Investigating Incidents: Steps and Level of Investigation

#incident #investigations #accident #events

What is incident investigation?

An incident investigation is the account and analysis of an incident based on information gathered by a thorough examination of all contributing factors and causes involved. It is widely accepted that incidents occur as a result of a chain of events.

(Refer :https://www.safemanitoba.com/topics/Pages/Incident-Investigations.aspx#:~:text=An%20incident%20investigation%20is%20the,of%20a%20chain%20of%20events )

Investigating a Worksite Incident

Investigating a worksite incident—a fatality, injury, illness, or close call- provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Most importantly, it enables employers and workers to identify and implement the corrective actions necessary to prevent future incidents.

Incident investigations that focus on identifying and correcting root causes, not finding fault or blaming, also improve workplace morale and increase productivity, by demonstrating an employer's commitment to a safe and healthy workplace.

Incident investigations are often conducted by a supervisor, but to be most effective, these investigations should include managers and employees working together, since each brings different knowledge, understanding and perspectives to the investigation.

In conducting an incident investigation, the team must look beyond the immediate causes of an incident. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure alone was the cause of an incident. To do so fails to discover the underlying or root causes of the incident, and therefore fails to identify the systemic changes and measures needed to prevent future incidents. When a shortcoming is identified, it is important to ask why it existed and why it was not previously addressed.

For example:

If a procedure or safety rule was not followed, why was the procedure or rule not followed?
Did production pressures play a role, and, if so, why were production pressures permitted to jeopardize safety?
Was the procedure out-of-date or safety training inadequate? If so, why had the problem not been previously identified, or, if it had been identified, why had it not been addressed?

These examples illustrate that it is essential to discover and correct all the factors contributing to an incident, which nearly always involve equipment, procedures, training, and other safety and health program deficiencies.

Addressing underlying or root causes is necessary to truly understand why an incident occurred, to develop truly effective corrective actions, and to minimize or eliminate serious consequences from similar future incidents.

Refer : https://www.osha.gov/incident-investigation

Why investigate?

There are hazards in all workplaces; risk control measures are put in place to reduce the risks to an acceptable level to prevent accidents and cases of ill health.
The fact that an adverse event has occurred suggests that the existing risk control measures were inadequate.
Learning lessons from near misses can prevent costly accidents.
You need to investigate adverse events for a number of reasons.

Reasons for Incident Investigations / Function of Investigation Team

(Why do Incident Investigations ?)

Reasons to carry out investigations of an accident :

To identify the immediate causes of the incident.
To identify the underlying causes of the incident.
To identify the root causes of the incident.
To identify & implementation of the corrective action
To prevent a recurrence. (Prevention of similar losses in future)
To record the facts & evidence of the incident.
For legal reasons and legal compliances. (MHSWR 1999, regulation 5)
For claim management
For Insurance Purposes.
For Lesson Learning – specific & general ( e.g. to identify the training needs, further recommendation)
For increasing staff morale.
For disciplinary purposes.
For data gathering & analyzing purposes.
To Review / update risk assessments/
To Review SSW/ update SSW
To Review PTW / update the PTW

Legal reasons for investigating

(Refer : www.hse.gov.uk)

To ensure you are operating your organisation within the law.
The MHSWR 1999, regulation 5, requires employers to plan, organise, control, monitor and review their health and safety arrangements.
Health and safety investigations form an essential part of this process.
you are expected to make full disclosure of the circumstances of an accident to the injured parties considering legal action. The fear of litigation may make you think it is better not to investigate, but you can’t make things better if you don’t know what went wrong!
The fact that you thoroughly investigated an accident and took remedial action to prevent further accidents would demonstrate to a court that your company has a positive attitude to health and safety.
Your investigation findings will also provide essential information for your insurers in the event of a claim.

