Incident Investigation &

Reporting

Ahmed El Makaty
HSE Department

Rev.2
 COURSE MATERIALS

Please make sure that below described materials are provided to you
throughout the course:

1. Training presentation handout (total of 60 slides).

2. Notebook for writing notes.

3. Case study for conducting Root Cause Analysis & identifying corrective
actions; which will be used for group activities and audited by the
trainer by end of the course.

4. Evaluation form; which must be filled and returned to L&D Department

Training Coordinator after completion of the training course.

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 COURSE INFORMATION MAP
Course
Elements

Start Unit A Unit B End

Introduction to Accident
Accident Investigation 8
Administrative Investigation Steps Course
Information Summary
(Before We
Begin) Definitions Initial Response
Feedback
Form
Course What is Form
Introduction accident Investigation
investigation? Team

Course Main
Objectives What to Determine Facts
investigate?

Why do we Determine Key

need to Factors +
investigate Group Activity
accidents?
Determine
Systems to be
What makes a
Strengthened
good
investigation?
Recommend
Corrective
Common Actions
failings in
investigations
Document &
Communication

Follow up +
3 Group Activity
 BEFORE WE BEGIN

Mobile Phone Emergency No. Assembly Point

on Silent Mode 4477 8333 & Floor Marshall

Break Times Activities & Test Recognition

4
 INTRODUCTION

• According to the ILO, 2.3 million fatalities occur each year. 350,000 due to
occupational accidents and 1,950,000 due to occupational diseases.

= 1,000 killed daily due to accidents

= 860,000 injured persons per day

• Misconceptions about accidents domain organizations.

• Understanding why accidents occur and how to prevent their occurrences

in an essential part of improving safety in any industry.

Occupational accidents and occupational diseases are preventable!

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 OBJECTIVE

The overall objective of this training is to prevent recurrence of accidents

similar in nature of which are being investigated. This will be achieved
through providing employees with an understanding of Qatar Steel
accident investigation process; and investigation skills and techniques.

By the end of this training, employees should be able to:

1. Collect required evidence for investigation.

2. Establish incident chronology.
3. Conduct witness interviews and root cause analysis during accident
investigation meetings with team members.
4. Prepare incident reports and recommend control measures correctly
to ensure future recurrences are prevented.

The purpose of this training is not to discuss the incident investigation procedure.
Reading and understanding the procedure is still mandatory and a pre-requisite.

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 UNIT A: INTRODUCTION TO ACCIDENT INVESTIGATION

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 DEFINITIONS

Unsafe Condition: any situation that could result in injury or damage to

people, property or equipment.

Unsafe Act: any act or omission by an individual that poses a risk of injury
or damage, such as breaching a safety procedure, or the failure to act upon
an unsafe condition.

Near miss: an unplanned or uncontrolled event or chain of events that has

not resulted in recordable injury, illness, asset damage or environmental
damage but had the potential to do so in other circumstances (incident has
occurred).

Accident: any event that has resulted in injury or damage to a person,

property or equipment such as the following that result in undesirable
consequences.

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 DEFINITIONS

Unsafe Condition Unsafe Act Near miss Accident

Other examples?
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 DEFINITIONS

Immediate Cause: apparent cause that resulted in injury or damage to people,

property or equipment.

Underlying/Root Cause: hidden cause(s) that resulted in injury or damage to

people, property or equipment.

Flower = accident / incident

To prevent flowers – what is required?

Destruction of the stem?

= immediate cause of
accident.

Destruction of the root?

= underlying/root
cause of accident.

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 WHAT IS ACCIDENT INVESTIGATION?

Accident Investigation is a process of:

1 2 3
Identifying Identifying Learning
the remedial from those
underlying steps to be experiences.
causes of taken to
incidents. prevent
similar
events.

When those three elements are correctly applied, past mistakes will not be
repeated.

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 WHAT TYPE OF INCIDENTS TO INVESTIGATE?

1. Personal injuries (Qatar Steel employees, contractors and visitors at

Qatar Steel premises).
2. Environmental releases.
3. Near miss events.
4. Explosions and fire events.
5. Property damages.
6. Vehicle incidents (Qatar Steel owned vehicles and accident in premises).
7. Other violations (e.g. security incidents).
8. Process safety events.

