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OHC TRAININGLEVEL 2
www.worksafesask.ca
Inspections and Investigations Workbook
1Level 2 - Inspections and investigations Workbook
Workplace inspections
1
Level 2 Occupational Health Committee Training
Slide 2: How to conduct inspections
2
How to conduct inspections
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Form OHCs
• Number off
• Move to occupational health committee (OHC/committee) with your number
• You will practice working through the projects with your committee
33
Administration
• Emergency exits
• Washrooms
• No smoking policy
• Cell phones
• Breaks
3Level 2 - Inspections and investigations Workbook
Workplace inspections
55
Course materials • Name card
• Workbook
− Self check
− Evaluation
• Reference publications
− Inspections: A Guide for Committees and Representatives
− Investigations: A Guide for Committees and Representatives
• Legislation
Slide 6: Learning objectives
66
Learning objectives
1. Purpose of inspections
2. How to plan an inspection
3. How to conduct an inspection
4. How to handle inspection results
5. How to review inspection system
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Icebreaker project
• Select a spokesperson to guide the discussion as you review questions
• Discuss each question and record answers in workbook
• Spokesperson will explain to class
77
Introductions • Instructor
• Introduce yourselves
− Name
− Employer
− Industry
− How long have you been part of the OHC?
− Does the OHC conduct regular inspections at your workplace?
5Level 2 - Inspections and investigations Workbook
Workplace inspections
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Icebreaker project
1. What personal experiences have you had with inspections in your workplace?
2. Can you think of some reasons why people may not want to conduct inspections? Think of ways to overcome each reason.
3. Record what you want to learn about workplace inspections today (one point for each person in your group/OHC).
Notes
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Icebreaker project
What personal experiences have you had with inspections in your workplace?
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Can you think of some reasons why people may not want to conduct inspections? Think of ways to overcome each reason.
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Record what you want to learn about workplace inspections today.
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7Level 2 - Inspections and investigations Workbook
Workplace inspections
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What is an inspection?
A formal inspection is a planned walk-through or an examination of:
• A workplace
• Selected work areas
• Particular hazard(s)
• Work practices
• Machinery, tools, equipment
Slide 10: Objective 1
10
Objective 1
Purpose of inspections
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Project: Benefits of inspections
• Take five minutes to discuss how inspections can make your workplace healthy and safe
• Record answers in workbook
• Be prepared to share with class
How can inspections make your workplace healthy and safe?
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Purpose of inspections
• Compare current conditions with standards
• Determine if gaps exist
• Identify causes for gaps
• Develop recommendations for corrective action
1313
Benefits of inspections
• Prevent incidents and illnesses
• Help avoid many of the costs associated with incidents
• Communication with workers
• Raise OHC’s profile and improve awareness of occupational health and safety
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Employer inspections
OHS legislation requires employers to inspect:
• Plant (SEA 3-1(1)(w))
• System of work
• Working environment
• Specific hazards related to the work
15
Employer’s duties
Employer is accountable to:
• Ensure inspections required by OHS legislation are performed effectively
• Ensure that OHC or representative conducts regular and effective inspections (regulation 28)
• Provide OHC and workers with all required information at place of employment (SEA 3-16)
11Level 2 - Inspections and investigations Workbook
Workplace inspections
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Examples of inspections employer must perform
What to inspect? Regulation
Inspecting workplace Reg 23, Examination of plant
Duty to ensure safety of respirators
Reg 89, Inspection of respiratory protective devices
Work at height Reg 107, Inspection of full body harness, etc.
Mobile equipment Reg 155, Visual inspection
Mobile equipment Reg 156, Inspection and maintenance
Scaffolds Reg 193, Maintenance and inspection
Cranes Reg 216, Inspections
WHMIS Part XXII, Controlled Products – Workplace Hazardous Materials Information System
Slide 18: What inspections does OHC perform?
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What inspections does OHC perform?
• Regular, planned inspections of the workplace (reg 28)
• Inspections with an occupational health officer (OHO) (reg 20)
• Intermittent and special inspections
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Purpose of OHC inspections
• To identify hazards
• To check effectiveness of inspections conducted by employer
• To check effectiveness of elements in employer’s health and safety system
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When to conduct special OHC inspections
• Increasing health and safety concerns
• Introduction of new equipment
• Inexperienced workers start work
• Incidents occur
• Dangerous occurrences take place
• An OHO finds a deficiency
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How can employer help with OHC inspections?
• Provide training
• Provide resource and time
• Help plan and schedule inspections
• Help develop checklists
• Encourage OHC to look for root causes
2121
Purpose of OHC inspections
• Discuss concerns with workers
• Review records, logs, books required by employer
− First-aid register
− Maintenance logs
− Crane logs
− Lists of chemical and biological substances
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OHC inspections training
Site-specific information about:
• Workplace hazards and hazardous areas
• PPE information (including limitations)
• Work processes and work areas
• Workplace engineering controls
23
OHC inspections training
Include general knowledge about:
• Health and safety standards
• Legislation
• Process to conduct inspections
• How to identify hazards and assess risk
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OHC inspections training
• Worker orientation and training necessary to work safely
• Equipment and materials suppliers’ recommendations
• How to handle concerns
Slide 26: How inspections make OHCs effective
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Project: How inspections make OHCs effective
• In your group, list three ways inspections can make your committee more effective
• Record answers in workbook
• Be prepared to share answers with class
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How inspections make OHCs effective
• Listen to worker concerns
• Learn more about the workplace (hazards and risks)
• Identify root causes that help employer’s health and safety system
• Recommend corrective action (including follow up)
List three ways inspections can make your committee more effective.
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How often to inspect?
• Work out schedule with employer
• OHS Division recommends before each OHC meeting
28
Objective 2
How to plan an inspection
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What should OHC inspect?
• It’s up to the OHC
− Divide workplace and assign areas to OHC members or teams
− Members inspect specific items
3030
How in depth should inspections be?
• Work with employer to decide
• Consider workplace
− Tools and technology
− Work processes and people
• Get help from outside OHC when needed
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Plan inspection
OHC and employer decide:
• Inspection schedules
• How often an item/area must be inspected
• How to notify employer of inspection results
3232
Who on OHC should inspect?
• All OHC members
• Co-chairpersons
• Ask employer to involve specialists
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Inspecting for hazardous conditions
Video
3434
Inspection reminders
• Consider what to inspect
− Entire workplace
− Every hazard
− Every item in employer’s OHS system
• Inspect entire workplace with reasonable time (at least annually)
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Health hazards A health hazard is any agent, situation or condition that can cause occupational illness
Five types:
1. Chemical hazards
2. Biological hazards
3. Physical agents
4. Work design (ergonomic) hazards
5. Workplace stress (harassment and violence)
Slide 36: Workplace hazards
3636
Workplace hazards
• What is a hazard?
− Activity, situation or substance that could harm a worker
• Two broad categories:
− Health hazards
− Safety hazards
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Safety hazards • A safety hazard is anything that could cause an injury
• Injuries caused by a safety hazard are usually obvious:
− Slip, trip or fall
− Pinch or nip point on machinery
− Fall from a height
− Material falling on a worker
− Fire or explosion
Slide 39: What is risk?
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What is risk?
• A risk is the chance that a hazard will actually harm a worker
• Risk factors to consider:
− Frequency: How many workers and how often
− Severity: How serious the harm
− Probability: How likely could it happen
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What to inspect
Make list of things to inspect
• Plant
− Structures
− Materials
− Machines, tools and equipment
− Chemical and biological substances
4040
Risk assessment
• To help set priorities
• Think about:
− How many workers and how often are they exposed to each hazard?
− How seriously could workers be harmed?
− How quickly could a dangerous situation arise?
− Have problems come up before?
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What to include on list?
• Work environment
− Light, noise, heat/cold, ergonomics, ventilation
• First-aid, fire and emergency plans
• PPE
− Respirators, hard hats, safety shoes, safety glasses, clothing
4242
What to include on list?
• Health and safety programs
− Policies, plans and procedures
• People
− Orientation, training and supervision
• Task procedures and safe work practices
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What to inspect?
Talk with workers
• Workers may grow used to a hazard
• OHC is a fresh pair of eyes that can help identify hazards
44
What to inspect?
