Incident Investigation

Topics
Establish an effective incident investigation
program
Learn effective analysis tools relating to
incident investigations
Learn how to conduct an incident
investigation that identifies the contributing
factors to the incident
Minimize the recurrence of workplace
incidents that are contributing to injuries and
illnesses

Why Should We Investigate?

To prevent or decrease the likelihood of
future injury or illness
To identify and correct unsafe behaviors
and conditions
To identify training needs

When Do You Conduct an Accident

Investigation?
All incidents
All injuries, even very minor ones
All incidents with the potential for injury
Property damage, product damage, and
near miss situations

Steps to Assure a Good

Investigation
Emphasize that safety is a value, not just a priority
Remind employees to report incidents immediately
Explain how accident investigations are critical to
the organization
Ensure quality forms exist to guide your efforts and
provide necessary reminders.
Fix the cause, not the blame
The 2nd, 3rd and 4th items are part of groundwork
that needs to be laid before an incident occurs.
These can also be reiterated as part of the
investigation.

Steps to Assure a Good

Investigation
Emphasize that safety is a value, not just
a priority
Values do not readily change and remain
unaffected by the competing, daily
fluctuation of other factors in the work
environment.
Priorities can change daily in response to
situational demands.
When safety is a basic value, it becomes the
natural way of performing a job, anything
Making Safety
a Basic Value; R.E. Earnest; Professional Safety, August 2000; American Society of
less
is
unacceptable.
Safety Engineers

Unsafe Acts and Conditions

Unsafe Act
Violation of established safety
policies/procedures which could result in
an incident.
Unsafe Condition
A mechanical or physical condition which
if not eliminated, guarded or altered could
result in and incident.

Unsafe Acts:
Cause 90% of ALL incidents

Unsafe Conditions:
Cause 10% of ALL incidents

*Industrial Safety and Health Management; Liberty Mutual , 1995

Unsafe Acts Vs Unsafe Conditions

*Industrial Safety and Health Management by
C. Ray Asfahl cites H.W. Heinrich, whose research
concluded that 88% of all industrial incidents are
from unsafe acts. A 1995 survey completed by
Liberty Mutual of 400 Risk Managers and Safety
Consultants found that, excluding acts of God,
92% of all workplace incidents result from
performance deficit (unsafe behavior).

*Industrial Safety and Health Management; Liberty Mutual , 1995

Before an Incident
Establish
Who should conduct the investigation
Supervisor, foreman, safety committee,
safety director/Coordinator.
Why? Supervisors know the job.
When incident investigations are to be
completed
ASAP after the incident
How the investigation will be conducted
Forms used
Procedures

Before an Incident
Establish
What will be done with findings
Reviewed by senior management
Safety committee discussion
Follow up on corrective actions
Incident trend analysis

After an Incident
Conduct investigation ASAP
Control & preserve the scene
Interview injured worker promptly while
information is clear
Interview witnesses individually
Ask open ended questions
Who, What, When, Where, Why, and How?
Compile background information
Seek facts not fault

After an Incident
Document investigation
Determine cause(s) of incident
Determine what can be done to prevent a
similar incident from happening again
Implement corrective actions
Follow-up

Incident Causes
Immediate Cause
A sequence of unsafe acts that led to the
incident
Example: Water on the floor
Basic Cause
The reasons why the immediate cause was
allowed to occur or failed to occur
Example: Why is the water on the floor?

General Causal Categories

Materials/equipment
Environment
Personnel
Management
Task

Incident Scene
Where did the incident occur?
What was the employee doing when the
incident occurred?
What steps did the employee take while
performing the task?
What equipment/tools were being used?
How were the equipment/tools used?

Incident Description
What task was being performed?
What were nearby employees (if any) doing?
What happened with the equipment/tools
being used?
What was the injury or damage?
What steps should be taken to perform this
task safely?

Identify Unsafe Conditions &

Unsafe Acts
Work environment and equipment
Was work environment safe?
Housekeeping?
Additional factors?
Noise, heat, lighting, fatigue, height
Were equipment/tools in good condition?
Defective?
Missing guards?