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 TYPES OF PERSONAL INJURIES

Minor Injury Major Injury Fatality

First Aid Cases Restricted Work Cases Multiple Fatalities
Medical Treatment Cases Lost Time Injuries

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 WHY DO WE INVESTIGATE?

1. To understand how and why things went wrong.

2. To prevent accidents.
3. To prevent “near-misses” becoming “accidents”.
4. To prevent future losses or injuries.
5. To find weaknesses in operating procedures so they can be
strengthened.
6. Examine method statements and improve them.
7. To find deficiencies in risk assessments.
8. Explain to senior management / authorities what, how and why the
accident or incident happened.
9. Have a formal record of the accident.
10. Demonstrate commitment to health and safety.

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 ACCIDENTS RATIO

Practical Loss Control Leadership, F E Bird and G L Germain, 1969.

Thus, if near miss incidents were investigated, immediate and root

causes identified and actions implemented to reduce the likelihood of
these immediate and root causes from being reestablished, then
accidents can be prevented.
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 WHAT MAKES A GOOD ACCIDENT INVESTIGATION?

A good investigation will identify the immediate cause(s) of the accident and
the root cause(s) of the accident and measures that could break the chain of
causation.

Employee
injured his
back

Immediate cause: employee slipped on oil.

but a good investigation identifies gaps in chain of causation…

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 WHAT MAKES A GOOD ACCIDENT INVESTIGATION?

Employee
Lack of
slipped on oil Inadequate
supervision /
spilled on the housekeeping
monitoring
ground

Inadequate
No commitment No process of
health and
to health & housekeeping
safety
safety inspection
management

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 WHAT MAKES A GOOD ACCIDENT INVESTIGATION?

Employee
Lack of
slipped on oil Inadequate
supervision /
spilled on the housekeeping
monitoring
ground

Inadequate
No commitment No process of
health and
to health & housekeeping
safety
safety inspection
management

Actions against all root causes prevents accidents from recurring.

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 COMMON FAILINGS IN INVESTIGATIONS

1. Failing to identify all causes of the accidents (root causes).

2. Failure to identify corrective action for root causes identified.
3. Failure to notice important pieces of evidence.
4. Failure to apply incident lessons learned once received.
5. Failure to consider HIRA/SOP update requirements.
6. Failure to consider re-training requirements.

Other examples?

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 UNIT B: ACCIDENT INVESTIGATION STAGES

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 ACCIDENT INVESTIGATION 8 STEPS

1. Make initial response and report.

2. Form investigation team.

3. Determine the facts.

4. Determine the key factors.

5. Determine systems to be strengthened.

6. Recommend corrective and preventative actions.

7. Document and communicate findings.

8. Follow up

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 ACCIDENT INVESTIGATION 8 STEPS

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 STEP 1 – INITIAL RESPONSE

Firstly, when the incident happens, it is reported to the Site Supervisor

who in turn informs HSE Coordinator in the area. Secondly, we have to:

1. Make the area safe – remove energy sources if any;

2. Take care of injured people – comforting the witnesses, and reporting

any injury to the emergency number;

3. Coordinate with emergency services if necessary – when emergency

number is dialed.

4. Barricade the incident site – to preserve evidence as much as possible.

Compile evidences e.g. PTW and its attachments, witness statements,

photos, etc. to help write the initial notification.

If incident involves contractors, request them for their reports and

photographs and consider their accuracy.

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 STEP 1 – INITIAL RESPONSE

Thirdly, an initial report of the incident is made through ERP. Can be

accessed from iCenter:

Incident reporting to system must be done within the same shift.

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 STEP 1 – INITIAL RESPONSE

Click: Create > Report Incident

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 STEP 1 – INITIAL RESPONSE

Fill in the following sections:

All search fields must be

filled from system
(not automatically)

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 STEP 1 – INITIAL RESPONSE

Fill in the following sections:

You can add photos, Consequences can be Once all information is

permit attachments, etc. referred to from the added, you can click
Risk Matrix submit

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 STEP 1 – INITIAL RESPONSE

Risk Assessment Matrix (RAM):

Consequences Increasing Probability
Increasing Severity

Potential People Assets and Environment Reputation A B C D E

Severity Production Remote Unlikely Occasional Likely Frequent
Never heard of Has occurred in Has occurred in Occurs several Occurs several
in the Steel the Steel Qatar Steel times a year in times a year in
Industry Industry Qatar Steel a Department
0 No injury No damage No effect No impact
No Risk

