C12_Kelloway_MOHS8e_fina (Incident Investigations)l.pptx

PowerPoint
Presentation for
Management of
Occupational Health
and Safety
Prepared by
Bernadette Gatien
Copyright © 2021 by Nelson Education Ltd.

Chapter 12
Incident Investigation
Copyright © 2021 by Nelson Education Ltd. 12-2

Learning Objectives
• After reading this chapter, you should be able
to:
– Describe the intent and steps of an incident
investigation
– Gather information to analyze the human,
situational, and environmental factors
contributing to incidents
– Outline the legal requirements of incident
investigation results
continued…

Learning Objectives
• After reading this chapter, you should be able
to:
– Explain the concept of a walkthrough survey
– List the steps to conducting interviews concerning
an incident
– Conduct a re-enactment
– Complete the various types of incident and injury
reports

Poll
• Open the MindTap Mobile App and select your course.
Which of the following is included as the first step of an incident
investigation?
a) gathering evidence
b) calling a supervisor
c) controlling hazards
d) making recommendations

Opening Vignette:
Workplace Fatality Investigation
• Niklas Jay Kristen Taylor was killed at Fountain
Tire after an industrial tire fell on him
• An investigation found that there were a
number of causes and the company was
charged
• Investigations often result in charges and
orders being written but the real goal of an
investigation is prevention

Rationale for Incident Investigation
• Investigation of Incidents
– Component in a hazard recognition, assessment,
and control (RAC) program
• RAC program
– A hazard recognition, assessment, and control
program; a key element in most health and safety
programs

Rationale for Incident Investigation
• Benefits of Incident Investigation:
– Determines direct causes
– Identifies contributing causes
– Prevents similar incidents
– Creates a permanent record
– Determines cost
– Promotes safety awareness among employees

Critical Factors in the
Investigative Process
• Incident investigations are influenced by:
– Timing:
• Time affects several types of information
– Severity:
• Given that investigations are time consuming,
companies tend to examine only those incidents that
have the most serious consequences
continued…

Critical Factors in the
Investigative Process
• Incident investigations are influenced by:
– Legal requirements:
• Events (e.g., injury requires medical aid or results in lost
time) must be reported to a Workers’ Compensation
Board, normally within three days.

Types of Information Collected
Human
Factors
Environmental
Factors
Situational
Factors

OH&S Notebook 12.1
The Steps of an Investigation
• Legislative or policy requirements often do not
specify how to investigate
• A general approach to incident investigation:
– Secure the scene
– Gather evidence
– Analyze information
– Report the results of the incident investigation
– Make recommendations
– Follow up

Human Factors
• Examples of questions to ask :
– What was the worker doing at the time of the
incident?
– Was the work being performed according to
procedures?
– Was a supervisor present?
– What was the employment status of the worker?

Situational Factors
• Examples of questions to ask:
– Was the machine operating in a satisfactory
manner?
– What tools, equipment, or objects were involved
in the incident?
– What personal protective equipment was being
worn?

Situational Factors

Environmental Factors
• Environmental factors (e.g., light, noise) may
increase likelihood that an incident will occur
• Examples:
– Setting sun may blind delivery truck driver
– Machine noise may mask approaching vehicle
– Equipment vibration may dislodge another tool

Who Investigates?
• Supervisor
• Technical advisers and specialists
• Safety and health officer
• Safety and health committee or representative
• Safety team

Investigative Methods
• Observations or walkthroughs
– Inspection of incident scene to get a picture of the
total environment

• Interviews: Basic Rules
– Interview witnesses on the spot as soon as
possible after the event
– Interview witnesses separately and in a neutral
location
– Put the witness at ease
– Let the individual recall the event in his or her
own way
continued…

• Interviews: Basic Rules
– Ask necessary questions at appropriate times,
without interrupting the speaker’s train of thought
– Give the witness feedback
– Make sure that critical information is recorded in a
timely fashion
– End the interview on a positive note by thanking
the witness for his or her valuable time and
assistance

• Re-enactment
– Simulation designed to recreate circumstances
leading up to incident
– Guidelines for conducting a re-enactment:
• A qualified observer is necessary.
• Do not show. Tell.
• Shut down every energy source and lock them out.
• Carefully act out the events.

Investigative Tools
• Walkthrough, interview, and re-enactment can
be supplemented by:
– Photographs
– Drawings
– Computers
– Tape measures, clipboards,
water-resistant pens, flashlights
– Record check

Incident Reports
• Once information has been gathered, incident
reports must be completed.

Incident Reports
• Reports should consider:
– Factor most closely associated with the cause of
an incident, referred to as the agency
– Incident type; categorize the nature of the
incident
– Personal factors (e.g., lack of knowledge, fatigue,
restricted vision) to assist in entry, recordkeeping,
and analysis

Incident Analysis
• Once data are collected, analyze information
to identify cause
• Analytic models and techniques available for
use in assessing cause of incident

Incident Analysis
• Domino theory
– The theory that every incident results from a
series of events

Domino Theory

OH&S Today 12.2
Hazardous Occurrence Investigation
in the Canadian Forces
• Canadian Forces advocates the analysis of hazardous
occurrences as a means of preventing recurrence
• Identify root causes by assembling, categorizing, and
analyzing data
• An incident is viewed as failure in one or more of the
following categories:
– Materials
– Task
– Management
– Personnel
– Environment

The Swiss Cheese Model
• Updated version of domino model by
J. Reason
• Series of dominoes with holes demonstrate
that a series of events must occur for an
incident to occur

• Unsafe acts are a product of:
– Organizational culture
– Level of supervision
– Variety of other contextual factors

• Specifies four levels of defence:
1. Organizational influences
2. Local working conditions
3. Unsafe acts
4. Defences, barriers, and safeguards

Bow-Tie Analysis

Bow-Tie Analysis
• Combines a fault tree with an event tree
• On the left of diagram is a listing of potential
hazards and measures to control those
hazards
• On the right are the measures to mitigate the
consequences of an event
• The “knot” in the bow-tie is the event or
incident to be prevented

Normal Incidents
• Normal Incidents
– The theory that incidents are expected outcomes
of interactive complexities
• High-Reliability Organizations
– Organizations in hazardous industries that
maintain a high safety record over time

The Psychology of Incidents:
Cognitive Failures
• Cognitive Failure
– Mistake or failure in the performance of an action
that an individual is normally capable of
performing
• Often a sign of individuals under stress
• Related to occurrence of both motor vehicle
and work-related incidents

End-of-Chapter Activities
• Answer the end-of-chapter questions to learn
about:
– The three factors that may contribute to an
incident
– The methods and tools used for conducting an
investigation
• Provide examples of how human,
environmental and situational factors can
combine and contribute to an incident

C12_Kelloway_MOHS8e_fina (Incident Investigations)l.pptx

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