronological order. Be specific include dates, times, places, people involved, conditions, acts etc. Attach diagrams, photos, manufacturer s specifications etc. Recommendations for corrective action should address the underlying causes of the accident, not the symptoms. o If a worker not wearing a hardhat is struck on the head, the problem is not that he wasn t wearing a hardhat as much as WHY he wasn t wearing one. Recommendations should address all of the contributing factors. 41

42 The report should contain enough details to provide readers with as much if not more information than they would have obtained if they had witnessed the accident or incident themselves. WorkSafeBC has developed sample report forms. These reports contain the minimum required content to satisfy the Act. If you choose to customize any report forms, you may add fields but you cannot delete any of the current fields. To view and download the report forms, visit Facilitator note: It would be helpful to have some sample investigation reports of different styles to show the participants at this point. It is important to stress the point that there is more than one way to write an accident/incident report. What is important is that the final report contains all the information to make corrective actions so that the accident/incident will not occur again. Note: Refer to the blank incident investigation report form, included as Appendix 7 of the Workbook, and the sample completed preliminary incident investigation report, included as Appendix 8. 42

43 4.4.1 Reporting timelines Show Slide The Act sets out timelines for an employer to complete incident investigation reports, and corrective action reports. Employers must immediately undertake the preliminary investigation and complete a preliminary investigation report within 48 hours of the incident. Employers must undertake the full investigation and then submit the full investigation report to WorkSafeBC within 30 days of the incident, unless WorkSafeBC grants an extension. Depending on the complexity of the incident, an employer may complete its full investigation report within 48 hours. The 48 hour period can be extended if it expires on a Sunday or other holiday, or it expires on a day the employer is not normally open. 43

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