13-Incident Investigation and Corrective ActionREVISED PDF

Incident Investigation And
Corrective Action
Safety And Health Officer Certificate
Course
Copyright@NIOSH 2005/1
Learning Objectives
To describe the importance of
incident investigation
To list 4 types of incident
To describe principles of
investigation
Learning Objectives
To explain 8 steps in incident
investigation
To explain ways to plan and implement
corrective and preventive action
Scope
Overview of an Incident Investigation
Principles of Incident Investigation
Pre-Planning and Strategy of an

Investigation
Corrective Action
What is an Incident?
Incident is:
An unexpected
Unplanned event in a sequence of events
That occurs through a combination of
causes
Which result in:
Physical harm (injury, ill-health or disease) to
an individual
Damage to property
A near miss, a loss
Any combination of these effects
What is a Near miss?

A Near miss is:
An event which did not result in injury
or damage to property but had the
potential to do so
Shares the same root causes as an
accident. It is only because of chance
that no harm or damage occurred
Needs similar attention as an accident
Four Basic Types Of Incidents

Minor accidents:
Paper cuts finger, box of materials
dropped
Serious accidents (cause injury or

damage to equipment or property):
Falling off a ladder, hazardous
chemical Spill, forklift dropping a load
Four Basic Types Of Incidents

Long Term
Hearing loss, an illness resulting from
exposure to chemicals
Near misses
Accident Causation Model

An accident is the result of a sequence of
an immediate cause and an underlying
cause.
1. Results of the accident - harm or damage
2. Incident the accident
3. Immediate causes symptoms of lack of
control
4. Basic (underlying) causes the real
problems Copyright@NIOSH 2005/1
9
Three Basic Accident Causes

Management Safety Policy
Management Decisions
Personal Factors
Environmental Factors
Unsafe
Unsafe Act
Condition
Basic Causes
Immediate causes
Unplanned Incidence
Direct Causes
ACCIDENT/ INCIDENT
10
Contributing Factors To
Accidents
Immediate Causes (Symptoms)
The unsafe acts and unsafe conditions
can be categorised as follows:
1. Human behaviour
2. Design of equipment and plant
3. Systems & procedures including use of
materials
4. Environmental surroundings
11
Root Causes Of Incident Management (The Real Problem)

Personal Factors
Lack of knowledge or skill,
improper motivation,
physical or mental
conditions
Job Factors
Physical environment, substandard equipment,
abnormal usage, wear &
tear, inadequate standards,
design & maintenance,
purchasing standards
Supervisory
Performance
Inadequate instructions,
failure of SOPs, rules not,
enforced, hazards not
corrected, devices not
provided
Management Policy &

Decisions
Measurable standards,
work in progress measure ,
work-v-standards,
evaluation , corrective
action
12
What is An Incident Investigation

A management tool by which:
Work-related injuries, ill health, diseases and
incidents are systematically studied so that
their root causes and contributing factors
can be identified
The organisations Occupational Safety And
Health management system can be
continually improved
13
Why Investigate an Incident

To prevent repetition of the same workrelated injuries, ill health, diseases and
incidents
Legal Requirement
14
Why Investigate an Incident

Accurate record (for insurance, legal
prosecution, public enquiries)
Organisations own policy and business
reasons
15
Who Should Investigate?

Depends On Severity Of The
Incident
Internal Investigation team
Individuals involved
Supervisor, Safety officer
Upper management
external consultants
Members of the Safety and Health Committee
16
Who Should Investigate?

