Incident Investigations Handbook

The following agencies may respond to an incident (insert phone numbers of your location) Police Fire/rescue Ambulance Coroner WorkSafeBC BC Safety Authority ICBC BC Hydro Gas Company TDG Directorate Environment Agency Air Transportation Safety Board Incident Investigations Page 1

Incident Investigation Prevention of an accident or incident is the primary goal of conducting an investigation. Investigations are not to place blame, but are used as a means of measuring the effectiveness of the health and safety program. Investigations discover or uncover where the organizations health and safety systems break down. It is the employer s responsibility to ensure that investigations into incidents or accidents take place and are conducted as soon as possible after the occurrence. It is also the employer s responsibility to ensure that recommendations from the Joint Investigation Team are responded to quickly to prevent reoccurrence. The Workers Compensation Act section 172 and 173 requires that: An employer must immediately undertake an investigation into the cause of any accident or other incident that is required to be reported to WCB, resulted in an injury to a worker requiring medical treatment, did not involve an injury to a worker, or involved only minor injury not requiring medical treatment, but had the potential for causing serious injury or was an incident required to be investigated. The prevention division of the WCB must be notified immediately of any accident resulting in serious injury or death; a major structural failure or collapse of a building, bridge tower, crane hoist, temporary construction support system or evacuation, a major release of a hazardous substance, or was an incident required to be reported. WorkSafeBC 1-866-922-4357 Incident Investigations Page 2

Incident Investigations Seven Step Process 1. Secure the scene 2. Collect Information 3. Develop a Sequence of Events 4. Determine the Causes 5. Recommendations and Actions 6. Write the Report 7. Refer Hazards Typical Incident Investigation Procedures Incident Investigations Page 3

Accident Investigation Kit should contain: Flashlight Measuring tape High visibility tape and PPE Scissors Tape First aid kit Gloves Report form (PSC 38) Digital camera Pens Paper Clip board Graph paper Determine who is responsible for the kit should this be moved to another list as it s not technically part of the contents? Know where the kit is located - ditto Ensure that the contents if the investigations kit is in working order ditto, again Assign responsibility for the investigation kit redundant; see 3 bullet points earlier Who Should Be Involved The investigation team consists of a worker representative from the health and safety committee and an employer representative, both of whom have had training in the investigation of incidents.. The names of the representatives should be part of the terms of reference for the health and safety committee. Phone and contact numbers are required and should be available to all supervisors and first aid attendants. Incident Investigations Page 4

When an incident is reported the supervisor or person receiving the call must immediately initiate contact with the investigation team. The investigation team is called, and responds immediately. Incident Investigations Page 5

Step 1 Secure the Scene It is imperative that the team(s) conduct the investigation immediately. Evidence disappears, material is moved and memories change. Ensure that your investigation team is trained and knowledgeable about the work and conditions where the work is performed. If they are not, request another person who is knowledgeable to assist the team. This should be jointly agreed to. Arrival at the scene take a mental snap shot ensure that there is no further danger preserve the scene remain objective, regardless of what you might think occurred note housekeeping and the general work environment note the floor or surface condition determine if any other agency such as WCB should be involved determine how and who will contact other groups Incident Investigations Page 6

Step 2 Collect Information The incident scene is marked off information is gathered including measurements, pictures, block diagrams list of witnesses there prior, during and after the incident location and time the incident occurred record initial information record observations date and time you were notified what activities were occurring name of persons involved who is injured/were any others affected bystanders first aid attendants on the scene record the physical data take pictures photograph the scene from all angles observe conditions of equipment, machinery and tools include makes and models of equipment maintenance records and other information relevant information related to weights and capacities Use a digital camera as it is instant and accurate. Make sure that there are extra batteries for the camera. Create a photo log that describes each picture that is taken, time, location, direction and description. Incident Investigations Page 7

Conduct Interviews Good interview techniques include: conducting the interview in a relaxed atmosphere in a neutral, private location Interview as soon as possible after the incident The investigation team should conduct interviews jointly Advising the witness as to your purpose, that you are looking to collect facts to prevent a reoccurrence Ensuring the witness has the opportunity to tell the entire story, even though some information may not be relevant Ask questions to clarify the information, and start by writing the sequence of events Ensure that your notes are reflective of the facts Treat witnesses as equals Some questions that could assist are: Can you tell me where you were at the time of the incident? Can you tell me what you were doing at the time? What did you see? What did you hear? What did you smell? What were the environmental conditions such as weather, light, noise, heat, rain, snow etc. Where was the injured worker? Incident Investigations Page 8