1 Slight injury or Slight damage, Slight effect Slight impact

health effect (< QAR 50,000)
Low Risk

2 Minor injury or Minor damage Minor effect Limited impact

health effect (QAR 50,000 to
500,000)

3 Major injury or Local damage Local effect National impact

health effect (QAR 0.5M to
Medium Risk
5,000,000)

4 Single Major damage Major effect Regional

Fatality or (QAR 5M to impact
High Risk
permanent 25,000,000)
total disability
5 Multiple Extensive damage Massive effect International
fatalities (>QAR 25,000,000) impact

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 STEP 1 – INITIAL RESPONSE

Based on the potential severity level of the accident, the decision to

investigation will take place (if different than the actual).

Actual S3, Actual &

S1 or S2 Potential S3
Potential S4 or S5

• Detailed investigation. • Detailed investigation. • Detailed investigation.

• Root cause analysis not • A detailed root cause • Root cause analysis
required. analysis may be conducted required.
for potential S3 (HIPO) or
Recurrence of accident.
• This is at the discretion of
the HSE Manager (in
consultation with relevant
Department Manager).

Then, initial incident report will be formulated through Shift Supervisor

and Safety Coordinator.

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 STEP 2 – FORM INVESTIGATION TEAM

Incident investigation team should consist a minimum of 5 and maximum 7

core members.

Selection of investigation team leader shall be as follows:

• In the case of Actual or Potential S3, the chair shall be at Section
Head level and above.
• In the case of Actual or potential S4 or S5, the chair shall be at
Manager level.

The investigation team should be composed of:

1. Lead investigator (chair).
2. HSE representative.
3. Subject Matter Experts (SMEs) e.g. operations, maintenance, nurse, etc.
4. If incident involved contract work, contractor management/employees.

At least one member of the investigation team shall be knowledgeable of

the process, where the incident occurred.

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 STEP 2 – FORM INVESTIGATION TEAM
The roles of the investigation team include:
Lead Investigator
• Initiate investigation meetings.
• Plan and lead detailed investigation.
• Lead Root Cause Analysis process.
• Ensure participation of members.
• Ensures systematic identification of
root-causes and corrective actions.
• Ensures investigation report is
completed on time.
• Communicate to management and
to relevant parties the report
findings.
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Team Members
• Actively participate in meetings.
• Support collection of evidence.
• Contribute to investigation report.
• Complete all investigation actions as
requested by investigation leader.
• Participate in Root Cause Analysis.
• Ensure confidentiality is maintained
during the investigation.
 STEP 3 – DETERMINE THE FACTS

The investigation team can now determine facts behind the accident. Facts
can be obtained from 4 elements:

• Location of incident • Tools & machinery

• Maps/drawing – if an • Chemical – if used
• Photographs • PPE
1 3

• Documentation
• Training records
• SOPs • Witness interviews 2
• Maintenance records
• HIRA/ JSA
• TBT 4

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 EXERCISE

Group Activity

Identify what types of evidences are required for

verifying:

1. Involved persons competency.

2. Involved persons had followed correct work/safety
procedure(s).
3. Involved persons were aware of activity hazards.
4. Equipment used in activity was in good condition.
5. Location of accident.
6. Involved persons version of events.

10 min

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 STEP 3 – DETERMINE THE FACTS

• Facts must cover the 5W & 1H questions: Who? Where? When? What?
How? Why?

• These are the basic questions that require answering for any investigation.

• The skill involved in accident investigation is to be able to find sensible and

relevant answers to these six fundamental questions.

Example:

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 WITNESS INTERVIEWS

The PEACE Technique:

1. Plan - to ensure all matters are covered.

2. Engage & explain - make the witness feel at ease.
3. Account/clarify & challenge - listen to their version of events & contest the
information if required.
4. Closure - close the interview, thank the interviewee.
5. Evaluate - assess what they have told you.

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 WITNESS INTERVIEWS - PLAN

• All interviews will require planning.

• What subject areas will be covered and in what order?
• List areas to ensure they will be covered.
• Draft questions may be required.

• Other resources:
• PTW, method statement, risk assessment, toolbox talk attendance,
training records etc.

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 WITNESS INTERVIEWS - ENGAGE

• First impressions counts.