Review
• Maintenance records
• Incident history
• Incident reports
• Manufacturers’ manuals
• SDS sheets
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Items inventory form
46
Housekeeping
Consider:
• Clutter
• Exits and entrances
• Tools and equipment
• Overcrowding
• Waste, spills, leaks
27Level 2 - Inspections and investigations Workbook
Workplace inspections
Notes
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Slide 48: Project inspections
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Project: Inspections
1. Discuss hazards at your workplace
2. Record one hazard that needs to be inspected for each person in your group
3. Select three items from your group’s list
− What sections from the regulations apply?
4. Discuss hazards with class
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Project: Inspections
Discuss hazards at your workplace. Record one hazard that needs to be inspected for each person at your table. Select three items from your group’s list and identify what OHS legislation applies.
Inventory of critical parts, items, substances and hazardous conditionsItem: (identify machine, tool, equipment, material, work area, etc.)
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Department: _______________________________ Location: _________________________________________
Inventoried by: ______________________________ Approved by: ______________________________________
Item Potential for harm Regulation
1 Example: WHMIS degreaser Employer requires current SDS for controlled product 325
2
3
4
5
6
29Level 2 - Inspections and investigations Workbook
Workplace inspections
Inventory of critical parts, items, substances and hazardous conditionsItem: (identify machine, tool, equipment, material, work area, etc.)
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Department: _______________________________ Location: _________________________________________
Inventoried by: ______________________________ Approved by: ______________________________________
Item Potential for harm Regulation
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8
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10
11
12
13
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Hazard and risk assessment
• Establish priorities
− Some hazards may have higher priority
▪ Chemical and biological hazards
▪ Tools and equipment
▪ Machinery
• OHCs need to inspect all hazards
4949
What’s next?
• Use your list to:
− Identify risk and potential exposure to each hazard
− Use hazard lists to develop checklists and inspection recording forms
• Lists are never final – always re-evaluate
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Project: Risk assessment
1. Discuss risk for three hazards identified by your group
2. Determine priority list from highest to lowest hazard
3. Choose spokesperson to discuss priorities
Notes
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Project: Risk assessment
Discuss risk for three hazards identified by your group.
Hazard 1: ___________________________________________________________________________
How many workers are exposed to the hazard and how often?
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How serious could workers be harmed if something went wrong?
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What is the likelihood that a dangerous situation could occur? _______________________________
Hazard 2: ___________________________________________________________________________
How many workers are exposed to the hazard and how often?
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How serious could workers be harmed if something went wrong?
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What is the likelihood that a dangerous situation could occur? _______________________________
Hazard 3: ___________________________________________________________________________
How many workers are exposed to the hazard and how often?
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How serious could workers be harmed if something went wrong?
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What is the likelihood that a dangerous situation could occur? _______________________________
Prioritize hazards from highest risk to lowest.
Highest risk: ________________ Next: ___________________ Lowest: ___________________
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Standards measure workplace conditions
• Equipment (operators’) manuals
• Industry best practices
• Legislation
• Supplier information/instructions
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Identify standards
Standard: A workplace requirement
• Inspection will compare what you find against standards and identify deficiencies
• Build standards into checklist questions
• Use standards when writing recommendations
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Places to look for standards
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Checklists
Advantages
• Consistent, systematic and efficient
• Help inspectors remember what to inspect (won’t miss anything)
• Allow for comparing current conditions with standards
• Help with developing recommendations
55
Develop inspection documents
Create/Develop what types of documents?
• Checklists
• Recording forms
Note: It’s not a legal requirement and there are no standard forms
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Example: WHMIS degreaser
Step
1. Identify what to inspect
2. Identify standards to measureworkplace conditions
3. Take each standard and developyes/no question
Checklist development
Safe use of a controlled product
Regulation 325: An employer who acquires acontrolled product for use at workplace musthave an SDS for that product
Did a current SDS come with the controlledproduct?
4. Organize questions by topic• SDS• Container labels• Worker training
5757
Checklists
1. Identify what to inspect
2. Identify standards to measure workplace conditions
3. Take each standard and develop yes/no question
4. Organize questions by topic
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Checklist: Orientation and training Work practices Safety procedures Supervision Experience Ergonomics
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Checklists
Organize checklist/questions by topic
• People
• Work environment
• Chemical/Biological hazards
• Machinery, tools and equipment
• Safe operating procedures
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Checklist: Light and illumination Dust, fumes and vapours Work area design Hot and cold conditions Noise Housekeeping and storage
Slide 61: Forklift truck checklist
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Checklist: Machines and mobile equipment Electrical equipment Hand tools, PPE and clothing Elevators, hoists and lifts First aid and fire protection Emergency response
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Checklist: Work operations Types of equipment/tools New process/machinery Safe operating procedures Maintenance Cleaning operations
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Checklist: WHMIS products Biological substances Chemicals Other materials of concern to workers
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Project: Checklists
1. For the three recorded hazards, use OHS legislation to create two question to use on a checklist
2. Use blank checklist in workbook to record questions
• Questions determine if inspection condition meets standard
Notes
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41Level 2 - Inspections and investigations Workbook
Workplace inspections
Project: Checklists
For the three hazards you recorded, use OHS legislation to create two questions to use on a checklist.
Checklist questions
Work area and substance inspected: _________________________________________________
Date/Time/Shift: __________________________________________________________________
Employer inspector: _______________________________________________________________
Worker inspector: _________________________________________________________________
Item NotesMeets standard?
Yes NoWHMIS degreaser
1. Did a current SDS come with controlled product? Reg 325
Hazard 1:
1.
2.
Hazard 2:
1.
2.
Hazard 3:
1.
2.
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Inspection recording form
• Identify hazards not on checklist
• Record:
− Each area or item inspected
− Hazards and risk for each item
− Exemplary situations (e.g., excellent housekeeping or safe work procedures)
66
Checklists
Shortcomings
• May not cover everything
• Do not perform inspections simply to complete a checklist
• Inspection monitors employer’s health and safety system
• Inspectors may miss hazards and worker concerns
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Inspection recording form • Record worker concerns
• Supplement checklists
• Discuss at next OHC meeting
Slide 69: How to conduct an inspection
69
Objective 3
How to conduct an inspection
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Identify:
• Inspection routes and meeting places
• Hazards and incidents
• Bottlenecks
• New technology
• Storage rooms
Floor plans and work-flow diagrams
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Before inspection
• Review necessary documents
• Determine inspection route
• Assemble resources
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Resources
• Monitoring equipment
− Air monitors, noise metres
• Sampling containers
− Approved containers for sending samples to lab
• Special PPE for specific hazards/conditions
7272
Resources
• Employer provides resources you need to conduct inspection
• Resources depend on what you inspect
− Clipboards − Pens/Pencils − Inspection checklist − Recording forms − Measuring tape/ruler − Flashlight − PPE
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The inspection
• Look in out-of-the-way places
• Use your senses
• Take careful notes
• Follow up on concerns raised on previous inspections
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The inspection
• Communicate with workers and supervisors
• Use inspection checklists and forms
− Look for hazards
− Check employer’s health and safety system
• Inspect safely
• Minimize disruptions
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Communicating with workers
• Purpose of inspections are to find facts – not faults
• Ask about patterns (e.g., incidents, illnesses)
• Ask about orientation and training
• Pay attention to new and inexperienced workers
• Discuss previous concerns raised by workers
Slide 76: The inspection
76
The inspection
What if there is something wrong?
• Record concern
• Talk with workers
• Determine hazard and assess risk
• Tell supervisor or employer
• If it’s serious, hold an OHC meeting
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Subcontractor concerns
• Note hazard and inform supervisor
• If it’s serious, discuss with supervisor immediately
• Check effectiveness of employer’s policy
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Subcontractors and inspections
• OHC has no authority over workers of other employers
• Employer must coordinate OHC activities with any other employers at the workplace
• OHC follows employer’s process to identify safety concerns regarding subcontractors
49Level 2 - Inspections and investigations Workbook
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Project: Hazard identification
1. Review photo assigned to your group
2. Identify hazards/concerns on inspection record form in workbook
3. Determine a standard using OHS legislation
4. Share with class
Notes
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Project: Hazard identification
Review the photo assigned to your group. Identify hazards or concerns. Determine a standard using OHS legislation.
