Incident Investigations
Handbook
Incident Investigations Page 1
The following agencies may respond to an incident (insert phone
numbers of your location)
Police _________________________________________
Fire/rescue ________________________________________
Ambulance ________________________________________
Coroner _________________________________________
WorkSafeBC _________________________________________
BC Safety Authority __________________________________
ICBC _________________________________________
BC Hydro ________________________________________
Gas Company ________________________________________
TDG Directorate ________________________________________
Environment Agency __________________________________
Air Transportation Safety Board ___________________________
Incident Investigations Page 2
Incident Investigation
Prevention of an accident or incident is the primary goal of conducting
an investigation. Investigations are not to place blame, but are used as
a means of measuring the effectiveness of the health and safety
program. Investigations discover or uncover where the organizations’
health and safety systems break down.
It is the employer’s responsibil ity to ensure that joint investigations
into incidents or accidents take place and a preliminary investigation
is completed with 48 hours of the reporting of incident. It is also the
employer’s responsibility to ensure that a full investigation of the
incident is completed and sent to WorkSafeBC within 30 days.
Recommendations from the Joint Investigation Team must be
responded to quickly to prevent reoccurrence. The Workers
Compensation Act section 172 and 173 requires that:
An employer must immediately undertake a preliminary investigation
under section 175 and a full investigation under section 176, into the
cause of any accident or other incident that is required to be reported
to WCB, resulted in an injury to a worker requiring medical treatment,
did not involve an injury to a worker, or involved only minor injury not
requiring medical treatment, but had the potential for causing serious
injury or was an incident required to be investigated.
The prevention division of the WCB must be notified immediately of
any accident resulting in serious injury or death; a major structural
failure or collapse of a building, bridge tower, crane hoist, temporary
construction support system or evacuation, a major release of a
hazardous substance, or was an incident required to be reported.
WorkSafeBC 1-866-922-4357
Incident Investigations Page 3
Incident Investigations Page 4
Incident Investigation Kit should contain:
Flashlight
Measuring tape
High visibility tape and PPE
Scissors
Tape
First aid kit
Gloves
Report form (PSC 38)
Digital camera
Pens
Paper
Clip board
Graph paper
Thoughts around the kit:
Determine who is responsible for the kit
Know where the kit is located
Ensure that the contents if the investigations kit is in working
order
Make sure the camera is charged
Incident Investigations Page 5
Joint Investigation Team
The investigation team consists of a worker representative from the
health and safety committee and an employer representative, both
of whom have had training in the investigation of incidents. The
names of the representatives should be part of the terms of reference
for the health and safety committee. Phone and contact numbers are
required and should be available to all supervisors and first aid
attendants.
Choosing a Worker Representative
The Worker representative should:
Be a member of the BCGEU
Be a member of the Joint Occupational Health and Safety
Committee
Have completed Incident Investigations training through the
Learning Centre
Be familiar with the work (See Worker's Compensation Act
Section 174, BCGEU Master Agreement Section 22.5)
If an employee meeting these criteria is not available to complete the
investigation within 48 hours of the incident, or if the worker
representative was involved in the incident being investigated, the
worker representative should be a BCGEU member who sits on the
Joint Occupational Health and Safety Committee who is familiar with
the work.
If a BCGEU and JOHSC committee member familiar with the work is
not available, the worker representative should be a BCGEU member
from the workplace who is familiar with the work.
Incident Investigations Page 6
If the preliminary investigation is completed by a worker
representative who is not on the JOHSC, the full investigation must be
completed by one who is. (See Section 176 of the Worker's
Compensation Act.)
If there are multiple unions on-site, please contact MyHR for
assistance in choosing a worker representative.
NOTE: If the preliminary investigation and full investigation are being
completed within 48 hours as one report, the worker representative
must be a BCGEU and JOHSC member.
Incident Investigations – Seven Step Process
1. Secure the scene
2. Collect Information
3. Develop a Sequence of Events
4. Determine the Causes
5. Recommendations and Actions
6. Write the Report
7. Refer Hazards
Incident Investigations Page 7
Step 1 – Secure the Scene
It is imperative that the team(s) conduct the investigation
immediately. Evidence disappears, material is moved and memories
change.
Ensure that your investigation team is trained and knowledgeable
about the work and conditions where the work is performed. If they
are not, request another person who is knowledgeable to assist the
team. This should be jointly agreed to.
