EHS BEST PRACTICE FOR INCIDENT REPORTING, INVESTIGATION AND ANALYSIS

Transcription

1 EHS BEST PRACTICE BP/1.9 EHS BEST PRACTICE FOR INCIDENT REPORTING, INVESTIGATION AND ANALYSIS JUNE 2016

2 Contents 1. Introduction Incidents and Accidents Objectives Scope Incident Reporting, Investigation and Analysis... 8 General... 8 Performance Criteria... 8 Expectations... 8 Reporting... 8 Investigation... 8 Analysis... 9 Review Responsibilities... 9 Employees... 9 Supervisors Line Manager HSE Manager Expectations Verification Investigation/Analysis Procedure When to Investigate Accidents? What to Investigate? How to Conduct the Investigation? Key Questions to Ask Accident/Incident Reporting Identifying Information Page 2

3 What Happened Cause of Accident Recommended Actions Review by Senior Management Fundamental Concepts Best Management Practices Preparing a Lessons learned Document Best Management Practices Taproot Methodology.. 17 Introduction... Error! Bookmark not defined. Taproot System... Error! Bookmark not defined. Flowchart... Error! Bookmark not defined. Circle...Error! Bookmark not defined. Rectangle...Error! Bookmark not defined. Oval...Error! Bookmark not defined. Barriers...Error! Bookmark not defined. Practical Application... Error! Bookmark not defined. Preparation...Error! Bookmark not defined. Introduction of System to Stakeholders Initial MeetingError! Bookmark not defined. Starting the Flowchart...Error! Bookmark not defined. Second Meeting...Error! Bookmark not defined. Observation of the Flowchart Process...Error! Bookmark not defined. Role of Facilitator...Error! Bookmark not defined. Observations Regarding Experiences Using Taproot... Error! Bookmark not defined. 14. References Page 3

4 Acronyms Acronym BP DOSHS ERC HSE EHS MS OSHA PA RC Description Best Practice Directorate of Occupational Safety and Health Services Energy Regulatory Commission Health, Safety and Environment Environment, Health and Safety Management System Occupational Health and Safety Act Preventive Action Root Cause Page 4

5 Terminology Acronym Accident Incident Investigation Investigation Team Hazard Near Miss Non-conformity Preventive Action Potential Incident Recordable Injury/Illness Root Cause Unsafe Act Unsafe Condition Description Undesired event arising out of and in the course and scope of an employee s employment and resulting in personal injury An unplanned event that occurs with potential to cause harm, injury Gathering of information on the causes of an incident Individuals responsible for conducting and documenting the incident investigation. A potential source of serious harm to people, property or the environment. An unplanned event that did not result in injury, illness, or damage but had the potential to do so. Only a break in the chain of events prevented an injury, fatality or damage. Non-fulfillment of a requirement. Note: Nonconformity can be any deviation from work standards, practices, procedures, legal requirements, or applicable code of regulations. Action to eliminate the cause of a potential nonconformity or other undesirable potential situation. A potential incident creates the possibility of an event, but nothing actually happens. With a potential incident nothing happened at all. Potential incidents can be classified as either unsafe acts or unsafe conditions. Failures to employ authorized management systems properly can also be considered as being potential incidents. Any occupational injury or illness resulting in death, days away from work, restricted work or transfer to another job, medical treatment beyond first aid. An identified reason for the presence of a defect or problem. The most basic reason, which if eliminated, would prevent recurrence. The source or origin of an event. An element of unsatisfactory behavior immediately prior to an accident event which is significant in initiating the event. A hazard e.g. risk taking, short cuts, carelessness, lack of attention, horseplay etc An unsatisfactory physical condition existing in the workplace environment immediately prior to an accident event which is significant in initiating the event. A hazard e.g. slippery floor, broken glass, unguarded machine, trailing cable, low lighting levels etc. Page 5