Inspection recording form
Work area(s): ________________________________ Department: _______________________________________
Date/Time/Shift:
Inspectors: _____________________________________________________________________ Page ____ of ____
Date discussed by OHC:
Item Item detected Regulation
1
2
3
4
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7
51Level 2 - Inspections and investigations Workbook
Workplace inspections
Inspection recording form
Work area(s): ________________________________ Department: _______________________________________
Date/Time/Shift:
Inspectors: _____________________________________________________________________ Page ____ of ____
Date discussed by OHC:
Item Item detected Regulation
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9
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15
16
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2.
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3.
4.
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5.
6.
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7.
8.
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9.
10.
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11.
12.
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OHC responsibilities
• Discuss what was found
• Develop recommendations
• Meet immediately if concerns are serious
• Record meeting minutes
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Objective 4
How to handle inspection results
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Recommend corrective action • Gather consensus
• Report to appropriate authority
• Develop and present recommendations (advantages and disadvantages)
• Identify root causes
• Encourage promptness (include short-term recommendations if necessary)
• Record minutes and inform workers
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Effective recommendations
• Short-term solutions solve immediate causes of problem
• Long-term solutions remove the root cause
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Corrective action
• Employer may not be able to correct some problems without lengthy research or outside help
• Employer must still make it safe for workers (short-term solutions)
• Inform workers of status through process until complete
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Regulation 28, Inspection of place of employment
On written notice by OHC of an unsafe condition or contravention, employer must:
• Take immediate steps to protect workers’ safety
• Take suitable action to correct situation
• Inform OHC in writing of actions taken (or not taken)
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Develop recommendations
1. Use hazards/concerns noted from hazard identification project (photo)
2. Note applicable OHS legislation
3. Develop short- and long-term recommendations (use minutes form in workbook)
4. Share with class
Develop recommendations
Using the hazards and concerns noted from the previous project to develop short- and long-term recommendations. Use the OHC meeting minutes form to record your recommendations.
Include applicable OHS legislation.
Complete the OHC minutes form. Create a company name, address, dates, number of workers, etc. Use the people in your group as OHC members and record their names. Include employer and worker members and determine co-chairpersons.
Have the co-chairs review the minutes and sign the form.
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OHC minutes form
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Notes
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No recommendations?
• Be proactive
• Record inspection in meeting minutes
• Promote organization’s health and safety success stories
• Plan OHC meetings, video screenings and safety talks
Slide 101: Objective 5
101
Objective 5
How to review inspection system
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What to ask
• Is inspection system working properly?
• Are inspections identifying concerns, hazards and risks?
• What effects are inspections having?
• Is the frequency of inspections appropriate?
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Inspection evaluation
• OHC’s role to review effectiveness of employer’s health and safety system
• Inspections are proactive – taking action before someone is injured
• Aspects of work can change and require updates to inspection process
− Processes, technology, chemicals, tools and equipment
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How does employer help?
• Sets standards
• Provides resources and training
• Shares information and consults OHC
• Helps OHC evaluate effectiveness of inspection system
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How to improve
• Talk about inspections at OHC meetings and with workers
• Good documentation
• Post meeting minutes for others to review
• Look for new ideas
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Important websites
• saskatchewan.ca
• worksafesask.ca
• ccohs.ca
Slide 106: Summary
106106
Summary
1. The purpose of inspections
2. How to plan an inspection
3. How to conduct an inspection
4. How to handle inspection results
5. How to review inspection system
69Level 2 - Inspections and investigations Workbook
Workplace inspections
Self-check for Level 2 - Workplace Inspections Name: _______________________ Instructor’s name: _______________________
1. Identify three types of inspections performed by the OHC.(a) Identify and list of all chemical and biological substances
used, handled, stored or disposed of at workplace(d) Intermittent inspections warranted by special
circumstances, such as new workers
/3(b) Inspection with OHOs (e) Specific inspections of machinery, tools and equipment required by specific regulations
(c) Regular workplace inspections under regulation 28 (f) Inspections of plant required under regulation 23
2. Identify three reasons for inspections.(a) Ensure compliance (d) Identify problems other inspections missed
/3(b) Perform detailed technical checks (e) Identify responsibility for defects
(c) Evaluate effectiveness of employer’s health and safety management system
(f) Discuss concerns with employees
3. Identify five health hazards to look for during inspections.(a) Chemical hazards (d) Anything that could cause a physical injury
/5(b) Tool, equipment and machinery hazards (e) Work design (ergonomic) hazards
(c) Physical agents (energy) (f) Biological hazards
4. Identify four steps in the inspection process.(a) Decide what to inspect (d) Develop inspection checklists
/4(b) Follow up to ensure compliance (e) Take corrective action
(c) Meet to discuss what the inspection found and prepare OHC minutes to recommend corrective action
(f) Conduct an inspection and record findings
5. Identify four questions to ask when assessing and setting inspection priorities.(a) How many workers are exposed to the hazard? (d) How often could danger occur?
/4(b) How difficult is the item to inspect? (e) What inspections have been performed recently?
(c) How quickly could a dangerous situation occur? (f) How serious could workers be harmed?
6. Identify three steps to develop checklists.(a) Identify standards to measure conditions (d) Make each standard a question
/3(b) Assess the risk of harm (e) Identify how to record concerns
(c) Record findings (f) Organize questions by topic
7. Identify four steps in conducting an inspection.(a) Meet with employer to discuss concerns (d) Inspect methodically using checklists
/4(b) Organize the inspection (e) Discuss concerns with workers
(c) Note concerns on recording forms (f) Prepare recommendations for short- and long-term corrective action
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8. Identify seven procedures that OHS Division recommends to resolve health and safety concerns.(a) Encourage workers to bring specific concerns
to supervisor and general concerns to OHC or representative
(f) If the co-chairs cannot resolve a concern, discuss it at the next OHC meeting (representative meet with employer)
/7(b) If the supervisor cannot resolve the concern, take it to
the OHC or representative(g) If the OHC member cannot resolve the concern, take
it to the co-chairs
(c) Report concerns directly to the OHC or representative (h) Communicate status and outcomes with workers
(d) Check effectiveness of employer’s corrective action (i) Take serious concerns directly to the employer
(e) Contact OHS Division for advice
9. Identify six reasons to use an OHC form.(a) To identify who is responsible for action and follow up (e) To identify outstanding concerns
/6(b) To identify who attended the meeting (f) To identify new concerns
(c) Set target dates for corrective action (g) Identify responsibility for workplace problems
(d) Identify who raised an issue
10. What is the difference between short- and long-term corrective actions?.(a) Short-term action is what the employer should do right
now to protect workers. Long-term action removes the underlying cause.
(d) Long-term action is what the employer should do right now to protect workers. Short-term action removes the underlying cause.
/1(b) Short-term action fixes the technical issues of a problem. Long-term action corrects the underlying problems.
(e) The OHC takes short-term action. The employer takes long-term action.
(c) Short-term action addresses compliance issues. Long-term action addresses management issues.
(f) Essentially, short-term action is set within a set time period. Long-term action is not.
Total /40
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Occupational Health and Safety training
Participant evaluationLevel 1: Committees/Representatives
Level 2: Inspections Investigations
Supervision and Safety
Date: ____________________ Instructor: _________________________ City: ________________________
We want to know what you think. Your answers are important because they help us improve our courses.
Legend: 'A' Strongly agree 'B' Agree 'C' No opinion 'D' Disagree 'E' Strongly disagree
A. General
A B C D E I enjoyed this course.
A B C D E The course met my expectations.
A B C D E I will be able to apply what I learned today to my workplace.
A B C D E I would recommend this course to other OHC members and employers.
The most important thing I learned today:
___________________________________________________________________
___________________________________________________________________
B. The instructor
A B C D E Instructor was well prepared, organized and made good use of time.
A B C D E Instructor knew course content well.
A B C D E Provided adequate opportunities for discussion.
C. The course
A B C D E The content and materials will be directly useful to me in my workplace.
A B C D E The projects and lectures helped me learn and practice my occupational health and safety duties and responsibilities.
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A B C D E I had no trouble understanding the lectures and project instructions.
There was enough time provided for:
A B C D E (a) Questions
A B C D E (b) Group projects
A B C D E (c) Discussion
A B C D E I felt free to get involved in discussions and projects.
A B C D E I felt free to ask the instructor questions.
A B C D E The course materials were well organized, easy to read and understand.
A B C D E The overheads were easy to read and understand.
A B C D E The procedure used to register was efficient.
A B C D E The room was comfortable and appropriate for this course.
A B C D E The location of the course was convenient for me.