Identify Unsafe Conditions &

Unsafe Acts
Procedures
Are there inspection procedures to detect
hazard?
Rushed job?
Were task procedures followed?
Were correct equipment/tools used?
Was employee authorized to perform task?

Contributing Factors Human

Behavior Notes:
Common to all accidents
Not limited to the person involved in the
accident
Highly probable that the behavior had
occurred previously
Risk behavior that occurs regularly becomes
part of the system
Behavior has been observed, condoned and
encouraged, at least indirectly by
management

Identify Unsafe Conditions &

Unsafe Acts

Behavior

Was employee supposed to be in vicinity of

incident area?
Was PPE worn?
Does employee know PPE is required?
Did employee know where PPE is stored?
Was PPE adequate?
Were safety rules broken?
Were shortcuts taken?

Find the Root Causes

When you have determined the contributing
factors, dig deeper!
If employee error, what caused that behavior?
If defective machine, why wasnt it fixed?
If poor lighting, why not corrected?
If no training, why not?

Find the Root Causes

A man falls off an unstable step ladder with a
damaged rung
Unsafe Act
Climbing a defective ladder
Unsafe Condition
A defective ladder
The Correction
Get rid of the defective ladder

Have the root causes been identified?

Find the Root Causes

What are some of the contributing factors?
Why was the defective ladder not found in
normal inspections?
Why did the supervisor allow its use?
Did the employee involved know not to use
it?
Was the employee properly trained?
Did the supervisor examine the job first?
Have the root causes been identified?

Find the Root Causes

Ask yourself, What was the Root Cause
of the Injury?

Find the Root Causes

Initial information:
An employee is using the grinder and is not
wearing safety glasses. The glasses are on the
workbench near the grinder. The supervisor walks
by and sees it, but has other things to take care
of. The Plant Manager, who happens to be
passing through the plant on his way to the
regularly scheduled Operations meeting with
senior management, notices both the employee
and supervisor, but is in a hurry to get to the
meeting.

Find the Root Causes

Additional information:
Senior management is having the regularly
scheduled Operations meeting. Safety is not on
the agenda.

Find the Root Causes

Result:
A piece of metal becomes imbedded in the eye
of the employee using the grinder.
Ask yourself, What were the Root Causes of
the Injury?

Identify Possible Corrective

Actions
Engineering controls
Administrative controls
Personal protective equipment

Do not stop at familiar or favorite corrective actions

Lets look at a few

Engineering Controls
Automate hazardous process/use machine
Change the job task or equipment
Substitute high hazard materials for ones of lower
hazard
Specify correct equipment for job tasks

Modify work station

Change layout, location or position of equipment
Change position of employee
Provide barriers, warning signs or guardrails
Increase visibility in workspace

Administrative Controls
Modify employee functions
Clearly define expectations
Designate employees authorized to operate equipment
Enforce disciplinary policy for violation of safety rules

Provide training for employees

Equipment, job procedures, reporting procedures

Review hazards and controls

Perform job safety analysis and change job procedures
Review hazards and controls of infrequent tasks
Change frequency & depth of hazard inspections

Personal Protective Equipment

Review/specify PPE requirements
Provide personal protective equipment
Train employees on purpose and use
Ensure employees wear adequate
protective equipment.

Corrective Action Plan

Develop corrective action plan
Assign responsibility for corrective action
Follow-up
Ensure corrective actions are taken
Prevent similar incidents from occurring

Managing Recommendations for

Corrective Action
Should a policy be revised or developed?
Should the monthly self-inspection checklist be
modified?
Should training be conducted and will retraining on that
topic be needed/provided?
Should a work practice be modified or eliminated?
Should the supervisor monitor the work practice and if
so, how will this be accomplished?

Conclusion
Incident Investigation is both a reactive and
proactive process in that it uncovers the root
cause and other contributory factors as well as
providing valuable information to prevent similar
incidents from occurring in the future.
We cannot afford, nor is it acceptable to wait for
hazards to identify themselves through
someones accident

Questions

Zenith Insurance Company

Corporate Office: 21255 Califa Street
Woodland Hills, CA 91367
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