6 1. Introduction 1.1. These Health, Safety and Environment Best Practices (HSE BPs), herein referred as Best Practices (BPs), are guidance to Health, Safety and Environment (HSE) Practices for reporting, investigating and analyzing incidents and accidents, which cover normal, upset, abnormal and emergency situations and are produced by the Energy Regulatory Commission (ERC) in consultation with NEMA, DOSHS, KEBS, KMA and the Industry (Vivo Energy (K) Ltd) in Kenya. 2. Incidents and Accidents 2.1. The information contained in the BPs is not intended to be prescriptive, or to preclude the use of new developments, innovative solutions or alternative designs, materials, methods and procedures, so long as such alternatives provide an acceptable level of risk management The guidelines are provided for information and while every reasonable care has been taken to ensure the accuracy of its contents, the ERC cannot accept any responsibility for any action taken, or not taken, on the basis of this information Most accidents can be prevented. Finding the cause of each accident, regardless of how minor, is critical to preventing and controlling a recurrence Investigation of cause must go beyond identifying rule violations and may include, but not be limited to, human factors, process, supervision, as well as mechanical and/or infrastructure defects. There may be multiple causes and each must be understood through an analysis of the information collected during the investigation It may also be valuable to perform a risk assessment to better understand causes and to develop appropriate risk controls. The Investigating Team must recommend a cause (or causes) as well as preventative actions to management who will be responsible for implementing the required corrective actions. There are two categories of preventive actions: immediate protection and long-term correction The purpose of immediate protection is to reduce the immediate risk of another similar accident. The immediate protective actions, when required, must be implemented by the Investigating Team before operations are resumed Once the cause of an accident is known and all relevant conditions and failures have been identified, long-term corrections may be appropriate. The purpose of these actions is to reduce the likelihood of a similar accident recurring in the future With the introduction of the Health and Safety Committee Rules 2004 and OSHA 2007, the role of investigating accidents will increasingly be performed not solely by the supervisor but also committee members or representatives The BP provides basic guidelines for accident investigation. Page 6

7 3. Objectives 3.1. The BPs outline guidance for incident/near miss/unsafe acts/unsafe conditions and potential incidents reporting, investigation, and causal analysis procedures There are many benefits from an incident and near miss investigation, with one ultimate purpose prevention of injuries and future incidents. For this reason, incident reports should be written so that persons not familiar with the activity may understand and gain knowledge from the report Trending analysis will be done and used to evaluate: a. Frequency/severity of incidents b. Effectiveness of safety programs and work procedures c. Current incident prevention and awareness activities. Incident/near miss prevention is most effective when all incidents and near misses are promptly reported, thoroughly investigated, and the root causes identified, and corrective and preventive actions identified. An incident report must be completed within a reasonable amount of time following knowledge of an incident The main aim of investigating accidents is to: a. Prevent similar accidents recurring in the future. b. Identify any new hazards. c. Identify and choose suitable controls Facility Operators wish to reduce the cost in pain, suffering and loss of earnings of injured workers. Facility Operators also wish to reduce productivity losses. Therefore, they need to fully and accurately investigate the circumstances and causes of any accident. 4. Scope 4.1. Effective incident investigation, reporting, and follow-up are necessary to achieve HSE MS integrity. They provide the opportunity to learn from reported incidents and to use the information to take corrective action and prevent recurrence All incidents and near misses shall be investigated, analyzed, and recorded The depth of a near miss investigation is dependent on its potential to cause severe damage or personal injury should the incident occur. Page 7

8 5. Incident Reporting, Investigation and Analysis General 5.1. The reporting, recording, investigation, analysis and review of workplace incidents (including injuries, illnesses, and near misses) will help identify problem areas where incidents arise frequently It will also help the organization and agencies in their risk assessment process by providing useful information for injury prevention Recording workplace injuries is also a legislative requirement under OSHA Performance Criteria Expectations 5.4. All incidents should be recorded Investigation of all incidents is carried out regardless of seriousness Serious incidents are investigated by a senior manager of the area in which the incident occurred Incident information is periodically analyzed and categorized Information from the analysis of injuries and incidents is made available to staff. Reporting 5.9. Reportable incidents should be reported to regulatory agencies in accordance with Energy Act, EMCA and OSHA Notification of significant injuries (48 hours) and non-significant injuries (7 days) to insurer in compliance with legislative requirements The incident reporting process is communicated clearly to relevant staff A register of injuries (as required under OSHA 2007) is readily accessible There is a central repository for recording all workplace related incidents, injuries, illnesses and near misses as required by OSHA Data to be collected includes injury, incident and claims reports. Investigation An investigation is conducted as soon as practicable after an injury or incident occurs by a constituted team The facility owner/operator for the workplace where the incident occurred has primary responsibility for the investigation An incident investigation process is documented Incidents that lead to a worker s compensation claim or hazard report, including near misses, should be investigated to determine underlying causes. Page 8

9 5.18. There is a central repository for recording investigation report and corrective actions proposed Senior Management is informed of the outcome of all serious incident investigations. Analysis and Categorization Injuries, illnesses and other potentially serious incidents are analyzed at least yearly to determine underlying trends The results of these analyses are evaluated by Safety Committee to identify areas for improvement The risk assessment of the activity/process where injury or illness occurred is reviewed The results of the analysis are made available to Senior Management Incidents should be categorized in terms of risk, frequency, exposure and impact. Review Actions identified as a result of the investigation and analysis process: a. Are Prioritized and implemented. b. Require action parties and timelines Prioritized actions are incorporated into the HSE MS planning process Put in place a mechanism for checking corrective actions recommended from the incident investigation and analysis is implemented, monitored and closed out. 6. Responsibilities Employer 6.1. Competency development 6.2. Make workplace safe 6.3. Avail information on safety 6.4. Compliance with legal requirements 6.5. Carry out risk assessments 6.6. Review, monitor and implement corrective action plans Employees 6.7. Report any situation which would present a hazard and near misses Report to their supervisor any injuries/illnesses or any involvement in an incident regardless of how minor it may initially appear. Page 9