D. What did you like most about this course?
E. What did you like least about this course?
F. Additional comments or suggestions?
Thank you. Please return this from to your instructor before you leave.
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Administration
• Emergency exits
• Washrooms
• No smoking policy
• Cell phones
• Breaks
II: Day 2
2
Day 2 Incident investigations
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Introductions • Instructor
• Introduce yourselves
− Name
− Employer
− Industry
− How long have you been part of the OHC?
− Have you been involved in a workplace investigation?
44
Course materials • Name card
• Workbook
− Self check
− Evaluation
• Reference publications
− Inspections: A Guide for Committees and Representatives
− Investigations: A Guide for Committees and Representatives
• Legislation
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About this course
• Conducting investigations is an important function of occupational health committees (OHCs) and worker health and safety representatives
• This course will help you:
− Understand responsibilities
− Investigate effectively
66
Learning objectives
1. Learn regulatory requirements for investigating workplace incidents and dangerous occurrences
2. How to collect evidence for an investigation
3. How to analyze evidence for an investigation
4. How to develop a workplace investigation report
5. How to take action following a workplace investigation
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About this course
Two parts to course:
• Part I: Regulatory requirements
• Part II: CART (investigation techniques)
− Collect evidence
− Analyze evidence
− Report (reporting to OHC and writing report)
− Take action (employer)
II: Icebreaker project
99
Icebreaker project • From your personal experiences with investigations, discuss what
went well and what didn’t go well
− Did the investigation team create a report?
− Who did the report go to?
− What actions were taken, if any, to correct the situation?
• If your group does not have investigation experience, discuss what would be important in conducting an investigation
• What do you want to learn today?
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Notes
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Investigations
• Effective investigations must be part of an employer’s health and safety system
• Lack of incident investigation process can result in poorly organized and misunderstood investigations
• It’s important to understand the benefits of a properly organized investigation
II: Definitions
10
Definitions
Incident
• Not defined in legislation
• Any unplanned, unwanted event that causes injury or illness
Dangerous occurrence
• Regulation 9
• Essentially an incident that could have hurt someone but it did not
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Benefits of worker involvement
• More effective investigations
• Improved credibility
• Improved acceptance of recommendations
• The purpose of OHC investigations is prevention
1212
Benefits of investigations
• To understand what happened and why (i.e., causes)
• To identify corrective actions that will prevent a re-occurrence
• To determine trends and turn a reactive situation into a proactive opportunity
• To make the workplace healthier and safer
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Employer’s role
Employer responsibilities:
• Effectiveness of investigations
• Correct any problems
• Integrate investigations into health and safety system
• Provide investigation teams with appropriate time, training and resources
1414
Role of the OHC
• OHC and representative investigators are expected to:
− Help find root causes and recommend corrective action
− Check the employer’s health and safety system
− Not assess blame
• Taking corrective action is the employer’s responsibility
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The employer’s role
The employer is ultimately responsible for the effectiveness of incident investigations and for correcting any problems the OHC identifies. For effective incident investigations, the employer should integrate them into their organization’s health and safety system (i.e., emergency planning, training, etc.) and provide the investigation team with appropriate training and resources.
II: Part I regulatory requirements
16
Part I
Regulatory requirements
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Objective 1
Regulatory requirements for investigating incidents and
dangerous occurrences
Part I: Regulatory requirements
Use the investigation techniques from Part II to comply with the regulations.
In order to report an incident to OHS Division properly, conduct a preliminary investigation to collect the required information. Regulations 8 and 9 require an investigation to determine date, time and location, plus circumstances and, in the case where someone is hurt, apparent injuries. This preliminary investigation is often conducted by the supervisor or another agent of the employer.
Both regulations 8 and 9 require the employer, contractor or owner to provide the co-chairs or representative with a copy of the notice required by OHS Division.
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Regulation 8, Incidents causing serious bodily injury
The employer or contractor must report every incident as soon as possible to OHS Division that:
• Causes or may cause death
• Requires the worker to be hospitalized for 72 hours or more
− If unsure about length of hospitalization, inform OHS Division and an officer will discuss final reporting procedures
1818
Reportable incidents
• OHS regulations require the employer or contractor to report incidents causing serious bodily injury
• OHS regulations require employer, contractor or owner to report any dangerous occurrences
Incident Requirement Incidents causing serious bodily injury
Regulation 8
Dangerous occurrences Regulation 9
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Regulation 9, Dangerous occurrences
• An employer, contractor or owner must report every dangerous occurrence as soon as possible to OHS Division
• Dangerous occurrences could have hurt someone if conditions or circumstances had been slightly different.
− The factors (e.g., forces, chemicals, biohazards, etc.) involved in an incident were powerful enough to cause serious harm but no one was injured or became ill
20
Regulation 8, Incidents causing serious bodily injury
What to report to OHS Division?
• Name of each injured or deceased worker
• Name of employer or contractor involved
• Date, time and location
• Circumstances
• Apparent injuries
• Contact information of employer or contractor
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Regulation 9, Dangerous occurrences
• Dangerous occurrences are incidents that generally do not result in serious bodily injury
• Examples listed in regulation 9(1)(a-h)
− List is not all inclusive – only provides examples
• OHS Division encourages employers to report any incident that causes, or could have caused, serious injury
22
Regulation 9, Dangerous occurrences
What to report to OHS Division?
• Name of employer, contractor or owner involved
• Date, time and location
• Circumstances
• Contact information of employer, contractor or owner
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Examples of dangerous occurrences
• A worker using an inadequately maintained atmosphere-supplying respirator nearly is overcome by poisonous gas
• An overloaded crane becomes a dangerous occurrence if it overturns or fails
• A partially cut tree in a logging area is left standing but falls while the workers are out of the area (may have been struck had they been working there)
II: Required investigations
2525
Required investigations
• OHS regulations require the employer to investigate certain incidents
• OHS regulations require employer, contractor or owner to investigate dangerous occurrences
Incident Requirement Investigation of certain incidents
Regulation 29
Investigation of dangerous occurrences
Regulation 31
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Regulation 29, Investigation of certain incidents
To complete investigation, employer, in consultation with OHC or representative, prepares written report that includes:
• Description of incident
• Graphics, photos or other evidence to help determine cause or causes
• Explanation of cause or causes
• Immediate (short-term) corrective action
• Long-term action to prevent a re-occurrence or the reasons for not taking action
26
Regulation 29, Investigation of certain incidents
An employer shall ensure that every incident that causes or may cause death or will require a worker to be hospitalized for 24 hours or more is investigate as soon as possible by:
• Co-chairs or designates
• Representative and employer
• If there is no OHC or representative, then by employer
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Regulation 31, Investigation of dangerous occurrences
Employer, contractor or owner shall ensure every dangerous occurrence is investigated as soon as reasonable possible by:
• Co-chairs or designates
• OHS representative and employer
• If there is no OHC or representative, then by employer
2828
Regulation 30, If the incident involves a fatality
• Fatality site must not be disturbed, except to relieve suffering, until an OHO has investigated
• Where an OHO cannot investigate but gives permission, the site may be cleared once:
− Graphics, photos and evidence showing details is gathered
− Co-chairs or representative investigated and agree that site may be cleared
• When a site has been disturbed before an investigation completed, it becomes difficult to find out cause or causes and to prevent a re-occurrence
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Regulation 31, Investigation of dangerous occurrences
To complete investigation, employer, contractor or owner, in consultation with OHC or rep, prepares written report that includes:
• Description of dangerous occurrence
• Graphics, photos or other evidence to help determine cause or causes
• Explanation of cause or causes
• Immediate (short-term) corrective action
• Long-term action to prevent a re-occurrence or the reasons for not taking action
II: Project Dribbles Plastics
31
Project: Dribbles Plastics
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Project: Dribbles Plastics
• Herbert, a young worker with about six weeks experience, has just crushed his left hand in a powerful packaging machine called a dribbler
• You are the OHC and must investigate and prepare report for employer
33
Incident scenario What happened
Dribbles Plastics manufactures a variety of plastic products. Herbert, a young worker with about six weeks of experience, has just crushed his left hand in a powerful packaging machine called a dribbler. As the OHC, you must investigate and prepare a report for the employer.
