ACCIDENT/INCIDENT INVESTIGATIONS

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1 ACCIDENT/INCIDENT INVESTIGATIONS PURPOSE OF THIS GUIDE The Workplace Health, Safety and Compensation Commission is developing resource materials to help workplace parties employers, workers including supervisors and managers, and occupational health and safety committees to carry out their responsibilities for health and safety in the workplace. This specific booklet, Accident/Incident Investigations, is designed to provide workplace parties with an understanding of their role in effective accident/incident investigations. It includes an outline for planning and the six steps involved in conducting accident/incident investigations. A sample accident/incident report form and a sample accident/incident investigation form are also included in this booklet. ACCIDENT/INCIDENT INVESTIGATIONS Sources of Information Workplace Health, Safety and Compensation Commission Prevention Services Phone: (709) Toll free or Department of Government Services Occupational Health and Safety Branch Phone: (709) Toll free or Human Resources and Social Development Labour Program, Newfoundland and Labrador office Phone: (709) (call collect outside St. John s) May 2006

2 Disclaimer The Workplace Health, Safety and Compensation Commission (the Commission) provides information and health and safety advisory services for most aspects of occupational health and safety programming. The information presented is subject to a disclaimer. It is intended to provide examples of general use and may not apply to every circumstance. While all reasonable efforts have been made to ensure the accuracy of the information presented, the Commission does not and cannot guarantee the accuracy thereof. The Commission does not warrant or assume any legal liability or responsibility for the accuracy, completeness, or usefulness of the information presented nor for any actions taken in reliance thereon. The Commission shall not be liable for any damage or loss arising out of the use of the information or the application of the concepts contained therein. All those using the information do so at their own risk and shall be deemed to indemnify the Commission from any loss or damage arising from the use of the information. The information presented is subject to jurisdictional variation and is always subject to change. Individuals or organizations responsible for working with the information presented are responsible for ensuring that all applicable standards and regulations are fulfilled. The information presented cannot and should not be considered a definitive guide to government regulations nor does it relieve individuals or organizations using the information from their responsibilities under any or all applicable legislation.

3 May, 2006 Legislative Requirements The legislation is a minimum guide for developing occupational health and safety (OH&S) policies and procedures in workplaces. However, best practices should be incorporated into all areas of businesses/organizations to increase the effectiveness of the OH&S program. The majority of employers in Newfoundland and Labrador must follow provincial legislation for occupational health and safety: Occupational Health and Safety Act Occupational Health and Safety Regulations For official copies of the Occupational Health and Safety Act and the Occupational Health and Safety Regulations please contact the following: Office of the Queen's Printer Ground Floor Confederation Building, East Block St. John's, Newfoundland and Labrador A1B 4J6 Telephone: (709) Unofficial copies are available on-line at: Some employers fall under federal jurisdiction and must follow the Canada Labour Code-Part II ( Code). The Code applies to the following inter-provincial and international industries: railways; highway transport; telephone and telegraph systems; pipelines; canals; ferries, tunnels and bridges; shipping and shipping services; radio and television broadcasting and cable systems; airports; banks; grain elevators licensed by the Canadian Grain Commission, and certain feed mills and feed warehouses, flour mills, and grain seed cleaning plants; the federal public service and persons employed by the public service and about 40 Crown corporations and agencies; employment in the operation of ships, trains and aircraft; and the exploration and development of petroleum on lands subject to federal jurisdiction. Note: Part II of the Canada Labour Code, Part II does not apply to certain undertakings regulated by the Nuclear Safety and Control Act. For an official copy of the Canada Labour Code please contact: Canadian Government Publishing, Communication Canada Ottawa, ON K1A 0S9 Telephone: (613) or FAX: (613) or Internet: Unofficial copies are available on-line at:

4 Introduction...1 More Information...2 Inside this Guide Accident/Incident Investigations...3 Requirements...3 Definitions...4 An Accident...4 An Incident...4 An Accident/Incident Investigation...4 Reporting and Investigating Accidents/Incidents...4 Benefits of an Effective Accident /Incident Investigation...5 Procedures...5 Roles in Accident/Incident Investigation...6 Employers...6 Investigation Team...7 Workers Including Managers and Supervisors...7 OH&S committees...7 Step 3 - Analyze the information to determine the root cause...14 Contributing Factors...14 Immediate/Direct Cause(s)...15 Root/Basic Cause(s)...16 Step 4 - Make recommendations...17 Step5-Write the accident/incident investigation report...18 Step 6 - Follow-up...19 Role of OH&S Committees...20 Accident/Incident Investigations and the OH&S Program...21 Planning Accident/Incident Investigations...8 Needs of the Investigation Team...8 Materials Needed for the Investigation...9 The Investigation Kit...9 Steps in Accident/Incident Investigations...9 Step 1 - Immediate response to the accident/incident...10 Step 2 - Gather information...11 Taking Notes...11 Conducting Interviews...11 Interviewing Tips...11 Sample Interview Questions...12 Tips for Taking Pictures for Evidence...12 Suggestions for Collecting Samples...12 Reviewing Documentation...13 Conclusion...22 Appendix A - Glossary...24 Appendix B - References to Legislation...28 Appendix C - Hazardous Occurrence Investigation Report...35 Appendix D - Sample Accident/Incident Report Form...36 Appendix E - Sample Accident/Incident Investigation Form...37