DO NOT DO Blame Point to poor judgement Jump to conclusions Interrogate Ask yes/no questions Ask who is to blame Ask leading questions Withhold or conceal notes Be sympathetic Be objective Use good listening skills Verify what the witness saw and record what they know Know what occurred at the time of the incident and prior to the incident occurring Always drill down to the why Share your notes with the witness at the conclusion of the interview. Incident Investigations Page 9

Review documentation Discuss what documents may be useful, for example: Written health and safety procedures Health and safety committee reports First aid records Training and orientation records Inspection Reports Maintenance records Prior complaints Accident and investigation reports Any WCB orders Machinery and equipment logs Material safety data sheets Safety audits Manufacturers manual Minutes of joint OH&S Committee meetings Incident Investigations Page 10

Step 3 - Develop the sequence of events Many events occur prior to any incident: How and why did the incident occur? When and where did the incident occur? List a sequence of events and time line Who was involved? What were the injuries, check for secondary injuries? Was equipment damaged? Use information such as sketches, photographs, physical evidence, witness statements, all documents that were relevant What were the environmental conditions? Create a clear timeline of the events to inform the causes List the events that led up to the incident List the emergency response and follow-up INCIDENT time pre incident 0.0 time post incident Incident Investigations Page 11

Step 4 Determine the Causes The purpose of incident investigations is to determine the causes and implement controls to prevent a recurrence of the incident. Incidents are preventable Incidents and injuries are unacceptable and a system has broken down and allowed them to occur Incidents are caused by multiple contributing factors coming together The more factors you remove or mitigate the less likely the incident will occur again Analyze the sequence of events Do you have all of the facts? Look at contributing factors Specific/unique hazardous conditions Causes or contributing factors should be controlled or preferably eliminated. Use the multi-causation model to determine all contributing factors. Task analysis of the actual work procedures being used at the time of the incident Materials causes resulting from the equipment and materials used Personnel the physical and mental condition of those individuals directly involved in the event and the training they may have had Environment the physical environment at the time of the incident, especially sudden changes to that environment Management examine the role and impact of supervisors, and managers and safety management systems Incident Investigations Page 12

Multi Causation Model Task Management Material Incident Environment Personnel Incident Investigations Page 13

Step 5 Recommendations and Actions The report and recommendations must be jointly agreed to. Do not sign a report unless actively involved in the investigation. Who is writing the report? What should happen to prevent future incidents? What resources are required? Who receives copies of the report? Who is responsible for implementing the recommendations? Who goes back to ensure the recommendations have been implemented? Ensure a brief outline of the events that led up to and include the incident Describe the events in chronological order Be specific include all conditions, weights, reaches, distance and photos along with a block diagram Who ensures that the fixes are adequate to prevent a recurrence? Fill out the PSC 38 remember this is simply a summary and not the actual investigation. It can be used as a cover page for the complete incident report. Recommend Corrective Actions and Improvements Hierarchy of controls Elimination of the hazard Substitution Engineering controls Administrative controls Personal protective equipment Incident Investigations Page 14

The priority is to provide recommendations that will prevent a similar incident from occurring. The second priority is to provide recommendations that will prevent injuries if a similar event does occur. The last priority is to write recommendations in addition to the first two priorities that reduce the injury severity Most Effective 1 Prevent incident recurrence -hazard control Prevent injuries protective equipment, clothing 2 and devices Reduce injury severity Least Effective recurrence 3 -first aid, response etc Incident Investigations Page 15

Sample Recommendations Include interim measures and ensure a time line for corrective measures to be implemented Further assessments required by subject matter specialists Education and training (designed and targeted) Updates, reviews and revisions of work assignments, procedures and policies Recommendations should be to correct: Program design deficiency failure to effectively develop safety policies, programs, plans, processes, procedures and practices Performance deficiency general failure to effectively implement safety policies, programs, plans, processes, procedures and practices Common or repeated hazardous conditions and unsafe conditions At a minimum, comply with the Workers Compensation Act, WCB Regulation and Master Agreement Check the most current version of the WCA and OHSR and Master Agreement Remember the intent is to prevent similar incidents and injuries occurring. Incident Investigations Page 16