Dribbles are one of the firm’s most popular products. Each dribble is wrapped in a dribbler immediately before shipping. During the wrapping process, each dribble enters the machine on a conveyor belt. It is then placed in a plastic package. Two powerful hot steel rollers at the mouth of the machine encase and seal each package in shipping plastic as it exits through the front of the machine. Once they exit the machine, packaged dribbles are put in containers and shipped.
Sometimes dribbles in the dribbler twist and jam the conveyor belts before reaching the packaging rollers. This stalls the machine and production comes to a halt.
The incident happened during one of these stoppages. Herbert opened the front cover of the dribbler and was trying to free the jam by jogging the machine. Jogging requires Herbert to turn the start/stop switch on and off quickly to move the mechanism enough to free the jam. While jogging the machine with his right hand, Herbert reached between the rollers with. his left to straighten the packages as the jogging freed them from the conveyor mechanism. Unfortunately, the dribbler started and the rollers closed on Herbert’s hand before the machine could be stopped. A manual mechanism-opening wheel on the machine was used to free Herbert’s hand.
Herbert was admitted to hospital and is waiting for reconstructive surgery on his hand.
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Dribbler open Dribbler closed
Dribbler mechanism
Incident scenario
What happenedDribbles Plastics manufactures a variety of plastic products. Herbert, a young worker with about six weeks of experience, has just crushed his left hand in a powerful packaging machine called a dribbler. As the OHC, you must investigate and prepare a report for the employer.
Dribbles are one of the firm’s most popular products. Each dribble is wrapped in a dribbler immediately before shipping. During the wrapping process, each dribble enters the machine on a conveyor belt. It is then placed in a plastic package. Two powerful hot steel rollers at the mouth of the machine encase and seal each package in shipping plastic as it exits through the front of the machine. Once they exit the machine, packaged dribbles are put in containers and shipped.
Sometimes dribbles in the dribbler twist and jam the conveyor belts before reaching the packaging rollers. This stalls the machine and production comes to a halt. Since the dribbler operator’s pay depends on how many dribbles are packaged in a shift, these stoppages are distressing.
The incident happened during one of these stoppages. Herbert opened the front cover of the dribbler and was trying to free the jam by jogging the machine. Jogging requires Herbert to turn the start/stop switch on and off quickly to move the mechanism enough to free the jam. While jogging the machine with his right hand, Herbert reached between the rollers with his left to straighten the packages as the jogging freed them from the conveyor mechanism. Unfortunately, the dribbler started and the rollers closed on Herbert’s hand before the machine could be stopped. A manual mechanism-opening wheel on the machine was used to free Herbert’s hand.
Herbert was admitted to hospital and is waiting for reconstructive surgery on his hand.
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Project: Dribbles Plastics Your OHC visits incident site and learns the following:
• The dribbler is very old. It was moved from previous plant and installed by the maintenance and sanitation engineer who saw incident.
• A yellowing, dusty policy hangs on a nearby wall. It states that troubles with the dribbler are to be reported to maintenance. Maintenance is to lockout the dribbler (i.e., cut all power sources and release any remaining energy in the machine) before working on it. Workers state that the policy has not been enforced for some time. The power breaker box is far away from the dribbler. It has no lock on it.
• The front cover is off the dribbler. Warning information on the caution plate is worn off. A worker informs you that a spring-loaded power cut-off switch on the chassis is supposed to pop and kill power to the dribbler if the front cover is raised. The worker states that this button has not worked for some time. She did not report it because “…no one is going to believe me or do anything about it anyway.”
Your OHC visits incident site and learns the following:• The dribbler is very old. It was moved from previous plant and installed by the maintenance
and sanitation engineer who saw incident.
• A yellowing, dusty policy hangs on a nearby wall. It states that troubles with the dribbler are to be reported to maintenance. Maintenance is to lockout the dribbler (i.e., cut all power sources and release any remaining energy in the machine) before working on it. Workers state that the policy has not been enforced for some time. The power breaker box is far away from the dribbler. It has no lock on it.
• The front cover is off the dribbler. Warning information on the caution plate is worn off. A worker informs you that a spring-loaded power cut-off switch on the chassis is supposed to pop and kill power to the dribbler if the front cover is raised. The worker states that this button has not worked for some time. She did not report it because “…no one is going to believe me or do anything about it anyway.”
• Workers say that the start/stop switch sometimes won’t turn the machine off immediately.
• The cover over the electrical components of the dribbler is missing. The wiring has been “creatively improved” to allow jogging and defeat the emergency stop system’s safety switches.
• Workers say that the dribbler malfunctions frequently and that Herbert and other workers were “trying to repair it in a rough, macho fashion” a few days ago.
• The supervisor has extra paperwork to do and is often in his office at the back of the plant
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Project: Dribbles Plastics Observations (continued):
• Workers say that the start/stop switch sometimes won’t turn the machine off immediately.
• The cover over the electrical components of the dribbler is missing. The wiring has been “creatively improved” to allow jogging and defeat the emergency stop system’s safety switches.
• Workers say that the dribbler malfunctions frequently and that Herbert and other workers were “trying to repair it in a rough, macho fashion” a few days ago.
• The supervisor has extra paperwork to do and is often in his office at the back of the plant when the dribbler is used. The supervisor was in his office doing paperwork at the time of the incident. It took sometime for the supervisor to be notified of the incident and reach the floor.
• No one knew what to do to help Herbert. None of the workers present had a valid first-aid certificate and the first-aid box was empty. No one knew what ambulance service to phone. In the end, the ambulance service contacted was the one that was the farthest away from the factory. This delayed Herbert’s transport to hospital. Due to complications resulting from the incident, he was hospitalized for four days.
when the dribbler is used. The supervisor was in his office doing paperwork at the time of the incident. It took sometime for the supervisor to be notified of the incident and reach the floor.
• No one knew what to do to help Herbert. None of the workers present had a valid first-aid certificate and the first-aid box was empty. No one knew what ambulance service to phone. In the end, the ambulance service contacted was the one that was the farthest away from the factory. This delayed Herbert’s transport to hospital. Due to complications resulting from the incident, he was hospitalized for four days.
Witnesses
• Herbert, the injured worker
• Herb’s supervisor
• Delbert, the employer
• The maintenance and sanitation engineer who saw the incident
Each witness will get a script from the instructor when it is time to conduct interviews.
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Project: Questions
1. Is this a reportable incident or dangerousoccurrence?
3737
Project: Instructions
• Use the Dribbles Plastics incident scenario to answer questions regarding legislation requirements
• Answer the questions in your workbook
• Select a spokesperson to present answers to the class
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Project: Questions
1. Is this a reportable incident or dangerous occurrence?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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2. If this incident must be reported, what must you send to OHS Division?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
3. Must this incident be investigated? If so, who must investigate?
____________________________________________________________________________________
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Project: Questions
2. If this incident must be reported, what must you send toOHS Division?
4. What must you include in an investigation report requested by an OHO?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Project: Questions 4. What must you include in an investigation report
requested by an OHO?
40
Project: Questions
3. Must this incident be investigated? If so, who must investigate?
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What other types of incidents must you investigate?
Regulation 311:
• Exposure to substances listed in Table 19 or 20
• Employer investigates in consultation with OHC
II Slide 42: What other types?
42
What other types of incidents must you investigate?
Regulation 85:
• Exposure to infectious organisms
(1)(d) “infection material or organism” means an infectiousmaterial or organism that has been identified in an approvedmanner as an infectious disease hazard that poses asignificantly increased exposure risk to a worker or self-employed person
• Employer investigates and may involve OHC in a manner thatrespects the confidentiality of exposed person
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Legislation summary
44
What other types of incidents must you investigate?
Potentially harmful injuries, illnesses and conditions that do not require hospitalization
• Employer reports any lost-time injuries to co-chairs orrepresentative
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Legislation summary
II: Part II
47
Part II
C.A.R.T. investigation techniques
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Supervisor involvement
Supervisors have vested interest when incidents happen in their area
• They know their workers and what jobs they perform
• They know what questions to ask
• Often part of the first-response group at the scene
• Can benefit from the investigation
4848
C.A.R.T. steps1. Collect evidence
2. Analyze evidence
3. Report
− Write report
4. Take action
− Employer takes action
− OHC or representative follows up
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How supervisor can help
Right after an incident, the supervisor can:
• Secure scene, summon emergency crews, have injuredtransported to hospital, etc.