Arrival at the scene
take a mental snap shot
ensure that there is no further danger
preserve the scene
remain objective, regardless of what you might think
occurred
note housekeeping and the general work environment
note the floor or surface condition
determine if any other agency such as WCB should be
involved
determine how and who will contact other groups
Incident Investigations Page 8
Step 2 – Collect Information
The incident scene is marked off
information is gathered including measurements , pictures,
block diagrams
l ist of witnesses there prior, during and after the incident
location and time the incident occurred
record initial information
record observations
date and time you were notified
what activities were occurring
name of persons involved
who is injured/were any others affected
bystanders
first aid attendants on the scene
record the physical data
take pictures
photograph the scene from all angles
observe conditions of equipment, machinery and tools
include makes and models of equipment
maintenance records and other information
relevant information related to weights and capacities
Use a digital camera as it is instant and accurate. Make sure
that there are extra batteries for the camera. Create a photo
log that describes each picture that is taken, time, location,
direction and description.
Incident Investigations Page 9
Conduct Interviews
Good interview techniques include:
conducting the interview in a relaxed atmosphere in a
neutral, private location
Interview as soon as possible after the incident
The investigation team should conduct interviews jointly
Advising the witness as to your purpose, that you are looking
to collect facts to prevent a reoccurrence
Ensuring the witness has the opportunity to tell the entire
story, even though some information may not be relevant
Ask questions to clarify the information, and start by writing
the sequence of events
Ensure that your notes are reflective of the facts
Treat witnesses as equals
Some questions that could assist are:
Can you tell me where you were at the time of the incident?
Can you tell me what you were doing at the time?
What did you see?
What did you hear?
What did you smell?
What were the environmental conditions such as weather,
l ight, noise, heat, rain, snow etc.
Where was the injured worker?
Incident Investigations Page 10
DO NOT
Blame
Point to poor judgement
Jump to conclusions
Interrogate
Ask yes/no questions
Ask who is to blame
Ask leading questions
Withhold or conceal notes
DO
Be sympathetic
Be objective
Use good listening skills
Verify what the witness saw and record what they know
Know what occurred at the time of the incident and prior to
the incident occurring
Always dril l down to the why
Share your notes with the witness at the conclusion of the
interview.
Incident Investigations Page 11
Review documentation
Discuss what documents may be useful , for example:
Written health and safety procedures
Health and safety committee reports
First aid records
Training and orientation records
Inspection Reports
Maintenance records
Prior complaints
Accident and investigation reports
Any WCB orders
Machinery and equipment logs
Material safety data sheets
Safety audits
Manufacturers manual
Minutes of joint OH&S Committee meetings
Incident Investigations Page 12
Step 3 - Develop the sequence of events
Many events occur prior to any incident:
How and why did the incident occur?
When and where did the incident occur?
List a sequence of events and time line
Who was involved?
What were the injuries, check for secondary injuries?
Was equipment damaged?
Use information such as sketches, photographs, physical
evidence, witness statements, all documents that were
relevant
What were the environmental conditions?
Create a clear timeline of the events to inform the causes
List the events that led up to the incident
INCIDENT
time pre incident 0.0 time post incident
List the emergency response and follow-up
Incident Investigations Page 13
Step 4 – Determine the Causes
The purpose of incident investigations is to determine the causes and
implement controls to prevent a recurrence of the incident.
Incidents are preventable
Incidents and injuries are unacceptable and a system has
broken down and allowed them to occur
Incidents are caused by multiple contributing factors coming
together
The more factors you remove or mitigate the less l ikely the
incident will occur again
Analyze the sequence of events
Do you have all of the facts?
Look at contributing factors
Specific/unique hazardous conditions
Causes or contributing factors should be controlled or preferably
eliminated.
Use the multi-causation model to determine all contributing factors.
Task – analysis of the actual work procedures being used at the time
of the incident
Materials – causes resulting from the equipment and materials used
Personnel – the physical and mental condition of those individuals
directly involved in the event and the training they may have had
Environment – the physical environment at the time of the incident,
especially sudden changes to that environment
Incident Investigations Page 14
Management – examine the role and impact of supervisors, and
managers and safety management systems
Multi Causation Model
Incident
Task
Management Material
Environment Personnel
Incident Investigations Page 15
Step 5 – Recommendations and Actions
The report and recommendations must be jointly agreed to. Do not
sign a report unless actively involved in the investigation.