5 Introduction As part of the internal responsibility system, all workplace parties employers, workers, including managers and supervisors, and occupational health and safety (OH&S) committees have a shared responsibility for the OH&S program to the extent of each party s authority and ability to be involved. This means everyone works co-operatively, shows ownership for the program and is committed to preventing injury, illness and property damage in the workplace. Under provincial legislation, where 10 or more workers are employed in a workplace, the employer is required to establish and maintain an OH&S program in consultation with the OH&S committee. In workplaces where less than 10 workers are employed, the employer is required to ensure a worker health and safety (WH&S) representative is in place to monitor the health, safety and welfare of workers. And, in workplaces with less than six workers employed and where it is impractical to assign a WH&S representative, the employer may designate a workplace health and safety designate to monitor the health, safety and welfare of workers. For federally regulated workplaces, employers are responsible for developing, implementing and monitoring a prescribed program for the prevention of hazards in the workplace in consultation with the health and safety committee, policy committee or the health and safety representative. For the purpose of this booklet, the duties and responsibilities of the OH&S committee will also include those of WH&S representatives and workplace health and safety designates in provincially regulated workplaces and health and safety representatives in federally regulated workplaces. This booklet is designed to assist those responsible to carry out effective accident/incident investigations in the workplace. It provides basic information about accident/incident investigations including the role of workplace parties, planning the investigation, and the steps involved in conducting the investigation. Best practice is a standard that exceeds minimum legislative requirements and supports working in the safest possible way. Carrying out investigations on all accidents and incidents, finding root causes, and implementing corrective actions demonstrate best practices. For commonly used OH&S terms, please refer to Appendix A Glossary. 1

6 More Information For more information on building a health and safety program, there are several booklets and information resources available in this series. Fact Sheets: Introduction to an OH&S Program Leadership and Administration OH&S Committees Education & Training Safe Work Practices and Procedures Hazard Recognition Evaluation and Control Workplace Inspections Accident and Incident Investigation Disability Management Ergonomics and the OH&S Elements Worker Health and Safety Representative/Workplace Health and Safety Designate Look for these fact sheets in the near future: Communication Emergency Preparedness Booklets: Guide to Writing an Occupational Health & Safety Policy Occupational Health & Safety Committees Introduction to an Occupational Health and Safety Program Workplace Inspections Accident/Incident Investigations Look for these booklets in the near future: Communication Emergency Preparedness 2

7 Accident/Incident Investigations Accident/incident investigations are an important part of the OH&S program. They include a process of fact finding to identify the root (basic) cause of accidents/incidents as a means of preventing further occurrences. Ergonomic considerations should always be part of accident/incident investigations. Including investigations in the OH&S program strengthens the internal responsibility system and is essential to building a positive health and safety culture in the workplace. Requirements Specific OH&S requirements for employers who are provincially regulated can be found in the Occupational Health and Safety Act and Regulations. Requirements for federally regulated employers can be found in the Canada Labour Code, Part II and the Canada Occupational Health and Safety Regulations. Contact information for obtaining provincial and federal OH&S legislation can be found at the beginning of this booklet and in Appendix B References to Legislation. The legislative references in Appendix B refer to the content in this booklet and may not be complete. Workplace parties must refer to the appropriate legislation to find complete information regarding legislative requirements for developing an OH&S program. Employers must also comply with industry-specific or hazard-specific legislation. Examples include: Asbestos Abatement Regulations; Asbestos Exposure Code Regulations; OH&S First Aid Regulations; Workplace Hazardous Materials Information System (WHMIS) Regulations; Radiation Health and Safety Act and Regulations; Mines Safety of Workers Regulations; and Workplace Health, Safety and Compensation Act and Regulations. Employers should be aware of legislation that relates to their industry and specific hazards in their workplaces. Appendix B References to Legislation contains details of the following legislation. OH&S Act OH&S Regulations Canada Labour Code Part II Canada OH&S Safety Regulations Workplace Health, Safety and Compensation Act Sections Sections Sections Sections Sections 4 41 (1) 42.1 (1) 54 4(1) (f) (iv) 4 (1) (j) 15.3, 15.4, 15.5, 15.6, 15.7, 15.8, (1) and (4) (d) 135 (1) and (7) (e) 136 (1) 136 (2) 3

