Incident Investigation

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Presentation Transcript

Incident Investigation Training : 

Incident Investigation Training

Objectives : 

Objectives At the end of this session, participants will be able to: Conduct an incident investigation Realize the cost of incidents Identify causal factors Determine/implement corrective actions Share lessons learned

Benefits of Incident Investigation : 

Benefits of Incident Investigation Prevent incident reoccurrence Improved employee morale – shows management cares Implement corrective actions Improve method or process Meet regulatory requirements Improved profitability

What is an Incident? : 

What is an Incident? Any unplanned/undesired event resulting in or having the potential result: Personal injury Property damage Environmental release Including near misses or near hits

What Incidents to Investigate : 

What Incidents to Investigate All injuries All occupational illnesses Incidents resulting in property damage Incidents (near misses) with the potential for injury and/or property damage Environmental releases

Slide 6: 

1 10 30 600 Serious or Disabling Injuries Minor Injuries Property Damage Incidents Incidents with no Injury or damage i.e.; Near Hit Incidents Source: Practical Loss Control Leadership, Bird & Germain, 1969 BIRD’S TRIANGLE

Incident Investigation Based on The Following Facts : 

Incident Investigation Based on The Following Facts All can be prevented Are not isolated events Have a triggering mechanism or event (for example, a wet floor – which results in a slip/fall.) Have multiple causes

Slide 8: 

Understanding Incident Costs

Cost of Incidents : 

Cost of Incidents Direct Costs Medical expenses Workers compensation costs Damage to machines and equipment Insurance costs Legal Expenses

Cost of Incidents : 

Cost of Incidents Indirect Costs Lost Time – injured worker Loss of efficiency and production Cost to train and replace worker Hardship to family Damage to the company image Loss of customers Pain and suffering

Incident Causes : 

Incident Causes Events, situations, and conditions that result in incidents in the workplace. Contributing Factors Personal Job Root Cause Unsafe Acts Unsafe Conditions

Root Causes : 

Root Causes Unsafe Acts Operating at unsafe speed Horseplay Nullifying safety devices or guards Unsafe Conditions Inadequate guards or devices Poor housekeeping Inadequate maintenance

Responsibilities : 

Responsibilities Incident investigation is a front line supervisory responsibility The supervisor is responsible for ensuring an investigation is conducted The supervisor is responsible for completing the Incident Investigation Form Involved employee(s) written statement(s)

Responsibilities : 

Responsibilities Why the Supervisor? On the scene Personal interest – “MY” Department Can communicate more effectively with those in the department Supervisors will take corrective action Trains employees Know employee strengths and limitations Knowledge of hazards associated with each task

Responsibilities : 

Responsibilities Safety Committee Contribute safety expertise Reviews all incident reports Discover previously unrecognized causes Provide training on incident investigations

Serious Incident Investigation : 

Serious Incident Investigation Investigator(s) For serious incidents a team approach can be used Supervisor Plant Manager Safety Committee Representative Human Resources Representative Corporate Risk Manager

Incident Investigation Tools : 

Incident Investigation Tools Incident investigation form Digital camera Instructions, operating manuals for involved equipment Clipboard, notes PPE

Key Facts in Incidents : 

Key Facts in Incidents Nature of Injury Type of physical injury incurred Part of Body Part of body directly affected by the injury Source of Injury The object, substance, exposure or bodily motion which directly inflicted the injury Environmental Location Substance Regulatory Agencies involved

Conducting the Incident Investigation : 

Conducting the Incident Investigation

Immediate Action : 

Immediate Action Primary concern is safety and health Provide emergency rescue and medical help Take steps to minimize injury & property damage Secure incident scene to make safe Preserve evidence Collect information Determine extent of damage

Investigation Process : 

Investigation Process Interview employee(s) involved Have employee(s) demonstrate how incident occurred at the scene (use extra caution here!) Visit the incident scene Collect the facts Interview Witnesses/document statements Take photos Notes

Investigation Process : 

Investigation Process Answer the questions: WHO WHAT WHEN WHERE WHY HOW

Conducting the Incident Investigation : 

Conducting the Incident Investigation Interviewing the employee Put the employee at ease Keep interviews private at scene of incident Get the person’s own version Try not to interrupt Avoid “leading” questions Repeat story as you understand it Close on a positive note ...prevention Ask employee for corrective suggestions Emphasize fact finding, not fault finding

Root Causes : 

Root Causes Once you’ve gathered the info it’s time to get to the roots! Let’s look at some root causes…

Identifying Root Causes : 

Identifying Root Causes Equipment Defects Recognized hazard Equipment inspection procedures Correct Equipment

Identifying Root Causes : 

Identifying Root Causes Environment Location/Position Pre-existing condition Sufficient work space Environmental conditions

Identifying Root Causes : 