Who is writing the report?
What should happen to prevent future incidents?
What resources are required?
Who receives copies of the report?
Who is responsible for implementing the recommendations?
Who goes back to ensure the recommendations have been
implemented?
Ensure a brief outline of the events that led up to and include
the incident
Describe the events in chronological order
Be specific – include all conditions, weights, reaches, distance
and photos along with a block diagram
Who ensures that the fixes are adequate to prevent a
recurrence?
Fil l out the PSC 38 – remember this is simply a summary and not the
actual investigation. It can be used as a cover page for the complete
incident report.
Recommend Corrective Actions and Improvements
Hierarchy of controls
Elimination of the hazard
Substitution
Engineering controls
Administrative controls
Personal protective equipment
Incident Investigations Page 16
The priority is to provide recommendations that will prevent a similar
incident from occurring.
The second priority is to provide recommendations that will prevent
injuries if a similar event does occur.
The last priority is to write recommendations in addition to the first
two priorities that reduce the injury severity
Prevent injuries
protective equipment, clothing
and devices2
Reduce injury severity
recurrence
-first aid, response etc3Least Effective
Prevent incident recurrence
-hazard control1Most Effective
Incident Investigations Page 17
Sample Recommendations
Include interim measures and ensure a time line for
corrective measures to be implemented
Further assessments – required by subject matter specialists
Education and training (designed and targeted)
Updates, reviews and revisions of work assignments,
procedures and policies
Recommendations should be to correct:
Program design deficiency – failure to effectively develop
safety policies, programs, plans, processes, procedures and
practices
Performance deficiency – general failure to effectively
implement safety policies, programs, plans, processes,
procedures and practices
Common or repeated hazardous conditions and unsafe
conditions
At a minimum, comply with the Workers Compensation Act,
WCB Regulation and Master Agreement
Check the most current version of the WCA and OHSR and
Master Agreement
Remember the intent is to prevent similar incidents and injuries
occurring.
Incident Investigations Page 18
Step 6 - Write the Report
Report format – PSC 38
o PSC 38 is a summary not a complete investigation, it
may serve as a cover page for the rest of the report
Immediately provide a copy of the report to the supervisor
and to implement corrective measures
Provide a copy to the Joint Committee
Follow up
Joint OSH committee make recommendations
Corrective actions are delegated
Timeline for implementation is established
Corrective actions are completed
Results are communicated
Follow up to ensure corrective actions are effective
Incident Investigations Page 19
Step 7 – Refer Hazards
Report any hazards that you find during the investigation
Remedy any hazards that can be dealt with right away
Involve the Joint Occupational Health and Safety Committee
Make sure that the committee follows up on recommendations and
the correction of hazards.
Incident Investigations Page 20
Musculoskeletal Injury (MSI) Investigation
Records and Statistics
Sufficient records relevant to MSIs should be kept including:
First aid reports
Incident reports
Incident investigation records
Inspection records
MSI complaints and hazard reports
Maintenance records
OSH committee minutes
Instruction and training records
Review and Evaluation of the MSI Programs
Is there a MSI prevention policy?
Are there written practical safe work procedures?
Are job risks identified?
Has there been an ergonomic risk assessment?
Have workers and supervisors been trained in control
measures?
Is there regular inspection and monitoring?
First aid treatment – check records
Incident Investigations Page 21
Investigating Occupational Exposure
Factors that should be considered
What is the job process? – Identify all tasks required to complete the
task.
What are the environmental and other factors at the time the incident
occurred, not when you are investigating, such as:
Poor l ighting
Floor condition
Snow
Poor visibility
Hours of darkness
Noise levels
Poor housekeeping
Any chemicals that were used in the area
Staffing level
End of a shift
Hours of work
Ergonomic factors
Indoor air quality
Worker training
Supervision
New or young worker
Was equipment appropriate for the job?
Are maintenance records available?
Has there been any modification to equipment?
Were the right tools available to complete the tasks?
Were safety devices in place?
Is there a culture of safety in the workplace?
Have there been any complaints?