Benefits of carrying out investigations of an accident :

helps to identify and eliminate the hazards)
Discover trends & patterns of Accidents .
Helps in developing safe/Safety culture ,
Stakeholders satisfaction, ( Customer Satisfaction, Insurance agency, Vendors, Supplier, Workers etc.)
Increase in business reputation ,
Financial benefits as avoid the reoccurrences, ( to avoid the further financial losses)
Improve HSMS system performance, integrity, creditability, assurance ,
Review the system HSMS ,
Helps to reduce the accidents/ incidents , ( Reduce the Accident rate)
Reduce injury and Severity rates
Reduction in fines ,
Reduction in penalty ,
Reduction in compensation claim,
Reduction in Human sufferings (pain and injury)
Helps in developing safe system of work ( developing PTW)
Helps in continuous improvement process
Demonstrate improvement & ownership of outcomes
Development of managerial skills – can be applied to other areas of the organisational

Which events should be investigated?

All events should be investigated.

For Example:

Accident.
Injury accident.
Damage-only accident.
Near-miss. (e.g. undesired circumstances, potential or significant NM)
Dangerous occurrence.
Work-related ill health.
LTI (Lost Time Injury)
MTC (Medical treatment Case)
etc.

NEGATIVE OUTCOMES OF ACCIDENTS:

Injury & possible death ( Fatality)
Disease
Damage to equipment & property
Litigation costs (Legal costs), possible citations( court judgement), Enforcement notices, Legal Actions
Lost productivity,
low Efficiency,
Low Morale (Staff & workers)
Financial Losses, e.g. Compensation
Loss of reputation

POSITIVE OUTCOMES OF ACCIDENTS

(it leads to )Accident investigation
(it helps into)Prevent repeat of accident
(it helps to improve) Change to safety programs
(it helps to improve) Change to Policy , procedures, system & rules
(it helps to improve) Change to equipment design
Lesson Learning
Training required./requirement

Having been notified of an adverse event and given basic information on what happened, you must decide whether it should be investigated and if so, in what depth.

It is the potential consequences and the likelihood of the adverse event recurring that should determine the level of investigation, not simply the injury or ill health suffered on this occasion.

For example:

is the harm likely to be serious?

Is this likely to happen often?

Similarly, the causes of a near miss can have great potential for causing injury and ill health.

When making your decision, you must also consider the potential for learning lessons.

For example, if you have had a number of similar adverse events, it may be worth investigating, even if each single event is not worth investigating in isolation.

It is best practice to investigate all adverse events which may affect the public.

In RoSPA's view, some of the major pitfalls in accident and incident investigation include:

No reporting of accidents and near misses (often due to employee fear of consequences)
No investigation at all (coupled with massive under-reporting to enforcing authorities)
No clear procedures for investigation (and/or no managerial involvement)
No workforce involvement (trades union safety representatives have a legal right to investigate accidents)
No scaling of the level of investigation (everything investigated in the same way rather than matching investigation effort to safety significance or learning potential)
Failure to gather all the relevant facts (particularly as a result of inadequate approaches to witness interview)
No use of structured methods to integrate evidence
Distortions in evidence gathering and analysis due to uncritical biases
Concluding the investigation too early (not going far enough)
Simply focusing on the errors of individuals
No search for "root causes"
In that context, no examination of safety management system failures
Failure to think outside conventional rules and operating systems
Poor communication of lessons learned
Failure to secure closure on resulting recommendations.

Frank Bird Accident Triangle (Safety Pyramid )

The accident triangle, also known as Heinrich's triangle or Bird's triangle, is a theory of industrial accident prevention. It shows a relationship between serious accidents, minor accidents, and near misses and proposes that if the number of minor accidents is reduced then there will be a corresponding fall in the number of serious accidents.

Who Should Investigate?

An Investigation Team—Competent Members (KATES), Detailed knowledge of work activities, Familiar with H&S good practices, standards, & legal requirements including report writing ability.

Team members should have investigative skills like information gathering, interviewing, evaluating and analysing the causes of accidents.

Minor incidents. (Trival) - Investigated by line manager/ Supervisor.

Major incidents, more complex events or incidents with high potential, Investigated by a team:

Safety specialist / H&S professionals
Senior manager/ partners/ Directors
Technical specialist.
Worker representative/ Safety Representative/ Union Safety Rep.
Witnesses / Workers
Supervisor / Line Manager
etc.

When accident investigation should start?