8 Definitions An Accident An accident is an unplanned/undesired event that results in a personal injury or illness, or in damage to property, process or the environment. An Incident An incident is an unplanned/undesired event that has the potential to result in an injury, illness, or property damage. An Accident/Incident Investigation An accident/incident investigation is a well planned analysis of an event that identifies the root cause and recommends corrective action to prevent the event from happening again. Despite what many people think, workplace accidents/incidents don t just happen; they result from a series of events that usually stem from an ineffective OH&S program. The aim of an OH&S program is to prevent accidents and incidents; however, as part of the internal responsibility system, when accidents/incidents do happen, there should be a process in place to find the root cause of these events. Reporting and Investigating Accidents/Incidents Employers must immediately report accidents resulting in serious injury or death or the potential for serious injury or death to the assistant deputy minister and the OH&S committee ( OH&S Act, section 54). Employers must also report an injury to a worker for which the worker is disabled from earning full wages or the worker is entitled to medical aid ( Workplace Health, Safety and Compensation Act, section 56). Federally regulated workplaces have reporting and investigation requirements in cases of work-related injuries or illnesses. Please refer to Appendix B References to Legislation under the heading Canada Occupational Health and Safety Regulations for these requirements. Appendix C Hazardous Occurrence Investigation Report contains a copy of the form employers are required to complete. A copy of this form may be found on the Human Resources and Social Development web site: Go to Click Forms Click List of Forms Under the heading Occupational Health and Safety, find number LAB1070 Hazardous Occurrence Investigation Report. 4 When developing accident/incident investigation procedures for workplaces, best practices would include an internal process for reporting and investigating all accidents and incidents. Incidents are warnings that

9 something is wrong in the workplace. If incidents are investigated and the root cause found, accidents can be prevented. Please refer to Appendix D Sample Accident/Incident Report Form. Benefits of an Effective Accident/Incident Investigation employers demonstrate their commitment to health and safety to their workers and the public; workers on the investigation team are trained in investigation techniques; workers are trained in the importance of reporting accidents/incidents; accidents/incidents are promptly reported; accidents/incidents are immediately investigated; root causes are identified; corrective actions are implemented, monitored and evaluated; workers are trained in how to prevent similar accidents/incidents; pain and suffering are reduced; findings can be used to identify accident/incident trends; and associated costs of accidents and property damage are reduced. Procedures Accident/incident investigations are a mandatory part of an OH&S program and should have procedures to ensure their effectiveness. Accident/Incident investigation procedures are the step by step way for completing an accident/incident investigation. All workplaces are different; therefore, the procedures should be developed with the specific workplace in mind. For example, in some workplaces, the procedures may outline the duties of groups of workers in a specific department while another workplace may outline the duties of groups based on their job titles. Duties and responsibilities depend on what works best for the individual workplace. Accident/incident investigation procedures should include a process for planning and the six steps for conducting the investigation. They also identify those responsible for each step in the procedure and those responsible for communicating the results of the investigation. Ergonomic considerations should be included in accident/incident investigations procedures. 5

10 Roles in Accident/Incident Investigation In keeping with the internal responsibility system and with best practice, workplace parties have a role in accident/incident investigations. To meet their legislative requirements for establishing and maintaining an OH&S program and conducting accident/incident investigations, employers should ensure accident/incident investigation procedures outline the responsibilities of all workplace parties. Following are examples of roles and responsibilities based on legislative requirements and best practice. Employers must immediately report accidents resulting in serious injury or death or the potential for serious injury or death to the assistant deputy minister and the OH&S committee; must report an injury to a worker for which the worker is disabled from earning full wages or the worker is entitled to medical aid; provide the resources human and financial to carry out accident/incident investigations; ensure accident/incident investigation procedures are developed and followed; ensure all workers are provided with the education and training needed to understand their responsibility to report accidents/incidents and to cooperate with those conducting investigations; review accident/incident investigation reports; ensure corrective action is implemented, monitored, evaluated and communicated; and review accident/incident investigation procedures at least every three years. Investigation Team Managers and supervisors are often the ones that carry out accident/incident investigations. However, it is a good practice, when possible, to include other workers and members of the OH&S committee on investigation teams. This practice would promote the internal responsibility system in the workplace. Those conducting the investigation are to: conduct the investigation as soon as possible after the accident/incident; follow accident/incident investigation procedures; put emphasis on finding the root cause not on finding fault or placing blame; 6