Depends On Severity Of The
Incident
External agency involvement
DOSH and / or DOE, Police, etc.
17
What & When to Investigate

All serious and long-term incidents &
near misses
As soon as possible to prevent:
Scene interference
Deterioration of evidence
Losing peoples recollection of the incidence
18
Principles Of Incident
Investigation
19
Principles of Investigation
Carried out according to procedure:
For all incidents
By competent persons with participation
of workers.
20
Should:
Be systematic and documented
Be treated as urgent (to prevent productivity
loss and deterioration of evidence)
Be objective (fact finding only)
Find the underlying (root) cause(s)
Identify failures in OSH management
system
Implement corrective action
21
The results should:
Be communicated to the Safety and Health
Committee who should make appropriate
recommendations
Include external investigation reports such as
DOSH and SOCSO
Be communicated to appropriate persons for
corrective action
Included in management review
22
Be Prepared
Before The Incident
Identify who has the authority to
investigate and carry out mitigation
action and corrective action to
completion
Have a system for notification and
recording of all incidents and injuries
23
Be Prepared
Before The Incident
Designated trained and competent
investigator
Only be responsible for investigating
24
How Much to Prepare

Dependent on:
The number and type of workplaces
The equipment required to conduct the
investigation
Ability for investigator to reach an
investigation site as soon as possible
Geographical location
Reliable transportation requirements
25
Notification Procedure
Notification:
To management after an incident
Initiated by the person involved
Should be to his immediate superior
To visitors and contractors
Recorded
Automatic system to notify investigator

Include members of Safety and Health
Committee (if any)
26
Investigation Procedure
1. For recording evidence
2. For observation and recording of fragile,
perishable or transient evidence
e.g.
Instrument readings, control panel

settings, weather & other
environmental conditions, chemical
spills, stains, skid marks
27
Investigation Kit Preparation

Camera &
Video Camera
Cassette Tape
Recorder
Flash and Batteries
Mobile Telephone /
Walkie-Talkie
Clipboard, Pre-printed
Forms
PPE
Containers for Taking
and Storing Samples
Barrier Tape
28
Responsibilities
Employee
Record in incident book (supervisor checks)
Supervisor / Manager
Initiate risk control response: first-aid, fence
area, etc. other preventive action
Inform SHO
29
Responsibilities
SHO
Organise camera, tape and report form
Check line management report
Investigate if incident is serious and require to
notify authorities such as DOSH, DOE, Police,
etc.
Complete incident record form
Summary report to Safety and Health
Committee
30
Responsibilities
Investigator
Visit and survey incident scene
Eliminate the hazards:
Control of chemicals
De-energise
De-pressurise
Light it up
Shore it up
Ventilate
31
On-Site Investigation Strategy
32
Steps In Incident Investigation

1. Gather information
2. Search for and establish facts
3. Isolate essential contributing factors
4. Determine the causes & root cause
33
Steps In Incident Investigation

5. Determine corrective actions
6. Report, review the findings
7. Analyze incidents
8. Implement corrective actions
34
Gathering Information
Time is of the essence
Take samples, photos, measurements and
sketch diagrams,
Preserve and protect data, Information and
evidence
Collect in order of fragility
People, Positions, Parts and Papers; (4Ps)
Record injury types & groups

35
Identify people involved
Excellent source of first hand knowledge
Interview injured, witnesses,

supervisors and others
36
Get preliminary statements as soon as
possible from all witnesses
May present pitfalls in the form of:
Bias, perspective, exaggeration, hidden
agenda
37
Gathering Information People ( Witnesses)

One-to-one in private
Put them at ease
Make it clear the objective of the investigation
is to avoid recurrence, not to apportion blame
Do not interrogate but Question!

Let each witness speak freely on their version
38
Gathering Information People (Questioning)

Strategic questioning - No leading
questions
Obtain facts not opinions
Ask What, Where, When, Why, Who and How
Get observation on events before, during and
after the incident
39
Gathering Information People (Questioning)

Make sure the witness understands
questions
Use sketches and diagrams to help the
witness
40
Gathering Information Recording Interview

Take notes without distracting the witness
Record the exact words used by the
witness to describe each observation
Use a tape recorder only with consent of
the witness
41
Gathering Information Recording Interview

Differentiate what is directly observed and
what is hearsay and note accordingly
Verify claims afterwards
42
Gathering Information Closing The Interview

