The term incident can be defined as an occurrence, condition, or situation arising in the course of work that resulted in or could have resulted in injuries, illnesses, damage to health, or fatalities.
When incidents are investigated, the emphasis should be concentrated on finding the root cause of the incident to prevent the event from happening again. This process is not to put blame on any party involved.
The company Incident Investgation Policy will include the detailed requirements on how to complete a thorough investigation.
An investigative report has many purposes.
- It’s a document that sparks some sort of action based on the official findings it presents. This could be a termination of employment, corrective action, implementation of training, counselling, or some other action taken based on the findings.
- The investigation report is also a record of the steps of the investigation. It can be used to prove that your investigation was timely, complete and fair.
- The information contained in the investigation report may be cited in any legal action, so it’s important that the report is detailed and accurate, but does not include unnecessary detail that can get the company into trouble.
- The process of writing the investigation report can sometimes clarify your thinking and can even uncover additional questions that provide new insight into a case.
- And finally, the investigation report provides valuable data that can be used to implement control and preventive measures in your company.
Who should Be involved in the investigation?
Ideally, an investigation would be conducted by someone or a group of people. The reason for the team approach is to have different perspectives on the incident; A manager may see things differently than an employee.
Members of the team can include:- employees with knowledge of the work
- supervisor of the area or work
- safety officer
- health and safety committee or rep
- union representative, if applicable
- employees with experience or training in investigations.
- "outside" experts
- representative from local government or police
The Steps to Complete An Investigation
Report the Incident:
The employee’s involved with the incident must report the incident to supervision.
The number one priority of any employee or supervisor is to ensure the safety of anyone involved in the incident. In the case of injury, make sure the individual is properly cared for before doing anything else. Do not, however, take any actions that will compromise your own safety.
The second priority is to ensure that there is no further damage to the environment. In the case of a spill, contain and control the damage before doing anything further. Once again, this should only be done if it can be done safely.
NEVER PUT YOURSELF OR OTHERS IN DANGER.
Gathering Information about the incident
Physical Evidence
Examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses. Physical evidence is probably the most non-controversial information available. It is also subject to rapid change or obliteration, so it should be the first to be recorded.
You may want to:- Take photographs before anything is moved. A later study of the pictures may reveal conditions or observations that were missed initially.
- Sketches of the scene based on measurements taken may also help in later analysis and will clarify any written reports.
- Re-enactments are also a good way to gain knowledge of the incident. Only do re-enactments if it is safe to do so.
- Complete an incident investigation checklist to ensure that all the requirements have been meet.
- positions of injured workers
- equipment being used
- products being used
- safety devices in use
- position of appropriate guards
- position of controls of machinery
- damage to equipment
- housekeeping of area
- weather conditions
- lighting levels
- noise levels
- time of day
Employee & Witness Accounts
Always document the employee & witness statements for reference while completing the report.
In some situations, witnesses may be your primary source of information because you may be called upon to investigate an incident without being able to examine the scene immediately after the event. Because witnesses may be under severe emotional stress or afraid to be completely open for fear of recrimination, interviewing witnesses is probably the hardest task facing an investigator.
The purpose of the interview is to establish an understanding with the witness and to obtain his or her own words describing the event. Sometimes the best way to complete the interviews is by using a Incident Investigation Interview Questionairre
DO...- put the witness, who is probably upset, at ease
- emphasize the real reason for the investigation, to determine what happened and why
- let the witness talk, listen
- confirm that you have the statement correct
- try to sense any underlying feelings of the witness
- make short notes or ask someone else on the team to take them during the interview
- ask if it is okay to record the interview, if you are doing so
- close on a positive note
- intimidate the witness
- interrupt
- prompt
- ask leading questions
- show your own emotions
- jump to conclusions
Witnesses should be interviewed alone, rather than in a group. The reason for this is to ensure that the statements are true and from that employee’s point of view.
Documentation
Gather the Field Level Hazard Assessments, HID/BBO cards, Safe job Procedures, Safe Work Practices, permits. These documents can inform the investigation team members of any hazards or conditions that were noted and what was not. The safe job procedure and safe work practices will let the team know if employees were following company standards and procedures.
Review of information and finding the causes.
Even in the most seemingly straightforward incidents, seldom, if ever, is there only a single cause. Review the documentation, pictures, and Employee & Witness statements.Was the incident caused by:
Substandard Practices: Failing
- to identify Hazards
- to identify PPE requirements
- following policies & procedures
- Improper use of tools, equipment
- Housekeeping
- Lack of guards
- Lack of preparation or planning
- Worksite conditions such as ground, lighting conditions
- attempt to save time/effort
- worker not able to physically do task.
- Fear & phobias
- Routine task
- Inadequate training,
- Inadequate equipment Maintenance
- Inadequate Tools/Equipment
- Lack of/ Inadequate documentation (SDS, SJP, FLHA, SWP).
- Inadequate Supervision
- Inadequate Engineering
Corrective actions
The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar incidents. Corrective actions should:- Be Achievable- do not put corrective actions in place if the company is not able to complete the task.
- Corrective actions should be assigned to a person(s) in the company to complete.
- be constructive- corrective actions should improve the process.
- correct the causes
- be shared with all employees and implemented.
The Incident Report.
The incident report will detail describe what happened. Remember that readers of your report do not have the intimate knowledge of the incident that you have so include all relevant details, including photographs and diagrams. Identify clearly where evidence is based on certain facts, witness accounts, or on the team’s assumptions.
Always communicate your findings and recommendations with workers, supervisors, and management. Present your information so everyone understands how the incident occurred and the actions needed to put in place to prevent it from happening again.
The report should be reviewed and signed by the employees involved, supervision, safety and management.
Follow-up
Once the corrective actions have been implemented, follow up is needed to see if the corrective actions are actually working to prevent the incident from happening again. If the corrective actions assigned have not worked, new corrective actions can be put in place. In most cases there might be a need to fine tune the processes developed.
Incident Reporting is curcial for companies, not just because it is a legal requirement, but they are excellent indicators of how well your safety program is working. The causes will show management excatly where improvements are needed.
If you need any assistance or need a Incident Investigation program feel free to head to our website or click on any of the links throughout the blog.
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