1. objectives describe the responsibilities and procedures for reporting and investigating ◦...

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Incident Reporting Procedure

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Objectives

Describe the responsibilities and procedures for reporting

and investigating

◦ incidents / near-miss incidents

◦ spills, releases,

◦ injuries, occupational illnesses,

◦ equipment or property damage,

◦ transportation incidents,

◦ fires or explosions

◦ security issues


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Objectives

Describe the importance of investigations in:

◦ Determining the root causes of incidents

◦ Determining corrective and preventive actions to prevent similar

incidents.

Describe the importance of initiating investigation

immediately after the incident situation is under control.


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Definitions

Incident –

◦ Any unplanned event or near miss occurring inside the

facility boundaries affecting employees, processes,

contractor employees, or visitors.

◦ Any off-site events involving company products or

equipment in transit or at customer sites

Incident Owner –

◦ The manager, supervisor or designated person

responsible for the facility, area or activity where the

incident occurred.


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Definitions

OSHA Recordable Cases –

◦ All work related illnesses and deaths, and those work

related injuries which result in:

Loss of consciousness,

Restriction of work or motion, transfer to another job, or

require medical treatment beyond first aid and/or use of

prescription medications.

Initial Notification–

◦ A brief communication providing basic details of an

incident


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Definitions

Investigation Team –

◦ Consist of personnel who shall investigate and analyze

the incident.

◦ If an incident involves contractor personnel, then non-

involved contractor employees may be included as team

members.

◦ Management personnel knowledgeable of investigation

methodologies and techniques shall be included in the

incident investigation.


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Definitions

First Aid –

◦ Any treatment and subsequent observation of minor

scratches, cuts, burns, splinters, and so forth, which do

not ordinarily require medical care or use of prescription

medications.

◦ Such treatment and observation are considered first aid

even though provided by a physician or registered

professional personnel.

Incident Reporting ProcedureDefinitions

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Responsibilities

All personnel are responsible for:

◦ Notifying their immediate supervisor of all incidents

immediately.

◦ Participating in generating the initial notification

◦ Participating in incident investigations as needed.

◦ Participating in generating the investigation report

◦ Completing corrective and preventive actions as

assigned.


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Responsibilities

Facility Manager or Shift Leader, or Control Room

Operator is responsible for:

◦ Being the Incident Owner for all incidents that occur

within their area of responsibility.

◦ Documenting initial incident details.

◦ Contacting regulatory agencies if necessary.

◦ Assigning personnel to the incident investigation team.

Incident Reporting ProcedureResponsibilities

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Responsibilities

Facility Manager or Shift Leader, or Control Room

Operator is responsible for:

◦ Leading and conducting incident investigations.

◦ Communicating with Maintenance when design issues or

equipment failures may be involved in the incident.

◦ Defining and recommending corrective and preventive

actions.

◦ Verifying all corrective and preventative actions assigned

during the incident investigation are completed.

◦ Communicating to employees incident summaries.


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Procedure for Investigation

An Incident Investigation shall begin immediately after

securing the scene.

If the area is quarantined, the investigation shall not

commence until release of the quarantine.

Documents associated with the incident should be attached

to incident file.

The Investigation Team shall produce an Investigation

report including corrective and preventive actions.


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Preparation for Investigation

An effective incident investigation starts before an incident

occurs with a well designed investigation procedure. The

following information will provide guidance when conducting

an investigation:

1. ORGANIZE AN INVESTIGATION TEAM.

◦ As few as two or as many as four employees.

◦ The size of the team may vary based on the type of incident.

◦ Must include at least one employee of supervisor responsibility.


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Preparation for investigation

2. ASSEMBLE AN INVESTIGATION KIT.

◦ This kit may include a camera, paper/pens, reporting forms and

any information such as notes on investigation.

3. SECURE THE ACCIDENT SCENE.

◦ Asses the situation to prevent additional accidents from

occurring based on hazards.

◦ Attend to any immediate medical emergencies.

◦ Preserve any evidence at the scene. DO NOT ENTER AN

ACCIDENT SCENE UNTIL IT HAS BEEN CLEARED FOR SAFETY.


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Doing the investigation:◦ Identifying and collect evidence –

This must be done quickly.

◦ Identifying contributing factors – Can include procedure violations or employee

knowledge.

◦ Photographing the accident scene – Take pictures necessary to reconstruct the scene. Take

close and long range.

◦ Sketch ing the accident scene – Will provide information that a photo will not.


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Doing the investigation:

◦ Writing notes –

Notes should be written as soon as possible while information

is fresh.

Notes, emails, communications should be initiated as soon as

possible by personnel involved in the incident

Consider who, what, when, where, how and why.


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Doing the investigation:

◦ Interviewing affected parties or witnesses –

Prepare interview questions. Ask questions but let the

employees describe their observations. Take notes during the

interview. Get facts, don’t assign blame or criticize. Don’t

focus on expense of the damages or legal issues. End the

interview on a positive note.


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Determining root cause

1. REVIEW ALL EVIDENCE.

◦ This will include all information collected

2. DETERMINE THE ROOT CAUSE.

◦ To determine the root cause, you must first identify

contributing factors (symptoms). As an example, an

employee’s action may have caused the accident, but

why did the employee perform this action.

◦ This could have been the result of procedural violations

or lack of training.


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Determining Corrective Actions

3. DEVELOP CORRECTIVE AND PREVENTIVE ACTIONS.

◦ A root cause may be a mechanical problem or personnel

issue.

◦ Corrective and preventive actions are implemented to

eliminate or reduce the chance of another accident.

◦ Actions are determined by the following methods; input

from employees, hazard assessments, safety

committees.


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Communicating to others in the organization

4. COMMUNICATE RESULTS.

◦ To effectively communicate the findings of the

investigation, a final report must be completed.

◦ The Company will communicate investigation reports

through a safety meeting.


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Approval & Closure

◦ An Incident Report is ready for approval and closure when

The investigation is completed,

The root cause has been identified

Corrective actions have been implemented.

◦ The Facility Manager is responsible for final closure of the

incident record.