• Report to appropriate authorities (internal and external)
• Take notes and make sketches
• Identify witnesses
• Brief and support OHC investigation team
II: Slide 51: Objective 2
51
Objective 2
How to collect evidence for an investigation
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Before you collect evidence
Get the big picture and ask questions:
• What was happening at the time of the incident?
• Who was involved and who may have seen what happened?
• What equipment, machinery, tools, chemicals, etc., wereinvolved?
• Did something fail or break?
• Consider factors like training, maintenance, workerexperience, etc.
Collecting information can be difficult and time consuming. Physical evidence may be damaged, lost, or lacking. Relevant documents may not exist, be out of print or inaccessible. Witness statements can be contradictory or sketchy. Each piece of information may generate more work.
It will be a challenge, but the investigation team must work hard, be persistent to find out what really happened — and what can be done about it.
Getting the big picture helps you get started. You might get some information from talking to someone at the scene. But, if this person was involved directly in the incident or first on the scene, their account of the incident is just one view and may not be entirely correct.
You will not totally understand the big picture until you are at the scene yourself. Even then it may be difficult to find out exactly what happened.
Ask questions to help you start gathering all the pieces of the puzzle.
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Physical evidence
• Use physical evidence to gather information aboutwhat happened before, during and after the incident
• Use physical evidence to help develop questions forwitness interviews
53
Collecting evidence
Collect evidence from:
• Physical evidence (e.g., debris, parts, photos, etc.)
• Documents (e.g., records, SDSs, etc.)
• Witnesses (interviews)
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55
Examples of physical evidence Evidence Information it may provide
Objects • Tools, equipment and materials (including damaged PPE)• Hardware, facilities and debris• Skid marks, patterns and other properties of items
associated with the incident
• What went wrong and why• What happened before, during and after the incident
Chemicals • Hydraulic fluids and liquids• Noxious gasses, smoke and fumes• Solids (e.g., pellets, dusts, powders, etc.)• Containers of chemical substances
• Hydraulic fluids and liquids can tell you aboutoperability of machinery, mobile equipment andvehicles
• Noxious gasses, smoke and fumes can tell you abouthazards in the work area, work practices, adequacyof engineering controls, etc.
Biological substances • Blood, body fluids, etc.• Potentially contaminated food and drink• Plants, spores and pollens• Insects and other animals
• What caused harm• How injury occurred
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Some evidence can be analyzed while you are still in the collection process. When checking these items you probably will analyze what you see and consider how it might have played a factor in the incident.
Check equipment, tools and facilities. Look for breakage, abuse, misuse, inadequate maintenance. See if key parts are missing, broken or out of place before the incident.
Check safety devices (e.g., guards, interlocks, etc), control indicators (e.g., dials, readouts, instruments, positions indicators, etc.) to see if they were working properly.
Check for damage and wear patterns, skid marks, the direction of debris, etc., to gather information about what happened before, during and after the incident.
For complex examinations, think about developing a checklist to help you organize items like equipment, electric schematics, plans, etc. Preparing these items in advance and putting together an incident investigation kit will help to keep your investigation organized, efficient and effective.
II Slide 56: Specific physical evidence
5656
Specific physical evidence
• Check equipment, tools and machinery for sign ofbreakage, poor maintenance, etc.
• Check operating controls and safety devices to see ifthey were working properly
• Check damage and wear patterns, skid marks,direction of debris, etc., for information on whathappened during the incident
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Handling physical evidence
• Use safe procedures
• Identify, collect, label, package and store
• If applicable, do not remove evidence until examinedby experts
• Mark locations of evidence you remove
57
Physical evidence samples
Samples can indicate:
• How technical failures, malfunctions, etc., happened
• Pre-existing defects
• The presence of chemicals, biological substances,noise, etc.
• Exposure levels
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Take photographs or video • 35mm camera
• Video camera
• Digital camera
• Start with overall area picture, then narrow down to specificincident location
• Keep log of photos and locations
• For spills, skid marks, etc., use a reference (like a pen orruler) when taking photos
Use photos and video to record information, especially information that cannot be collected in other ways. Photos can reduce the number of trips you have to make to the incident site and will give you an ongoing record of the incident scene once everything has been cleaned up.
Have an investigation team member direct the photographer to ensure that everything of importance is recorded. Move from general to specific shots. Start with shots of the general scene. Shoot each key item from several different directions to provide better information. Move the camera, but not the item that you’re photographing (moving an item may complicate subsequent examinations by specialists).
Select some way of indicating distance, direction and perspective in your shots, such as rulers to determine the size of an object in the photo or direction indicators.
Many cameras can print the date and time on each negative or slide. In some cases, this can be useful. In other instances, this feature can obscure evidence. If so, use a written log instead
Don’t forget to also take notes of what you observe. Don’t rely exclusively on photos.
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Create sketches, scale drawings and maps
• Use to show scene immediately after incident
• Use to get a bird’s-eye-view, locate debris position, etc.
• Make as soon as possible after incident
• Note locations, dimensions, directions, etc., of debris,equipment, etc.
Documentary evidence is just as important as physical evidence. It can tell you what should have happened at the time of the incident. Equipment readouts may even report what actually happened during some phases of the incident. The reasons for the difference between what should have happened and what actually happened are often the reason why the incident occurred.
Training records become very important. Did the worker receive training? How was it delivered? Who ensured the worker followed the training? These questions and the answers could tell you a lot about what happened and why.
II - Slide 61: Collect documentary evidence
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Collect documentary evidence
• Standards and technical information
• Inspection and investigation reports
• Records (e.g., training, maintenance, repair logs, etc.)
• Research
• Employer’s health and safety system
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Documentary evidence
Use it to help:
• Determine worker training
• Understand job procedures and practices
• Identify witnesses and the questions to ask
• Check witness statements
• Monitor employer’s health and safety system
Types of documentary evidenceStandards and technical information Reports• Policies, procedures, plans, programs and work
procedures• Requirements set by the employer• Regulatory and industry standards• SDSs and other technical information from suppliers,
safety associations, etc.
• Inspection reports• Investigation reports dealing with similar incidents• Computer files, photographs, video, diagrams and
drawings
Records Research
• Orientation and training records• Shift records• Maintenance files• Worker concerns and OHC minutes
• What are other organizations doing?• Experience of others in the industry• Changes made in other organizations• Internet• Health and safety publications
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Conduct research Research is a tool to learn more about the physical and documentary evidence:
• Benchmarking
− What are other organizations doing? − Have they had similar experiences? − Have they made changes to the way they do things?
• Technical research
− Internet − Journals
II - Slide 64: Dribbles collect evidence
64
Dribbles Plastics incident scenario: Collect evidence
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Instructions
Use the Dribbles Plastics incident scenario and record the physical and documentary evidence
• Include information on what each piece of evidencemay provide
• Record your answers in workbook
Physical evidence Information it might provide
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Documentary evidence Information it might provide
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Questions and answers
Evidence Information provided
66
Questions and answers
Evidence Information provided
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Plan the interview
• Identify who to interview and what information theinterview may provide
• Use physical and documentary evidence to helpprepare questions
• Interview in an appropriate location
• Minimize interruptions
II - Slide 68: Interviewing witnesses
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Collect evidence by interviewing witnesses
• Interview within first 24 hours, if possible
• Keep witnesses from talking with each other
• Have a plan and objectives for each interview
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Plan the interview
1. Interview those who were involved in the incident,saw it or were first on the scene
2. Interview those who know what was happeningbefore the incident
3. Interview others like a trainer, technical experts,facility staff, etc.
• Conduct follow-up interviews as required
Interview witnesses
Effective interviews play a key role in many investigations. Interviews often reveal critical information. Effective witness interviews are therefore crucial. Plan interviews carefully and use experienced interviewers when possible.
Experience has shown that it is best to start with eyewitnesses and the people involved. The sooner you can start your interview process the better, within 24 hours if possible, while the memories for each witness is still fresh in their mind. Interviewing witnesses can be confusing. Not everyone sees an event the same, so be prepared and expect contradictions. When you complete interviews, determine what is valid and what is not. Separate fact from fiction. Determine what is true and what is an opinion.
Good planning will give you better results. Have clear objectives about what you want to learn. What questions do I need to ask this person to better understand what happened? When interviewing witnesses the more experience you have the better you will get at it. Following an interview, take time to gather your thoughts. Did the interview accomplish what you set out to learn? If not, then a follow-up interview may be required.