11 consider multiple causes to find all factors contributing to the event; do not jump to the obvious answer keep looking; and ensure the results of the investigation are communicated to workplace parties. Workers Including Managers and Supervisors report accidents/incidents to their supervisors immediately; co-operate with the accident/incident investigation team; participate as members of the investigation team when requested; make suggestions for corrective actions to the investigation team; and take part in training required as the result of the investigation. OH&S committees are a resource to the accident/incident investigation team; may participate as members of the investigation team; review all accident/incident investigation reports to identify trends in injury, illness and property damage; monitor implementation, follow-up, and evaluation of corrective actions; review training required as the result of the accident/incident investigation; and regularly evaluate this element of the OH&S program. Planning Accident/Incident Investigations Accident/incident investigation procedures should identify the members of the investigation team, their training requirements, and their responsibilities. It is beneficial to have a core team of trained individuals to carry out an investigation. Depending on the accident/incident and the potential for it recurring, the team may differ in size. Having more than one person investigating means there is less of a chance to overlook something. Needs of the Investigation Team The accident/incident investigation team should be trained in investigation techniques including gathering information interviewing skills 7

12 collecting samples analysing information contributing factors of accidents/incidents identifying immediate/direct causes identifying root/basic causes writing recommendations writing reports; know what is expected of them in the investigation process; keep an open mind about the cause; never jump to a conclusion before all the information has been analyzed; be impartial; understand that there is rarely only one cause of an accident/incident; be familiar with work processes, the people that work in the workplace, and practices and procedures; have knowledge of OH&S legislation, standards, codes of practice, manufacturers specification, etc.; know the layout of the workplace; be objective and honest; and possess interviewing, analytical, organizational and report-writing skills. Materials Needed for the Investigation The accident/incident investigation procedure should include a list of the materials needed for an investigation plus the materials in the investigation kit. The accident/incident investigation procedure should identify required materials, equipment, and personal protective equipment (PPE); names and phone numbers of personnel such as the investigation team, first aid responders, members of the OH&S committee, management personnel, maintenance staff, security staff, etc.; and items to be included in an investigation kit. 8

13 STEPS in Accident/Incident Investigations Accident/incident investigation procedures should outline a step-bystep process for carrying out each of the six steps in the investigation: Step 1 Immediate response to the accident/incident Step 2 Gather information Step 3 Analyze the information to determine the root cause Step 4 Make recommendations Step 5 Write the accident/incident investigation report Step 6 Follow-up The Investigation Kit Items usually found in an accident/incident investigation kit accident/incident investigation forms 'Do Not Enter' tape clip board tape measure and ruler camera, batteries, film (or video camera) flashlight and batteries plastic bags and containers for samples labels and permanent marker for labelling samples pens/pencils eraser notebook and graph paper CAUTION: Some workplaces may not permit the use of devices such as cameras, flashlights, etc. because, depending on the workplace and the accident, they may pose a hazard to the investigation team. Therefore, the above items should be evaluated to ensure they do not create additional hazards. 9

14 STEP 1 Immediate response to the accident/incident CAUTION: The investigation team members must ensure that: the equipment they bring to the accident site does not endanger themselves or others; and they take particular care and follow safe work procedures so as not to be exposed to workplace hazards such as confined space, invisible gases, electrocution, engulfment, etc. as the result of helping injured workers or conducting the investigation. The steps to be taken immediately in case of an accident/incident are: eliminate immediate hazards to ensure no one else is injured; provide emergency care to the injured; secure the accident site: use ropes, barrier tape and/or cones or human guards if required, remove nothing from the site without permission, and maintain site until all information is collected; notify proper authorities governmental agencies, Workplace Health, Safety and Compensation Commission (the Commission), etc. Note: When an injury occurs in the workplace and a worker requires medical care, the employer is required to notify the Commission in writing within 1 three days. The amount of information gathered and the resources needed depend on the specific accident/incident. 1 If a worker is injured and requires medical care, the worker must complete a Form 6 Worker's Report of Injury, and the employer must complete a Form 7 Employer's Report of Injury. These forms are available at: 10