Step 6 - Write the Report Report format PSC 38 o PSC 38 is a summary not a complete investigation, it may serve as a cover page for the rest of the report Immediately provide a copy of the report to the supervisor and to implement corrective measures Provide a copy to the Joint Committee Follow up Joint OSH committee make recommendations Corrective actions are delegated Timeline for implementation is established Corrective actions are completed Results are communicated Follow up to ensure corrective actions are effective Incident Investigations Page 17

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Step 7 Refer Hazards Report any hazards that you find during the investigation Remedy any hazards that can be dealt with right away Involve the Joint Occupational Health and Safety Committee Make sure that the committee follows up on recommendations and the correction of hazards. Incident Investigations Page 20

Musculoskeletal Injury (MSI) Investigation Records and Statistics Sufficient records relevant to MSIs should be kept including: First aid reports Incident reports Incident investigation records Inspection records MSI complaints and hazard reports Maintenance records OSH committee minutes Instruction and training records Review and Evaluation of the MSI Programs Is there a MSI prevention policy? Are there written practical safe work procedures? Are job risks identified? Has there been an ergonomic risk assessment? Have workers and supervisors been trained in control measures? Is there regular inspection and monitoring? First aid treatment check records Incident Investigations Page 21

Investigating Occupational Exposure Factors that should be considered Comment [SM1]: I don't think this should be included in the handbook What is the job process? Identify all tasks required to complete the task. What are the environmental and other factors at the time the incident occurred, not when you are investigating, such as: Poor lighting Floor condition Snow Poor visibility Hours of darkness Noise levels Poor housekeeping Any chemicals that were used in the area Staffing level End of a shift Hours of work Ergonomic factors Indoor air quality Worker training Supervision New or young worker Was equipment appropriate for the job? Are maintenance records available? Has there been any modification to equipment? Were the right tools available to complete the tasks? Were safety devices in place? Is there a culture of safety in the workplace? Have there been any complaints? Incident Investigations Page 22

Investigating Occupational Exposure Routes of entry Skin contact Some chemicals damage the skin directly through contact Skin Absorption Other chemicals or biohazards are absorbed through the skin but affect other parts of the body Eye Contact Some airborne particulates harm the eyes on contact. Harm can be done by the chemical properties of a substance or by its physical properties Inhalation Some chemicals or biohazards are absorbed through the lungs into the body. Once absorbed, they can harm not only the lungs but can affect other parts of the body Ingestion Some chemical or biohazards can be absorbed by the body when ingested accidentally Once absorbed, they can harm some other parts of the body Incident Investigations Page 23

Investigating Occupational Disease Model Who Anyone having an affect Suspected cause Research 6 steps in Occupational Disease Investigation 1. Identify disease or symptoms 2. Determine exposures to chemicals, biohazards or infectious disease 3. Establish a relationship between the hazard and the disease through research 4. Try to establish a latency relationship 5. Report and make recommendations 6. Ask for assistance from appropriate professionals Determine the cause Determine why these conditions were in existence Conduct a why analysis as to why these conditions were in existence Incident Investigations Page 24

Investigating Violence Does the worksite have a violence prevention program? Has the employer conducted a risk assessment? What are the policies and procedures related to prevention of workplace violence? What are the environmental characteristics? What are the occupational characteristics? What were the client characteristics? What were the nature and circumstances of the work being done prior to the incident? What was the time and location of the incident? Was the worker working alone? What was the job or task that was taking place? Have workers been trained in workplace violence prevention procedures that reduce the risk of violence? Was the response time to the incident appropriate? Were workers debriefed and was counselling made available to the worker or workers? Was the worker working outside an office location? Was there a client history of violence and was this information made available to the worker? Are near misses reported? Was the worker affected physically or emotionally? Was the worker advised to consult a physician or the worker's choice as required by Regulation 4.31 (3) Did the worker receive treatment or counselling? Incident Investigations Page 25

Further information and resources: BC Government Employees Union: 1-888-991-6062 http://www.bcgeu.ca/members BC Public Service Agency: 1-877-277-0772 http://www.gov.bc.ca/myhr/contact WorkSafeBC 1-866-922-4357 Prevention 604-276-3100, 1-888-621-7233 www.worksafebc.com Canadian Centre for Occupational Health and Safety (CCOHS) www.ccohs.ca National Institute for Occupational Safety and Health www.cdc.gov/niosh Incident Investigations Page 27