•Immediate -Urgency will depend on the magnitude and immediacy of risk

•Adverse events should be investigated and analysed as soon as possible.

•Memory is best and motivation greatest immediately after an adverse event.

•NB –Consider the state of those being interviewed –May be in shock

General Question- What does involve in investigation?

•Analysis of all information available

–Physical –scene of incident

–Verbal –accounts of witnesses

–Written –documents

•Process drawings (P&ID’s)

•Risk assessments

•Permits to work

•Procedures

•Instructions,

job guides etc.

What makes a good Investigation?

•“To get rid of weeds you must dig up the root. If you only cut off the foliage the root will grow again.”

•Investigations which identify root causes that organisations can learn from their past failures and prevent future failures.

•Is suitable for purpose –proportionate to risk

•Thorough systematic and structured

•Is carried out with prevention in mind NOT apportioning blame.

•It does not jump to conclusions

•Based on facts provided

•Follows the causal chain all the way up to Management level

•Explores all lines of enquiry

•Timely, objective and unbiased

•Identifies immediate, underlying and root causes

•Reviews existing risk control measures

•Action plan AND implementation

Likelihood that an adverse event will happen again:

certain: it will happen again and soon;
likely: it will reoccur, but not as an everyday event;
possible: it may occur from time to time;
unlikely: it is not expected to happen again in the foreseeable future;
rare: so unlikely that it is not expected to happen again.

Consequence (as per HSG 245)

1. fatal: work-related death;

2. major injury/ill health: This includes alongwith RIDDOR, Schedule 1), including fractures (other than fingers or toes), amputations, loss of sight, a burn or penetrating injury to the eye, any injury or acute illness resulting in unconsciousness, requiring resuscitation or requiring admittance to hospital for more than 24 hours;

3. serious injury/ill health: where the person affected is unfit to carry out his or her normal work for more than three consecutive days;

4. minor injury: all other injuries, where the injured person is unfit for his or her normal work for less than three days;

5. damage only: damage to property, equipment, the environment or production losses. (This guidance only deals with events that have the potential to cause harm to people.)

Decision to level of Investigation

For Example :

Case 1:

1. Likelihood of recurrence : CERTAIN

2. Consequences : Leg Fractured happened after striking with Forklift Truck( Coming under MAJOR INJURY)

Worst Potential Consequence: If any Forklift Truck hit any worker, there are worst Potential Consequences may happen the FATALITY.

Same will be presented on Table

3. Level of Risk - RED ZONE -High Level of Risk

4. Level of Investigation- High Level of Investigation ( RED ZONE)

Level of Investigation

Minimal level: Immediate line manager/supervisor will look into the circumstances of the accident/incident and try to learn any lessons which will prevent future incidents. ( minimum 1 member )

Low-level : Investigation will involve a short investigation by the relevant supervisor or line manager into the circumstances and immediate , underlying and root causes of the accident/incident, to try to prevent a recurrence and to learn any general lessons. ( minimum 1 member)

Medium Level : Investigation will involve a more detailed investigation by the relevant supervisor or line manager, the health and safety adviser and employee representatives will look jointly for the immediate, underlying and root causes. ( minimum 3 members )

High level : a team- based investigation, involving supervisors or line managers, health and safety advisers and employee representatives. It will be carried out under the supervision of senior management or directors and will look for the immediate, underlying, and root causes. ( minimum 5 members)

Group Discussion

Discuss the first thing you should do when arriving at an accident scene, and then the later steps.

PRE-ACCIDENT PLANNING

Clearly defined roles and responsibilities
Training of key staff members
Communications established
Standard procedures established
Necessary equipment and forms on hand

Basic Investigation Procedure

Step 1 : Gathering the information.

Step 2 : Analyze the information.

Step 3 : Identify risk control measures.

Step 4 : The action plan and its implementation

Step 1 - Gathering Information (Where do I start?)

How and what? (Collecting information)

First Casualty care:

First-aid treatment.
Hospitalisation:
Also consider that by-standers may be in shock (mental trauma).Then start the following steps:

1. Secure the accident scene.

2. Identify witnesses.

3. Collect factual information: (Use investigation kit – Camera, Tape recorder, Measuring Tape, Barricade Tape , scissor, scotch tape, PPEs, gloves, plastic envelopes, Accident investigation and report forms, graph paper etc.)