10 6.9. Deliver the Injury/Illness Evaluation Reports to supervisor immediately upon return Complete an Incident Notification Form as soon as possible for any incident or near miss in which they were involved or witnessed Participate in the investigation as directed by the supervisor. Supervisors Direct injured employees for medical treatment Immediately report any incident or near miss to the Line Manager Complete documentation of the incident Ensure the preventive and corrective actions identified by the incident investigation are implemented. Line Manager Lead the investigation team Ensure investigations are completed within a reasonable amount of time Review the final Incident Report or near miss report to ensure that the root, direct and contributing causes and the corrective and preventive actions are appropriate Implement the recommendations of the incident report HSE Manager Offer expert advice as part of the investigation team Coordinate review and implement recommendations of the Incident Report For OSHA Recordable cases, enter investigation report containing all the information required by the OSHA as soon as practicable For OSHA Recordable Cases, assure that a causal analysis has been performed using the Causal Analysis Tree. Assure that corrective and preventive actions are sufficient to address these causal factors For near misses, report the summary of the incident, root cause(s), findings if applicable, and any corrective and preventive actions taken. A causal analysis tree review may be warranted depending on the nature of the near miss. Identify whether lessons learned need to be shared with other divisions/sections Monitor cases with continuing lost or restricted time to ensure restrictions are accommodated Maintain a staff of formally trained investigators to provide investigation technical assistance when requested Develop and maintain incident investigation/analysis policies. Page 10

11 6.28. Maintain a record of incident register, trending and training, and statistical information such as incident rates Assume the investigative readiness role in the event that an incident is severe enough to warrant an independent investigation With assistance of medical practitioners, assess occupational injuries and illnesses to determine extent of injuries, provide for treatment, and place medical restrictions, when necessary, to ensure quick and complete recovery Inform the supervisor and Line Manager of each employee who has reported injury or illness, or as the result of a vehicle collision or other vehicle incident Maintain injury/illness database (for worker s compensation purposes.) 7. Expectations 7.1. The Company should develop and implement procedures to ensure the following: a) A system is in place for the timely reporting, investigation, analysis and follows up of incidents and near misses. b) All incidents must be reported to management as soon as practical and reports must be completed within 24 hours. c) All personnel must be made aware of their responsibility to report all incidents and near misses. d) Investigations must identify the root causes of the incidents. e) Recommendations to prevent the recurrence of the incident must be monitored and tracked until implementation. f) Major incidents, such as day away injuries, must be investigated using a root cause analysis methodology. g) Lessons learned from incidents and near misses must be communicated across the organization. h) The HSE Function shall conduct an analysis of injuries and near misses and provide written feedback to the appropriate operating groups. i) All incidents, near misses and injuries must be recorded into the safety portion of the on-line HSE recordkeeping system. j) All injuries shall be recorded in the General Register in accordance to OSHA. k) A case management procedure is in place, which meets the requirements of the applicable insurance coverage for the operation. 8. Verification 8.1. Adherence with BPs will be verified by determining that: a. Employees are aware of the requirement to report injuries Page 11

12 b. All reported incidents are investigated within 24 hours. c. The root causes have been identified The results of investigations are communicated to the appropriate employees d. Trend analysis reports are developed and issued on a periodic basis. Page 12

13 9. Investigation/Analysis Procedure 9.1. Incident investigations and analyses are conducted to identify unsafe acts and conditions and then formulate corrective and preventive actions to prevent recurrence Besides a root cause investigation, reports must also state corrective and preventive actions identified during the investigation. The process described below is to be applied to all incidents, first aid cases and near misses: a. Preserve the accident scene b. Photograph the accident scene c. Supervisor completes incident report d. Interview witnesses e. Collect evidence f. Analyze incident, consulting with HSE as needed. g. Identify causes (root-direct-contributing) h. Determine needed preventive and corrective actions i. Identify lessons learned When to Investigate Accidents? 9.3. It is important that any investigation occurs as soon as possible. The less time between an accident and the investigation, the more accurate the information that can be obtained While concern for an injured worker should take precedence over everything else, when accidents involving injury or illness occur, early investigation is essential. What to Investigate? 9.5. Any accident, in which injury or significant property damage occurs, should be investigated. There will also be events usually referred to as 'near misses' or incidents, where employees have been 'lucky' to escape injury Accidents and incidents have the same causes and actions, only the consequences vary. Studies of incidents can therefore be used to prevent accidents. How to Conduct the Investigation? 9.7. Examine the causes and results of any accident objectively. The investigator must begin the investigation with an open mind. No assumptions should be made and any judgements should be based on information that is known to be full and accurate. Page 13