• Witnesses may be nervous placing them at ease will make it easier for
investigators to obtain information.
• Explain what is the purpose of your interview.
• Explain how the process works, this may be defined by national legislation.
• Thank them for agreeing to meet.

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 WITNESS INTERVIEWS - ACCOUNT

• The account is where information is obtained from the witness.

• Allow the witness to speak do not interrupt and thank them for
responding.
• Use active listening skills, make eye contact, nod your head, take
limited notes.
• Challenge stage where any inconsistences can be challenged – can be
conducted after a break for further planning.

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 WITNESS INTERVIEWS - CLOSE & EVALUATE

• This is at the conclusion of the interview.

• Summarize the information obtained, request conformation as to the
accuracy.
• Thank the witness as further interviews may be required.
• Information obtained must be evaluated to ensure the Who, Where, When,
What, How and Why questions have been answered.
• Closing some lines of enquiry.
• Potentially opening others.

Ensure witness statement is obtained/recorded in the investigation report.

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 EXERCISE

Group Activity

You will be show two videos representing good and

bad examples of conducting witness interview. You
have to identify both bad and good elements based
from the PEACE technique.

10 min

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 STEP 3 – DETERMINE THE FACTS

Lastly, a chronological order/timeline of the event must be made after

reviewing the facts and taking the witness statements into consideration.

Example:

TIME ACTION/ INTERVENTIONS

03:45 Quenching water activity started in yard
Mr. X got minor injury on right hand side index finger during arranging
03:50
quenching stand in yard
03:55 Information received from Mr. Y regarding the incident
04:00 As per the information received visited the IP on the site
04:05 Reported to QS emergency number regarding the incident
04:10 QS ambulance arrived for first aid and taken to QS clinic
Clinic team assess the cut injury and done the proper dressing avoid
04:25
the bleeding of blood

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 STEP 4 – DETERMINE KEY FACTORS

• The purpose of this stage is to determine the causes of the accident or

incident.
• To concentrate on finding the root causes not just the immediate causes.
• This stage is for conducting a Root Cause Analysis: 5 whys, fishbone
analysis or why tree – when required.
• For S1 and S2 incidents, determining root causes can be done with
reference to human, job, environment and organizational factors.

Human Factors
• Physical abilities
• Competence
• Behavioural issues
• Human error
• Other factors: Fatigue,
Stress, Morale,
Alcohol, Drugs etc.
Organizational Environmental
Job Factors
Factors Factors
• Divided attention • Work pressure and • Housekeeping
and distractions long hours • Lighting
• Inadequate • Availability of • Noise
procedures sufficient resources • Layout
• The amount of time • Quality of supervision • Traffic
available for the task. • Safety Culture
• How much attention
is needed for the task
being undertaken?

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 ROOT CAUSE ANALYSIS: 5 WHYS

Example of 5 whys:

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 ROOT CAUSE ANALYSIS: 5 WHYS

Practical example of 5 whys:

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 ROOT CAUSE ANALYSIS: FISHBONE DIAGRAM

Example of fishbone diagram template:

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 ROOT CAUSE ANALYSIS: FISHBONE DIAGRAM

Practical example of fishbone diagram (warehouse example spillage):

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 ROOT CAUSE ANALYSIS: WHY TREE

The Why Tree Root Cause Analysis technique has 5 steps:

1 Define the Significant Event to investigate

2 List observations (facts)

3 Choose an observation to pursue first

4 Hypothesize causes of the observation

5 Verify the hypotheses

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 ROOT CAUSE ANALYSIS: WHY TREE

Example: Crane#49 Electrical

Drive Room Fire
Incident in CC#4 Billet
Stacking Bay

Smoking Low flash Fire while Liquid slag or Electrical Delibarately

inside the point carrying out metal Fault inside lit up the fire
electrical substabnce any spashes / room

Over loading Over heating Short cicuit in Failure of Loose

Cable Electrical Battery
due to due to loose crane drive protection Connection in
insulation fault in air explosion due
operation connection electrical system electrical
overheating conditioning to heating from
circuit of Bus

Heat
dissipation
from the crane Fault in AC Fault in AC out
structure to indoor unit door unit
the cables

Moisture Overloading Failure in

Lack of formation in due to hot electronic Improper
planned indoor unit and dusty card selection of
maintenance AC unit

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 EXERCISE

Group Activity

You will be provided with an incident scenario and

you will work in a group of 5 to identify root causes
of the incident using Why Tree Root Cause Analysis.