Photo/sketch ,
Videos, CCTV recordings, mobile recording of where the accident occured
Photo of injuries before being treated
Accident scene Measurements.
Investigator Notes.
Mark-up plans. (Blue-Print/ Site Layout)
Samples , damaged parts of Machinery

4. Interview witnesses & witness statements

Medical reports of your injury or illness from a medical professional who examined you at the time of the accident.

5. The report from the company Accident Book, showing the details of your accident and any other similar accidents that have also occurred in the workplace.

6. Examine documents.

Safety of the accident scene: (Secure the accident scene.):

Is the area safe to approach? (e.g. fire , chemical spillage, electrocution etc.)
Is immediate action needed to eliminate danger before casualties are approached?

Why should the scene of the accident have been secured?

Due to the following reasons, the accident scene is secured:

To preserve the physical evidence: After accident, the safety door and gate and ram’s position to be recorded otherwise these evidences may be disappear which will help to identify the root cause, for claim and insurance purpose.
To identify the cause and sequence of events: It provides the memory of what could have happened before, during and after accident as witness can be identified immediately and by site condition, lot of relevant information is revealed.
Easy Gathering the factual information in timely manner: From accident scene, the photos, sketch, drawings, videos, measurements can be taken which will help in successful investigation.
How and what happened: By preserving the accident scene, it would help to recreate and to tell us how & what would have been happened like Safety gate was opened and safety device were not working.
Safe to approach: To ensure that Compactor’s area is safe to approach (e.g. undesired Ram’s movement, electrocution etc.) or any immediate action needed to eliminate danger before casualties are attended or investigation team are approached.

Due to the following reasons, the accident scene is secured:

To preserve the physical evidence
To prevent the temper of the evidences
To prevent any alterations to the scene of the accident
To prevent removal of evidences(critical evidences)
To prevent unauthorised access to accident scene (To avoid the unauthorised access at accident scene)
To allow the investigation to start
To allow external bodies to investigate
To prevent the further prevention of loss of material /life , reduce the severity of accident
To prevent the harm to others like other workers
To prevent additional hazards to others
To prevent the additional Risks to others
To ensure the safety of everyone who is involved in process/activity/work
To avoid the liability for any injury or damages
Helps to successful investigate by third parties i.e. enforcement Authorities/ Labour Inspector
Avoid losing of the evidences
Later on , it will help to identify the immediate/underlying/root cause and for claim and insurance purpose.
To identify the cause and sequence of events:
Easy Gathering the factual information in timely manner (Gather useful information about what contributed to the accident directly and indirectly)
Identify How and what happened
Help to recreate the accident scene
Safe to approach for others
Helps to identify the immediate action which are needed to eliminate danger before casualties are attended
Helps to inspection of the area

Witness Interview Technique(steps)

Quiet room, no distractions.
Establish a rapport. (positive image)
Explain the purpose of interview, not about blame.
Use open questions, e.g. Who? What? Where? When? Why? How? (5W1H)
Keep an open mind.
Take notes. (Record) (mobile/video/voice record after permission)
Ask for a written statement from witness.
Thank the witness.

Group Discussion - Question: You have to interview a witness who has just seen his friend injured at work. Suggest some golden rules that should be followed.

Document examination to be done during the investigation.

Site plans & actual Site conditions . ( e.g. exact location of accident and what should be actual site conditions)
Company H&S policy. ( As per policy , employer implement Safety CM or not etc.)
Risk assessments. ( Whether it was General / Generic / Specific done or not.)
Training records. ( What , when , whom –competent worker? )
SSW. E.g. SOP, Methods statement, JSA,PTWs ( Any effective SSW, PTW was followed?)
Maintenance records / Logs . ( Was maintenance done or not , or due for Maintenance of particular plant/ machinery or equipment)
Previous accident reports and relevant near misses. ( Similar Accidents & CAPA, sustainability)
Sickness records. , Staff Turnover Records . ( Health condition of worker before accident ?)
Enforcement notices which constitute previous advice; ( Actions were taken or not , what type of advices given by HSE inspector, their implementation and sustainability etc.)
Legal Compliances ( Legal requirement were met or not?)
Process parameters ( any changes in them)
Working Hours (beyond 8 hours i.e. 12 hours working / Overtime)
Personal details of Employee ( whether he was wilful defaulter or received any warning or censure against that worker), has he received induction and job specific training , Pre joining medical report, Any ill health condition , Health Surveillance report etc.
Weather conditions
Earlier near misses , Worker’s Complaints records
Check sheets
Shift Handover Report
PPE register
In and Out Register of worker
MOC documents , MSDS etc.