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Conduct the interview
• Get their version
• Expect contradictions between witnesses
• Take notes and record critical information
• If you use written statements, review each person’stranscript with them before they sign it
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Conduct the interview
• Each interview should be private
• Treat everyone with respect
• Create an informal environment
• Reassure each witness (they might be nervous)
• Don’t rush, but keep the interview on track
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Questioning techniques • Ask questions to gain knowledge and details
• Ask questions to clarify an observation from the scene
• Ask open questions (i.e., not yes/no answers)
• Ask clarifying questions (i.e., closed questions with a yes/noanswer) to narrow down a detail
• Pause and give the person time to answer
− Don’t interrupt
• Only use drawings, photos or visits to the site to jog memory
II- Slide 74: Interview witnesses
74
Dribbles Plastics incident scenario: Interview witnesses
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Instructions
Before interviews begin, develop questions to ask witnesses:
• Use question in workbook as starting point• What information do you want to get from each
witness?• Use the physical and documentary evidence to create
questions• Create additional questions as you see necessary• Deter who will take statements and notes
II Slide 76: Instructions
75
Instructions
Use the Dribbles Plastics incident scenario to conduct interviews
• Select worker and employer co-chairs to interviewwitnesses
• Others will be the injured worker, witnesses, supervisorand employer (each person/role will be providedinstructions)
• When your group has completed the interviews, assessthe information gathered
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You will use the physical and documentary evidence gathered so far in this investigation to assist you in planning and conducting interviews.
InstructionsDetermine everyone’s role in your group. The worker and employer co-chairs will conduct the interviews. Someone will be Herbert the injured worker. Another person will be the maintenance engineer who saw the incident. Someone will be the supervisor and another will be Delbert the employer.
Determine who will ask questions and who will take notes. The co-chairs could rotate interview to interview.
Now, spend sometime planning the interview.
• Determine what information you want from each witness.
• Create questions to ask each witness.
• Decide who is going to record the answers from each witness.
The sample questions will help you get you started. Don’t forget your physical and documentary evidence. This information will help to determine the questions you ask. You need to determine what happened, why, what factors put the worker in the position of getting hurt, what caused the injury, when did it happen, where did it happen, etc. Develop questions to accomplish that goal.
Take effective interview notes• Make your notes complete, specific, and legible.
• Keep separate notes for each interview.
• Use notes to help plan subsequent interviews.
• Don’t try and take notes and interview at the same time.
• Have one person take notes and another conduct the interview. If one person is responsible for both, take your time, don’t rush and record as much as you can. There will be times you have to ask the witness to repeat what they said.
• Concentrate on recording important facts — it will be tough to record everything.
An incident investigation interview is not an interrogation. OHC incident investigations find facts and do not fix blame. The role of the OHC is to help determine what happened and why, then recommend corrective actions so it does not happen again.
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Information to determineWho
Who do I need to talk to in order to understand what happened?
Who was involved (e.g., injured worker(s), supervisors, witnesses, first responders, etc.)?
Who did what before, during and after the incident?
What
What work was being done before and at the time of the incident?
What had the supervisor asked the workers to do?
What supervision and training were provided?
What was being used to do the work (e.g., tools, equipment, machinery, supplies, chemicals, etc.)?
What was the condition of the work environment before, during, and after the incident (e.g., weather, noise, chemical smells, temperature, distractions, etc.)?
What tools, equipment, supplies and people were brought to the incident scene to respond?
What was moved or repositioned after the incident (including casualties)?
Where
Where did the incident occur?
When
When did the incident happen (time, shift, etc.)?
When did you find out about the incident?
When did products, supplies and workers, involved in the incident arrive?
How
How was the work being performed at the time of the incident?
How was the work involved normally performed?
How did the response and rescue crews perform?
How do you think a similar incident could be avoided? (Each person’s views may help you develop recommendations for corrective action.)
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Interview results What did you learn from Herbert?
II Slide 77: Interview witnesses
7777
Interview witnesses
1. Interview Herbert
2. Interview maintenance and sanitation engineer
3. Interview supervisor
4. Interview Delbert
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Plan your interviewCreate two questions to get you started interviewing Herbert. Use the extra space for more questions as they arise.
Q1
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Q4
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Plan your interviewCreate two questions to get you started interviewing the maintenance and sanitation engineer. Use the extra space for more questions as they arise.
Q1
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Q2
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Q3
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Q4
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A6
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Plan your interviewCreate two questions to get you started interviewing the supervisor. Use the extra space for more questions as they arise.
Q1
A1
Q2
A2
Q3
A3
Q4
A4
Q5
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Q6
A6
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Plan your interviewCreate two questions to get you started interviewing Delbert the employer. Use the extra space for more questions as they arise.
Q1
A1
Q2
A2
Q3
A3
Q4
A4
Q5
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Q6
A6
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Interview results
What was the supervisor’s position?
79
Interview results What was the maintenance and sanitation engineer’s role?
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Interview results What is Delbert’s OHS program like?
II Slide 82: Objective 3
82
Objective 3
How to analyze evidence for an investigation
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Analyze incident factors 1. Go through each event before, during and immediately after the incident
2. Ask why each happened
3. Evaluate role of every factor:
− People (supervision, training and orientation)
− Material (substances, tools, equipment, etc.)
− Environment (workplace conditions)
− Work process (workflow design)
− System (policies, plans and procedures)
8383
Analyze evidence
• After interviews, examine each statement and what itreveals about incident
• Analyze physical and documentary evidence
− Correlate with interviews
• Consider what substandard actions and/or conditionswere factors
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Identify direct cause • Direct cause usually happens immediately before incident
• Actions that describe a direct cause
− Struck by
− Fall to lower level
− Caught in, on or between
− Contact with, exposure to, etc.
• Often involves an unsafe act or substandard condition
85
Analyze evidence
Link together the evidence and other factors to identify:
• Direct cause
• Indirect cause
• Root cause(s)
− Often health and safety system management problems
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Identify root cause(s)
• Root causes often explain why substandard acts andconditions exist
− Lack of knowledge – no training program
− Guards off machinery – there is no repair or maintenance program
− Worker not following safe operating procedures – a lack of supervision is putting workers at risk
• Health and safety system management problems are oftenroot causes
87
Identify indirect causes
These substandard acts, procedures and conditions usually set the stage for the incident
• Lack of training
• Departures from safe work practices
• Not following information on SDSs
• Using inadequate or defective tools, equipment or materials
• Inadequate guards or barriers
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Instructions
Use the physical and documentary evidence and the interview results to analyse the incident causes
• Answer the questions in the workbook
• Determine the direct, indirect and root causes for theDribbles Plastics incident
• Discuss answers with class
II Slide 89: Dribbles analyze evidence
89
Dribbles Plastics incident scenario: Analyze evidence
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Questions and answers
2. What were the indirect causes?
91
Questions and answers
1. What was the direct cause?
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Dribbles Plastics incident scenario
Analyze evidence and witnesses interviewsThere is a lot involved to reaching the conclusions of an investigation. It will take time to analyze all the evidence you’ve gathered. You must verify each fact as it relates to the physical and documentary evidence, and the statements of witnesses. Use all the information you have gathered so far and come to some conclusions about the direct, indirect and root causes for the Dribbles Plastics incident.
Instructions
Answer the following questions about direct, indirect and roots causes. Be prepared to have someone explain your table’s answers to the class.
1. What was the direct cause of the incident?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. What were the indirect causes of the incident?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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3. What were the root causes of this incident?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Could an effective OHC have improved workplace safety?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Questions and answers 4. Could an effective OHC have improved workplace safety?
93
Questions and answers 3. What were the root causes?
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What information is required in an investigation report?
• Regulations 8, 9, 29 and 31
• Required information:
− Name of injured worker(s) and their injuries
− Contact information
− Description of incident
− Graphics, photos and other evidence
II Objective 4: Investigation report
95
Objective 4
How to develop a workplace investigation report
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Investigation report
The investigation report must include:
• Short-term and long-term corrective action/solutions
• Who will do what by when
• Resources required
• Who will follow up
9797
What information is required in an investigation report?