Incident Investigations Page 22
Investigating Occupational Exposure
Routes of entry
Skin contact
Some chemicals damage the skin directly through contact
Skin Absorption
Other chemicals or biohazards are absorbed through the skin
but affect other parts of the body
Eye Contact
Some airborne particulates harm the eyes on contact. Harm
can be done by the chemical properties of a substance or by
its physical properties
Inhalation
Some chemicals or biohazards are absorbed through the
lungs into the body. Once absorbed, they can harm not only
the lungs but can affect other parts of the body
Ingestion
Some chemical or biohazards can be absorbed by the body
when ingested accidentally
Once absorbed, they can harm some other parts of the body
Incident Investigations Page 23
Investigating Occupational Disease Model
Who
Anyone having an affect
Suspected cause
Research
6 steps in Occupational Disease Investigation
1. Identify disease or symptoms
2. Determine exposures to chemical s, biohazards or infectious
disease
3. Establish a relationship between the hazard and the disease
through research
4. Try to establish a latency relationship
5. Report and make recommendations
6. Ask for assistance from appropriate professionals
Determine the cause
Determine why these conditions were in existence
Conduct a why analysis as to why these conditions were in
existence
Incident Investigations Page 24
Investigating Violence
Does the worksite have a violence prevention program?
Has the employer conducted a risk assessment?
What are the policies and procedures related to prevention of
workplace violence?
What are the environmental characteristics?
What are the occupational characteristics?
What were the client characteristics?
What were the nature and circumstances of the work being
done prior to the incident?
What was the time and location of the incident?
Was the worker working alone?
What was the job or task that was taking place?
Have workers been trained in workplace violence prevention
procedures that reduce the risk of violence?
Was the response time to the incident appropriate?
Were workers debriefed and was counselling made available
to the worker or workers?
Was the worker working outside an office location?
Was there a client history of violence and was this
information made available to the worker?
Are near misses reported?
Was the worker affected physically or emotionally?
Was the worker advised to consult a physician or the
worker's choice as required by Regulation 4.31 (3)
Did the worker receive treatment or counselling?
Incident Investigations Page 25
Incident Investigations Page 26
Appendix 1
Part 3 Division 10 - Accident Reporting and Investigation 172 Immediate notice of certain accidents
(1) An employer must immediately notify the Board of the occurrence of any accident that
(a) resulted in serious injury to or the death of a worker,
(b) involved a major structural failure or collapse of a building, bridge, tower, crane, hoist, temporary construction support
system or excavation,
(c) involved the major release of a hazardous substance, (c.1) involved a fire or explosion that had a potential
for causing serious injury to a worker, or
(d) was an incident required by regulation to be reported.
(2) Except as otherwise directed by an officer of the Board or a peace officer, a person must not disturb the scene of an accident that is reportable under subsection (1) except so far as is necessary to
(a) attend to persons injured or kil led,
(b) prevent further injuries or death, or
(c) protect property that is endangered as a result of the
accident.
173 Incidents that must be investigated
(1) An employer must conduct a preliminary investigation under
section 175 and a full investigation under section 176 respecting any accident or other incident that
Incident Investigations Page 27
(a) is required to be reported by section 172,
(b) resulted in injury to a worker requiring medical treatment,
(c) did not involve injury to a worker, or involved only minor injury not requiring medical treatment, but had a potential for causing serious injury to a worker, or
(d) was an incident required by regulation to be investigated.
(2) Subsection (1) does not apply in the case of a vehicle accident occurring on a public street or highway.
174 Investigation process
(1) An investigation required under this Division must be carried out by persons knowledgeable about the type of work involved and, if
they are reasonably available, with the participation of the employer or a representative of the employer and a worker representative.
(1.1) For the purposes of subsection (1), the participation of the employer or a representative of the employer and a worker
representative includes, but is not l imited to, the following activities:
(a) viewing the scene of the incident with the persons carrying out the investigation;
(b) providing advice to the persons carrying out the investigation respecting the methods used to carry out the investigation, the scope of the investigation, or any other aspect of the investigation;
(c) other activities, as prescribed by the Board.
(2) Repealed.
(3) The employer must make every reasonable effort to have available for interview by a person conducting the investigation, or by
an officer, all witnesses to the incident and any other persons whose presence might be necessary for a proper investigation of the incident.
Incident Investigations Page 28
(4) The employer must record the names, addresses and telephone numbers of persons referred to in subsection (3).