Availability of Information—Legal registers, Risk Register, previous examination and Inspection Reports, Personal File, etc.

Group Discussion :

What and WHY documents to be examined during investigation?

Step 2 – Analysing Information

(Find out the cause of adverse events/accidents)

Immediate causes (direct causes):

The immediate causes are the unsafe acts and unsafe conditions that gave rise to the event itself. These will be the things that occurred at the time and place of the accident.

For example, a worker slips on a patch of oil spilt on the floor - immediate causes: the slip hazard (unsafe condition), the worker walking through it (unsafe act).

Unsafe acts. ( Unsafe Behaviour)
Unsafe conditions.

Example-

Driving Forklift Truck at speed,
Opened wrong valve,
Using damaged equipment

Underlying cause : (Intermediate cause) -

The less obvious ‘system’ or ’organisational’ reason for an adverse event happening,

Underlying are the things that lie/hidden behind the immediate causes.

( e.g. Intermediate Reason / Technical Reason/ Technical Failures )

E.g.:

pre-start-up machinery checks are not carried out by supervisors;
the hazard has not been adequately considered via a suitable and sufficient risk assessment;
production pressures are too great etc.
guard removed,
ventilation switched off etc.

Root causes:

The Root cause is the most fundamental and indirect cause of an accident or incident. (Trace the reasons behind the immediate causes.)

Root causes are generally management, planning or organisational failings.

Example-

Failure to identify training needs, assess competence;
Failure to use the Risk assessments,
Failing to be proactive ( like no Safety Inspection etc.)
Failure to involve the workforce in health and safety etc.
Poor management Practices( No maintenance provision)

Management Failure (Root causes)

Root causes are the things that lie behind the immediate causes.

For example, with the slip we described above, the Root causes might be a poorly maintained machine that has leaked oil onto the floor, and a poorly inspected and maintained workshop with broken light-fittings and inadequate lighting levels.

Here, the worker might be blameless on the basis that, given those conditions, the accident was bound to happen eventually.

Examples of failures in the management system/ Root cause/ Basic Cause / Management Failure

Failed to provide effective supervision (No supervision) (Inadequate Supervision )- - - - -(only one-way communication)
Failed to provide the specific PPEs (No PPE provided.)
Failed to provide the induction training & Job-specific training (No training/ inadequate Training)
Failed to provide the proper maintenance schedule (No maintenance.) (Inadequate/ insufficient maintenance) (Maintenance errors)
Inadequate Safety monitoring
Failed to implement the Active monitoring
No Reactive monitoring (No provision of Active and Reactive monitoring ) (Inadequate Safety Monitoring)
No checking or inspections arrangement
Failed to develop and implement the effective risk assessment (Inadequate or no risk assessments.) Failure to carry out the risk assessment (inadequate risk assessment, or no review of RA)
Failed to develop the OH&SMS ,
H&S Policy (Lack of system, Policy )
Failed to provide the adequate resources (Lack of resources)
Failed to provide the effective Internal & External Communication (Lack of Communication) , Inadequate Communication issues e.g. between shifts, between personnel and management etc
Failure to develop effective SSW/SWP)Safe Working Procedures)
Failed to develop / implement the SOP (Inadequate procedures)
Failed to prevent the Violations
Non-compliance behaviour ( Management & young worker behaviour)
Inadequate Housekeeping ( Items stored in the FLT pathway / Aisles)
Disciplinary action not developed
Pressure to meet production targets ( busy retail store )
Failure to learn lessons from previous incidents (Lesson learn not shared) ( e.g. Previous collisions)
Modification/ updates to equipment without operator knowledge and/or revised risk assessments
Failed to act/resolve the Worker’s complaints/concerns
Inadequate SOP ( Not developed any SOP)
Failed to hire competent manpower (Lack of competency) ( e.g. Young worker)
Could not provided the right equipment/plant design (Poor workplace layout, poor design of tools and equipment, Poor workstation set-up)
Not planned & developed any H&SMS (Inadequate safety management systems)
Failed to avoid the Excess workloads, ( e.g 12 hours working, Rota system etc.)
Excessive work demands
Excess physical & mental pressure - - - - - (Excessive working hours resulting in mental fatigue)
Failure to monitor actual performance
Failure to provide feedback
Failed to implement the accident reporting procedure / system (Inadequate reporting systems)
Not implemented any accident Investigation System (ineffective accident investigation system)
Poor management practices e.g. inadequate supervision
Production focus instead of Safety Focus