Identify the designation and
qualifications of each witness (name,
address, occupation, years of experience,
etc.)
Supply each witness with a copy of their
statements
43
Gathering Information Closing The Interview

Get signed statements where possible
Thank the interviewee
44
Gathering Information Position

Document the incident scene before any
changes are made:
Victim location
Position of each witness on a master chart
(including the direction of view)
Machinery, energy and chemical sources
Other contributing factors
Take photos, draw scaled sketches

Record measurements
45
Gathering Information Parts

Around incident scene prior to, during or
after the incident that may have influence
Materials, pieces of plant, tools, equipment,
buildings
May require qualified person to examine

or comprehensive testing or sophisticated
equipment
Reports by expert witness." will form part
of the investigation evidence
46
Gathering Evidence
Paper
Production schedules or process diagrams

Check current working procedure
Check qualifications
Check training records
Check corrective actions
Check equipment maintenance records

Check incident records
47
Findings
Isolate essential contributory factors
Would the incident have happened if this
particular factor was not present?
Determine Causes
Employee actions, environmental conditions,
equipment condition, procedures, training
48
Findings
Find Root Causes. Ask:
What caused behaviour? Why equipment was
not fixed? Why condition was not corrected?
49
Determine Corrective Action

Recommendations made for
corrective actions
Recommendations for corrective
actions to improve OSH management
system
50
Incident Investigation Report

Clear, complete description and accurate
information of events leading up to the
accident
Clear, complete and correct identification of
all causal factors
Recommendations
Supporting documentation
Proper review and sign off
51
Preventive And Corrective

Action
52
Corrective And Preventive

Action
Preventive and corrective action should be
carried out for:
Incidents
Management system non-conformances
Recommendation(s) for preventive and

corrective actions must be communicated
clearly
53
Corrective And Preventive

Action Planning
Procedure for handling investigation and
preventive and corrective action
Identification and authority for personnel
handling investigation and preventive and
corrective action
Authority for initiating and confirming the
completion of corrective action
54
Implementing Corrective And

Preventive Action
Must be based on root causes
Appropriate to the problem at hand

Reviewed through risk assessment
process to ensure that the correction
will not introduce a new hazard
Strict time table for implementation
established
Follow up conducted
55
Summary
Aim of investigation is to find root
causes.
Purpose is so that similar incident will not
be repeated.
Prepare organisation, procedure and
equipment in anticipation of incidents.
Corrective and preventive action should
be carried out for incidents and
management system non-conformances.
56

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13-Incident Investigation and Corrective ActionREVISED PDF

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Incident Investigation And

Pre-Planning and Strategy of an

What is a Near miss?

Four Basic Types Of Incidents

Serious accidents (cause injury or

Four Basic Types Of Incidents

Accident Causation Model

Three Basic Accident Causes

Root Causes Of Incident Management (The Real Problem)

Management Policy &

What is An Incident Investigation

Why Investigate an Incident

Why Investigate an Incident

Who Should Investigate?

Who Should Investigate?

What & When to Investigate

How Much to Prepare

Automatic system to notify investigator

Instrument readings, control panel

Investigation Kit Preparation

On-Site Investigation Strategy

Steps In Incident Investigation

Steps In Incident Investigation

Record injury types & groups

Interview injured, witnesses,

Gathering Information People ( Witnesses)

Do not interrogate but Question!

Gathering Information People (Questioning)

Gathering Information People (Questioning)

Gathering Information Recording Interview

Gathering Information Recording Interview

Gathering Information Closing The Interview

Gathering Information Closing The Interview

Gathering Information Position

Take photos, draw scaled sketches

Gathering Information Parts

May require qualified person to examine

Production schedules or process diagrams

Check equipment maintenance records

Would the incident have happened if this

particular factor was not present?

Determine Corrective Action

Incident Investigation Report

Preventive And Corrective

Corrective And Preventive

Recommendation(s) for preventive and

Corrective And Preventive

Implementing Corrective And

Appropriate to the problem at hand

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