• Explain what happened and why
• Recommend corrective action:
Direct cause: Ensuring all workplace hazards are identified
Indirect causes: Ensuring workers are trained in the safe operating procedures for their job
Root causes: Reviewing the employer’s health and safety system to ensure programs are in place to identify hazards and that workers receive orientation and training before they perform their jobs
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OHC investigation and final recommendations
• Identify what factors led to the incident
• Identify potential solutions to correct deficiencies
• Select practical choices
• Present recommendations to employer and discusswhat actions to implement
• Follow up
II Dribbles: Develop investigation report
100
Dribbles Plastics incident scenario: Develop investigation report
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Questions and answers 1. What short-term recommendations will control the direct
and indirect causes?
II Slide 101: Instructions
101
Instructions
Use the incident causes (direct, indirect and root)
• Answer the questions in the workbook
• Determine short-term and long-term recommendations
• Discuss answers with class
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Dribbles Plastics incident scenario
Writing an investigation reportUp to this point, you have learned how to collect information to determine how and why an incident occurred. The next step is to write a report. It will take time to record all the information required, so the people who receive the investigation report can understand what happened, why it happened and what needs to do be corrected so that it doesn’t happen again.
When writing incident reports in your workplace, you will be expected to follow the criteria in the legislation required for your report. Here, you only need to come up with short-term and long-term solutions for the Dribbles Plastics incident scenario.
Instructions
Answer the following questions. Be prepared to have someone explain your group’s answers to the class.
1. What short-term recommendations will control the direct and indirect causes? List two or three recommendations.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Questions and answers 2. What long-term recommendations must the employer take
to prevent the occurrence of a similar incident?
2. What long-term recommendations must the employer take to prevent the occurrence of a similar incident?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Take action
It is the employer’s duty to:
• Take immediate action to protect workers
• Take long-term actions to correct root causes
• Comply with regulations
• Provide OHC with written report
II Objective 5: Employer’s responsibility
104
Objective 5
Take action: The employer’s responsibility
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Regulation 28(2) On written notice by the committee or the representative of an unsafe condition or a contravention of the Act or any regulations made pursuant to the Act, the employer, contractor or owner shall: (a) take immediate steps to protect the health and safety of any worker
who may be at risk until the unsafe condition is corrected or thecontravention is remedied;
(b) as soon as possible, take suitable actions to correct the unsafecondition or remedy the contravention; and
(c) inform the committee or the representative in writing of:(i) the actions that the employer, contractor or owner has taken
or will take pursuant to clause (b); or(ii) if the employer, contractor or owner has not taken any actions
pursuant to clause (b), the employer’s, contractor’s or owner’sreasons for not taking action.
106106
Take action
• Employer reviews investigation report
• Employer reviews OHC or representativerecommendations
• Employer decides what action to take
• OHC or representative provides input and monitorseffectiveness of employer’s corrective action
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Important websites
• saskatchewan.ca
• worksafesask.ca
• ccohs.ca
• Visit saskatchewan.ca and worksafe.ca for publicationto help resolve issues
108108
Summary
• Regulatory requirements for investigating workplaceincidents and dangerous occurrences
• Collect evidence for an investigation
• Analyze evidence for an investigation
• Develop a workplace investigation report
• Take action following a workplace investigation
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Questions?
• Complete evaluation
• Review Investigation Guide at meetings
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Self-check for Level 2 - Incident Investigations Name: _______________________ Instructor’s name: _______________________
1. What incidents and dangerous occurrences must be reported to OHS Division? Circle the correct answers.(a) Any incident that resulted, or could have resulted, in the
death of a worker, or that will require that hospitalization of a worker for more than 72 hours
(c) Any incident that could have caused serious injury or damage, such as the bursting of a grindstone or collapse of a scaffold
/2(b) Any incident that requires a worker to receive first aid (d) Any incident that resulted, or could have resulted,
in the death of a worker, or that will require the hospitalization of a worker for more than 24 hours
2. What incidents and dangerous occurrences must be investigated? Circle the correct answers.(a) Incidents that require a worker to be admitted to a
hospital as an in-patient for 24 hours or more(c) Incidents that require a worker to be admitted to a
hospital as an in-patient for 72 hours or more/2
(b) Incidents that cause serious economic loss (d) Incidents that caused, or may have caused, the death of a worker
3. What is the role of investigations conducted by OHCs and representatives? Circle the correct answers.(a) Improve the effectiveness of the employer’s health and
safety management system(c) Find and suggest corrections for the root cause of
the incident /3(b) Not assess blame (d) Ensure compliance
4. What information must be included in regulations 29 and 31 reports? Circle the correct answers.(a) The names of anyone who provided tools, equipment or
chemicals involved in the incident(e) An explanation of the cause or causes of the
incident
/5
(b) A physician’s report describing any occupational disease or physical injury affecting workers involved in the incident
(f) Any long-term action that the employer will take to prevent the occurrence of a similar incident or the reasons for not taking action
(c) Any graphics, photographs or other evidence that may assist to determine the cause or causes of the incident
(g) The immediate corrective action taken
(d) Signed transcripts of witness interviews (h) A description of the incident
5. What three types of evidence can provide useful information about the possible causes of an incident? Circle the correct answers.
(a) Documentary evidence (d) Witness interviews
/3(b) Media news reports (e) Physical evidence
(c) Discussions among witnesses before they are interviewed
6. Arrange the steps in the witness interview process (1 to 7).______ Research the issues and plan each interview carefully.
______ Schedule interviews in a neutral place where you can interview without interruption.
______ Conduct follow-up interviews and re-examine physical and documentary evidence as needed.
______ Interview technical specialists who are familiar with the technology and work practices involved.
______ Identify who you want to interview and the information each witness is likely to be able to provide.
______ Interview those who were involved in the incident, saw it or were the first on the scene.
______ Interview those who know something about what was going on before the incident.
/7
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7. Identify direct (D), indirect (I) and root (R) causes of an incident below.______ Fundamental problems that set events in motion that
ultimately led to the incident______ What directly caused the incident
/3______ What set the stage for the events leading to the
incident
8. What is the purpose of an OHC investigation report? Circle the correct answers.(a) Explain what happened and why (d) Propose what must be done immediately to prevent
the incident from happening again
/3(b) Propose what should be done in the long term to remove fundamental weaknesses in the health and safety systems (if any) that led to the incident
(e) Direct the employer to take specific corrective actions
(c) Identify who is responsible for the incident
Total /28
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Occupational Health and Safety training
Participant evaluationLevel 1: Committees/Representatives
Level 2: Inspections Investigations
Supervision and Safety
Date: ____________________ Instructor: _________________________ City: ________________________
We want to know what you think. Your answers are important because they help us improve our courses.
Legend: 'A' Strongly agree 'B' Agree 'C' No opinion 'D' Disagree 'E' Strongly disagree
A. General
A B C D E I enjoyed this course.
A B C D E The course met my expectations.
A B C D E I will be able to apply what I learned today to my workplace.
A B C D E I would recommend this course to other OHC members and employers.
The most important thing I learned today:
___________________________________________________________________
___________________________________________________________________
B. The instructor
A B C D E Instructor was well prepared, organized and made good use of time.
A B C D E Instructor knew course content well.
A B C D E Provided adequate opportunities for discussion.
C. The course
A B C D E The content and materials will be directly useful to me in my workplace.
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A B C D E The projects and lectures helped me learn and practice my occupational health and safety duties and responsibilities.
A B C D E I had no trouble understanding the lectures and project instructions.
There was enough time provided for:
A B C D E (a) Questions
A B C D E (b) Group projects
A B C D E (c) Discussion
A B C D E I felt free to get involved in discussions and projects.
A B C D E I felt free to ask the instructor questions.
A B C D E The course materials were well organized, easy to read and understand.
A B C D E The overheads were easy to read and understand.
A B C D E The procedure used to register was efficient.
A B C D E The room was comfortable and appropriate for this course.
A B C D E The location of the course was convenient for me.
D. What did you like most about this course?
E. What did you like least about this course?
F. Additional comments or suggestions?
Thank you. Please return this from to your instructor before you leave.
Labour Relations and Workplace Safety
Occupational Health and Safety Division300 - 1870 Albert StreetRegina SK S4P 4W1Phone 306.787.4496Toll free 1.800.567.7233
Online www.saskatchewan.ca
WorkSafe Saskatchewan
Head Office200 - 1881 Scarth StreetRegina SK S4P 4L1
Saskatoon Office115 24th Street EastSaskatoon SK S7K 1L5
Phone 306.787.4370Toll free 1.800.667.7590Fax 306.787.4311Toll-free fax 1.888.844.7773
Online www.worksafesask.ca
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