Difference between Immediate Cause & Root Cause

Difference between Immediate Cause & Root Cause

Inadequate policies & procedures – no clear objectives
Timeliness (Lack of time to complete)
Poor development of information
Change- Management , business, people , technology
Lack of motivation to complete
Reluctance to accept responsibility (Lack of accountability)
Narrow interpretations of Safety rules /Safety causes
Erroneous emphasis on a single cause
Allowing solutions (shortcut) to determine causes
Wrong person(s) investigating- incompetent / biased , lack of investigation skills
Corporate memory loss /short memories – we forget & have to relearn

Step 3 – Identifying Suitable Control Measures

(Identifying risk control measure)

Controls measures should be appropriate to unsafe act and unsafe condition of the worker and management failure. e.g. strict monitoring , trainings to workers.

•identify the risk control measures which were missing, inadequate or unused

•compare with standards, guidance and good practice

•identify additional measures needed to address the immediate, underlying and root causes

•provide meaningful recommendations which can be implemented.

(e.g. Elimination, substitution, Engineering Control, Administrative & PPES)

For immediate causes: Examples

Clean up the spill.
Replace the missing guard.
Relocate the trailing cable.

For underlying and root causes: (needs investigation)

More difficult.
Need to make changes in management system.

Step 4 – The action plan & its implementation

Remedial action should focus the prioritise to be given , within the timescale and action to be taken along with personal responsible to complete the action.

Need for prioritisation - Dangerous conditions must be dealt with immediately.
Interim actions may be possible.
Underlying causes and Management failure will require more complex actions- It will take time, effort, disruption, money etc.

Typical contains of investigation reports

Investigators details( Team-who are doing? )
Date, time & Location of the incident with description of the event ( Case number)
Details of injured persons/ person involve (Victim details age, etc.).
Details of the injury
List of evidence including witness interview ( if applicable) (documents examined etc.)
Assessment of breaches of the legislation. ( violations etc.)
Causes of the incident. ( e.g. immediate , underlying & root cause etc.)
Recommendations & conclusion

Typical contains of investigation reports

Investigation report format and structure

There is no specific investigative report writing format. All you need to know and stick to is a structure. Therefore, outlining is the first step in investigative report writing as it will help you understand what kind of information you need to gather and how to present it. Here is a basic example of the outline:

General case information - includes the name of the reporting person, case number, and important dates.
Brief summary - shortly overviews the incident, involved parties, causes, and outcomes.
Recommendations – pieces of advice on the measures that have to be taken.
The purpose of investigation - defines the objectives.
Incident descriptions - provides a full chronological incident description.
Interviews documentation - gives detailed information on the interviews, including notes of the interviewer.
Interviews summary - reveals the most important data gathered during interviews.
Evidence & other findings - show everything sufficient that has helped to understand the situation and find a necessary solution.
Conclusion - presents a final decision on a case, includes summarized information about a certain violation and the policies that will be applied.
Appendices - include necessary additional materials.

Group Discussion:

What are the main reasons for investigating an incident?
Who might investigate a minor injury to a worker, which had no real potential to be worse?
Who might investigate a major incident?
What are the four key steps in incident investigation?