14 9.8. Ask open-ended questions and not to put words into witnesses' mouths. It is also important not to blame people but rather to emphasize the importance of seeking the reasons for the accident to prevent a recurrence It is far less effective to attempt to change people or the environment, a more positive approach attempting to modify the environment is instead recommended, i.e. it is more effective to alter the situations producing an error than to attempt to change human nature The investigation may require photographs, sketches or another's technical expertise before the final causes of an accident can be determined and adequate controls considered and chosen When commencing the investigation: a. Constitute an investigation team. b. Gather appropriate investigation tools. c. Start the investigation as quickly as possible. d. Conduct interviews at the scene of the accident if possible. e. Ensure witnesses' discuss the accident in relative privacy. f. Begin with those who can contribute most After each interview, repeat the witness story, as you understand it to ensure that you have correctly understood Close each interview on a positive note Take immediate corrective action where warranted Complete report with recommendations Ensure follow- up action occurs. Key Questions to Ask a. Who? Get the names of everyone involved, near, present or aware of possible contributing factors. b. What? Describe materials and equipment involved, check for defects, get an exact description of chemicals involved, etc. c. Where? Describe exact location; note all relevant facts, i.e. lighting, weather, etc. d. When? Note exact time, date and other factors, i.e. shift change, work cycle, and break period, etc. e. How? Describe usual sequence of events and actual sequence of events before, during and after the accident. f. Why? Find all possible direct and indirect causes AND How to keep it from happening again. Page 14

15 10. Accident/Incident Reporting Each report is designed to suit the environment in which it is designed for Properly completed, report can be used for long-term analysis of accident trends, as a management tool to ensure that thorough investigation is occurring and as a means of complying with legislative requirements (there is a requirement for any serious accident putting someone off work to notify the DOSHS) Any accident/incident report should provide: a) Identifying information b) What happened c) Cause of incident d) Recommended action e) Requisite forms under OSHA 2007 to be filled. Identifying Information Who was involved and their background The exact location of the accident should be given as precisely as possible Dates, times and places will also be of value. What Happened A step-by-step sequence should be obtained as to what happened and to any contributing causes to the accident which may have been identified. This is a very crucial section to complete. Cause of Accident This section should give a reader an understanding of immediate cause(s) as well as the basic cause(s) of the problem Use of this section is made to determine whether the follow-up action recommended is adequate As this is the heart of the investigation report, its accuracy is crucial. The writer should have some training in identifying basic causes of accidents rather than, as is common, an approach that tends to blame the injured party. Recommended Actions This should include a judgement of the effectiveness of the recommended actions and should also detail any intermediate actions which have been taken to reduce the probability of a similar accident. Page 15

16 Review by Senior Management To consider and decide upon applying the recommendations It is important that all those involved understand what their responsibilities are It should be clear: a. Who they should report to b. How and when this should occur. 11. Fundamental Concepts Behind every accident or incident there are contributory factors, causes and subcauses Accident investigation should be related to an emphasis on control of injury and loss/damage rather than just injury-orientated Systems failure and human error are the basic causes of many accidents After identifying causes and factors, suitable solutions should be proposed and applied. 12. Best Management Practices Preparing a Lessons learned Document General Tips include: a. Use technical terms only when necessary. When used, explain the concept. b. Don t use acronyms. c. Don t use personal names; use titles. d. If there have been similar events, discuss trends. e. Don t use long, run-on sentences. f. Attach photographs if possible. g. Draft a review or have someone else review for factual accuracy. h. Title: i. Make it short but make it specific. Include date of incident i. Event: i. Summarize event, stick to pertinent facts ii. Summarize any tests that were performed j. Actions/Conditions that May have Contributed to the Incident: i. Based on incident analysis, identify causal factors Page 16

17 k. Identify Lessons Learned i. Write brief statements about what was learned Be specific about recommendations for other actions l. Recommended Corrective Actions for Other Division/Sections i. Identify corrective actions, if any, that were taken 13. Best Management Practices Taproot Methodology It is recommended for the facility owner to adopt a structured professional investigation methodology such as Taproot, Tripod etc 14. References TapRooT Incident Investigation Methodology Occupational Safety and Health Act Environment Management and Coordination Act Energy Act No. 12 of 2006 Page 17