175 Preliminary investigation, report and follow-up action
(1) An employer must, immediately after the occurrence of an incident described in section 173, undertake a preliminary investigation to, as far as possible,
(a) identify any unsafe conditions, acts or procedures that significantly contributed to the incident, and
(b) if unsafe conditions, acts or procedures are identified under paragraph (a) of this subsection, determine the
corrective action necessary to prevent, during a full investigation under section 176, the recurrence of similar incidents.
(2) The employer must ensure that a report of the preliminary investigation is
(a) prepared in accordance with the policies of the board of directors,
(b) completed within 48 hours of the occurrence of the incident,
(c) provided to the Board on request of the Board, and
(d) as soon as practicable after the report is completed, either
(i) provided to the joint committee or worker health and safety representative, as applicable, or
(i i) if there is no joint committee or worker health and
safety representative, posted at the workplace.
(3) Following the preliminary investigation, the employer must, without undue delay, undertake any corrective action determined to be necessary under subsection (1) (b).
Incident Investigations Page 29
(4) If the employer takes corrective action under subsection (3), the employer, as soon as practicable, must
(a) prepare a report of the action taken, and
(b) either
(i) provide the report to the joint committee or worker health and safety representative, as applicable, or
(i i) if there is no joint committee or worker health and safety representative, post the report at the workplace.
176 Full investigation, report and follow-up action
(1) An employer must, immediately after completing a preliminary investigation under section 175, undertake a full investigation to, as far as possible,
(a) determine the cause or causes of the incident investigated under section 175,
(b) identify any unsafe conditions, acts or procedures that significantly contributed to the incident, and
(c) if unsafe conditions, acts or procedures are identified under paragraph (b) of this subsection, determine the corrective action necessary to prevent the recurrence of similar incidents.
(2) The employer must ensure that a report of the full investigation is
(a) prepared in accordance with the policies of the board of directors,
(b) submitted to the Board within 30 days of the occurrence of the incident, and
(c) within 30 days of the occurrence of the incident, either,
(i) provided to the joint committee or worker health and
safety representative, as applicable, or
Incident Investigations Page 30
(i i) if there is no joint committee or worker health and safety representative, posted at the workplace.
(3) The Board may extend the time period, as the Board considers appropriate, for submitting a report under subsection (2)(b) or (c).
(4) Following the full investigation, the employer must, without undue delay, undertake any corrective action determined to be
necessary under subsection (1)(c).
(5) If the employer takes corrective action under subsection (4), the employer, as soon as practicable, must
(a) prepare a report of the action taken, and
(b) either
(i) provide the report to the joint committee or worker health and safety representative, as applicable, or
(i i) if there is no joint committee or worker health and safety representative, post the report at the workplace.
177 Employer or supervisor must not attempt to prevent reporting
An employer or supervisor must not, by agreement, threat, promise, inducement, persuasion or any other means, seek to discourage, impede or dissuade a worker of the employer, or a dependent of the worker, from reporting to the Board
(a) an injury or allegation of injury, whether or not the injury occurred or is compensable under Part 1,
(b) an il lness, whether or not the il lness exists or is an
occupational disease compensable under Part 1,
(c) a death, whether or not the death is compensable under Part 1, or
(d) a hazardous condition or allegation of hazardous condition
in any work to which this Part applies
Incident Investigations Page 31
Incident Investigations Page 32
Further information and resources:
BC Government Employees Union: 1-888-991-6062 http://www.bcgeu.ca/members BC Public Service Agency:
1-877-277-0772 http://www.gov.bc.ca/myhr/contact WorkSafeBC
1-866-922-4357 Prevention 604-276-3100, 1-888-621-7233 www.worksafebc.com Canadian Centre for Occupational Health and Safety (CCOHS)
www.ccohs.ca National Institute for Occupational Safety and Health www.cdc.gov/niosh
Acknowledgements: Special thanks go to the Public Service Agency and BCGEU participants
who jointly updated this handbook. BC Public Service Agency
Brad Buck – Manager, Safety Advisory Services Dean Gamblewest – Corporate Safety Specialist
Mark Offerhaus – Learning Consultant, The Learning Centre BCGEU
Sheila Moir – Safety Officer
Incident Investigations Page 33
Incident Investigations Page 34
Incident Investigations Page 35
Incident Investigations Page 36