incident investigations handbook -...

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 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 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


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.


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


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


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.


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?


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.


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


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


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


Management – examine the role and impact of supervisors, and

managers and safety management systems

Multi Causation Model

Incident

Task

Management Material

Environment Personnel


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


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


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.


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


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.


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


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?


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


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


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?


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


(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.


(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).


(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


(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


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

http://www.bcgeu.ca/members

http://www.gov.bc.ca/myhr/contact

http://www.worksafebc.com/

http://www.ccohs.ca/

http://www.cdc.gov/niosh

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