Identifying Root Causes People Employee capable of performing task Personal protective equipment Was task difficult to perform? Deviation occurred Training

Identifying Root Causes : 

Identifying Root Causes Management Was hazard reported or anticipated Was hazard detected or corrected Procedures/policies Training

Recommending Corrective Actions : 

Recommending Corrective Actions Must make recommendations to prevent recurrence Address immediate and long-range remedies Include target date for completion Corrective actions must be assigned Avoid the recommendation “told the employee to be more careful”

Examples of Corrective Actions : 

Examples of Corrective Actions Unsafe Physical or Mechanical Condition Guard Housekeeping Remove from service Awareness training Unsafe Acts Instruction (check orientation) Proper placement Change procedures Awareness training Discipline

Selecting Corrective Action : 

Selecting Corrective Action Effectiveness Feasibility Acceptance

Incident Investigation Form : 

Incident Investigation Form Supervisor, Employee and Safety Cmte. member to complete incident investigation forms within 24-hours Identify key facts (who, when) Root Causes Corrective Actions Involved employee(s) written statement(s) Forward to manager for review and approval

Communicating Investigation Results : 

Communicating Investigation Results All relevant facts Basic causes Lessons learned Corrective action recommendations

Summary : 

Summary Incident investigations are the single most important component of incident prevention program because they prevent reoccurrence Unsafe acts and conditions left uncorrected are likely to result in more serious events Investigations identify processes and procedures that need modifications or improvements

Quiz : 

Quiz 1. Accidents are: A. Preventable B. Costly C. Part of life D. Both A and B 2. If I have an accident or injury I should A. Fix what I broke B. Tell my supervisor C. Keep working and not worry about it D. Report it within a week 3. Most accidents are caused by A. Bad weather B. People C. Equipment D. Poor directions 4. I can help prevent accidents by A. Using my own equipment B. Doing only what I am trained to do C. Riding in car pools D. Helping others with their jobs

Quiz : 

Quiz 5. Most slip and fall accidents are caused by A. Rain puddles B. Things left on floors and walkways C. Not watching where you walk D. Both B and C 6. To help prevent accidents, people who use tools must A. Be very careful B. Not wear glasses C. Be trained and authorized to use them D. Not be sleepy 7. If I am unsure how to do a job I should A. Ask my supervisor B. Try different ways of doing it C. Ask a co-worker D. Do the job slowly 8. Which of the following situations could lead to an accident A. Drinking coffee B. Not getting a good nights rest before work C. Reading on my break D. Asking a supervisor how to do a job

Quiz : 

Quiz 9. Personal Protective Equipment such as safety shoes, glove and safety glasses A. Can be worn if I choose B. Are specifically required for some jobs C. Uncomfortable and not necessary D. Belong to me 10. Safety Signs provide A. Information about hazardous areas B. Caution information C. Warnings D. All of the above 11. If I see an accident at work, I should A. Talk to the person involved B. Ignore it because it none of my business C. Feel sorry for the person D. Tell my supervisor 12. If I see an electrical hazard I should A. Report it immediately B. Fix it on my next break C. Not use the equipment D. Both A and C

Quiz - Answers : 

Quiz - Answers 1. Accidents are: A. Preventable B. Costly C. Part of life D. Both A and B 2. If I have an accident or injury I should A. Fix what I broke B. Tell my supervisor C. Keep working and not worry about it D. Report it within a week 3. Most accidents are caused by A. Bad weather B. People C. Equipment D. Poor directions 4. I can help prevent accidents by A. Using my own equipment B. Doing only what I am trained to do C. Riding in car pools D. Helping others with their jobs

Quiz - Answers : 

Quiz - Answers 5. Most slip and fall accidents are caused by A. Rain puddles B. Things left on floors and walkways C. Not watching where you walk D. Both B and C 6. To help prevent accidents, people who use tools must A. Be very careful B. Not wear glasses C. Be trained and authorized to use them D. Not be sleepy 7. If I am unsure how to do a job I should A. Ask my supervisor B. Try different ways of doing it C. Ask a co-worker D. Do the job slowly 8. Which of the following situations could lead to an accident A. Drinking coffee B. Not getting a good nights rest before work C. Reading on my break D. Asking a supervisor how to do a job

Quiz - Answers : 

Quiz - Answers 9. Personal Protective Equipment such as safety shoes, glove and safety glasses A. Can be worn if I choose B. Are specifically required for some jobs C. Uncomfortable and not necessary D. Belong to me 10. Safety Signs provide A. Information about hazardous areas B. Caution information C. Warnings D. All of the above 11. If I see an accident at work, I should A. Talk to the person involved B. Ignore it because it none of my business C. Feel sorry for the person D. Tell my supervisor 12. If I see an electrical hazard I should A. Report it immediately B. Fix it on my next break C. Not use the equipment D. Both A and C