15 STEP 2 Gather information Taking Notes Keeping notes in a notebook throughout an investigation process keeps information together and organized. Notes should be neat and detailed, yet concise; and they should answer who, what, when, where, why and how. Good notes help to recall facts and are useful when analyzing information to determine the root cause. Notes should include: dates and times; names and addresses; information from interviews; observations; action taken by you and others; description of site and environmental conditions; reference to pictures, if taken; measurements; sketches and diagrams; and information about evidence gathered. Conducting Interviews Interview promptly and separately injured workers; witnesses to the event; immediate supervisor; staff from departments such as maintenance, purchasing or supplies (if necessary); and anyone else who can provide information; for example, a representative of the manufacturer or a company trainer. Interviewing Tips maintain privacy and put the person at ease; explain why the interview is being conducted; emphasize the investigation is for fact finding, not fault finding; ask people to explain what happened in their own words; let people tell what happened don t lead the witness; try not to interrupt; ask specific questions to clarify and fill in the gaps; repeat what is reported to verify your understanding; 11

16 thank people for their co-operation; and write-up a complete account as soon as possible after the interview to ensure the details are accurate. Sample Interview Questions Where were you when the accident (incident) happened? What were you doing at that time? What did you see? What did you hear? Who else was around at the time? Is there a standard procedure for the task? Are workers trained in the standard procedure? Was this the first time this task was done? Was the work being supervised at the time? Is there anything else you d like to add? Suggestions for Collecting Samples use a diagram of the area to note where samples were found; keep people away from area; ensure evidence is not damaged; place samples in a bag or container, seal it, and label with a permanent marker; label the evidence with a reference number the date and time evidence was collected the specific location evidence was found the collector s name; keep evidence in a secure place; and keep a record if evidence is moved. for Taking Pictures for Evidence The following tips will ensure pictures can be used as evidence: use adequate lighting; ensure unobstructed view of the area or object; date the photograph; reference the measurement (i.e. place a ruler, measuring tape, another object or person, etc. next to the area or object); and keep the negatives. 12

17 Reviewing Documentation Examples of documentation that may need to be reviewed log books work schedules files policy and procedure manuals specific legislation manufacturer s specification check lists training records formal workplace inspection reports previous records of this kind of event previous accident/incident investigation reports Once all information about the accident/incident is gathered, it must be reviewed to determine the root cause. The information should be organized into a logical sequence of events, working back from when the accident/incident occurred. All possible causes should be listed at each step and checked to see if they are supported by the evidence. If gaps in the evidence are discovered, there may be a need to re-interview witnesses, review the documentation again, or gather further information. 13

18 STEP 3 Contributing Factors Analyze the information to determine the root cause There are many factors that contribute to accidents/incidents; however they can usually be broken down into four major categories: people, equipment, materials and the environment. The following are some areas that may be explored when investigating accidents/incidents to determine the root cause(s). People (management, non-management workers, contract workers, visitors) knowledge, experience, skill, understanding, orientation,training job site analyses communication safe work practices and procedures documentation of hazards equipment preventative maintenance physical capability analysis workload workplace inspections Equipment design manufacturers specifications use preventative maintenance ergonomics job safety analysis safe work practices and procedures hazard recognition, evaluation and control documentation personal protective equipment (PPE) Materials manufacturers specifications use preventative maintenance ergonomics job safety analysis safe work practices and procedures hazards recognized, evaluated and controlled documentation 14 Environment lighting noise air quality housekeeping practices weather conditions

19 It is widely accepted that accidents/incidents occur as a result of a chain of events. There is rarely one cause. Causes of accidents/incidents are usually grouped into two main categories: immediate/direct cause(s) and root/basic cause(s). Immediate/Direct Cause(s) Immediate/Direct Cause(s) are events, conditions or acts that immediately precede the accident/incident. Immediate/direct causes are usually the symptoms of the root/basic cause, not the root cause itself. Immediate/direct causes are usually related to uncontrolled hazards arising from substandard conditions and/or substandard actions. Examples of conditions: machine guards in good working order; noise at acceptable levels; planning documented; good housekeeping practiced; and personal protective equipment maintained. Examples of actions: safe work procedures followed; equipment appropriately maintained and used; hazards communicated; rules followed; and personal protective equipment properly used and maintained. 15

20 Root/Basic Cause(s) Root/Basic Cause(s) are real or underlying cause(s) of accidents/incidents. They are not always immediately evident. Examples of job factors: design of equipment; knowledge of workplace parties; communication practices; workplace inspections scheduled and conducted; and appropriate equipment available and used. Examples of personal factors: orientation; communication and understanding of safe work practices and procedures; pace of work; education and training; and performance feedback. Analyzing all information contributing factors and the immediate/direct causes increases the likelihood of finding the root cause(s). Finding the root cause(s) and implementing corrective actions will in turn prevent similar accidents/incidents in the future. 16

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