1 hour

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 STEP 5 – DETERMINE SYSTEMS TO BE STRENGTHENED

This is the arriving at conclusions step. Analysis has been completed and
we have to determine what type of management systems to improve before
we decide on actions. The management systems that can be improved are:

1. Operating procedures/safe work practices.

2. Management of change.
3. Training/performance.
4. Contractor safety/performance.
5. Process hazards analysis.
6. Incident investigation/communication.
7. Emergency planning/response.
8. Quality assurance.
9. Mechanical integrity.
10. Audits.

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 STEP 6 – RECOMMENDED CORRECTIVE & PREVENTIVE ACTIONS

Investigators must now identify all risk control measures, that if in place,
can broke the causation chain.

Corrective & preventive actions should address key factors and include:

1. What is to be done? – Description of action.

2. Who will do it? – Person responsible for implementation.
3. When it is to be done by? – Completion date.
• Immediate e.g. reattach guards.
• Within 3 months e.g. install local exhaust ventilation
4. Consideration of hierarchy of hazard controls.

Number of actions may vary but must have at least one recommendation
for each key factor.

Ensure proposed actions are agreed with relevant stakeholders (affected

departments).

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 STEP 6 – RECOMMENDED CORRECTIVE & PREVENTIVE ACTIONS

Hierarchy of hazard control:

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 STEP 6 – RECOMMENDED CORRECTIVE & PREVENTIVE ACTIONS

Hierarchy of hazard control:

1. Elimination: measures that eliminate risk, e.g. by using safer products

(water – rather than solvent-based paints).
2. Substitution: e.g. replacing a machine currently in use with one that
has a better guard or a product less hazardous.
3. Engineering controls: measures that reduce the likelihood of exposure
to the hazard, e.g. the installation of guards or local exhaust
ventilation.
4. Administrative controls: measures that minimize the risk through safe
systems of work, e.g. rotation of workers to reduce exposure or
increased safety signage.
5. Personal protective equipment: to be used where collective protective
measures (those that protect several workers) cannot be identified.

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 EXERCISE

Group Activity

Working in the same groups, recommend corrective

and preventative actions for the incident scenario
provided.

1 hour

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 STEP 7 – DOCUMENT & COMMUNICATE FINDINGS

At the end of the day, what should be the evidence of a completed incident
investigation? The written report.

The written report:

1. Should be of complete sentences and good grammar.

2. Don’t include assumptions or general speculation – state the facts and
basis only.
3. Appendices such as digital photos, block flow diagrams, plot plans, etc.
can be attached to aid understanding. But lengthy references or
exhibits typically are not explicitly included in report.
4. Consider if it will be clear five years from now in terms of events,
information, root causes, recommendations.

Detailed investigation report must be signed within 30 calendar days

and communicated to all relevant parties.

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 STEP 7 – DOCUMENT & COMMUNICATE FINDINGS

Written report typically include:

1. Executive Summary 8. Management system elements to be
2. Introduction strengthened
• Event Title 9. Recommendations
• Event Classification • Immediate Actions (“Quick
Fixes”)
• Event Summary
• Actions related to Management
3. Incident Investigation Methodology
System Improvement
4. Incident Investigation Team
10. Conclusion
5. Sequence of Event/Facts
11. References
• Event Description
12. Appendix
• Chronological Description
• Initial Report Form
6. Analysis and learnings from past
• Root-Cause Analysis (e.g. Why
similar incidents
Tree, etc.)
7. Root Cause Analysis
• Witness statement

Sample report:
It also must be retained for 3 years for audit purposes.

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 STEP 7 – DOCUMENT & COMMUNICATE FINDINGS

In terms of communication, safety bulletins/alerts are shared by HSE

Department on weekly basis (covers recent incidents – if any).

Stay informed with weekly safety bulletins sent by HSE representatives.

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 STEP 8 – FOLLOW UP

Track recommendations periodically on ERP to ensure that they are carried

out by the Action Owners.

Require written management approval when recommendations will not

be followed.

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 SUMMARY: ACCIDENT INVESTIGATION STEPS

1. Make initial response and report.

2. Form investigation team.

3. Determine the facts.

4. Determine the key factors.

5. Determine systems to be strengthened.

6. Recommend corrective and preventative actions.

7. Document and communicate findings.

8. Follow up

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 Thank you!
Questions?

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