1. CHAPTER 5 INCIDENT INVESTIGATION AND REPORTING
BWU Occupational Safety & Health

2. Incident Prevention

3. Learning Objectives To define what is incident
To explain the causes of incident & role
of management control
To explain 3 theory on accident
causation
To list the cost involved in an incident
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4. Scope Principles of loss prevention Causes of incidents
Incidents and productivity
Approach to loss prevention
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5. Principles of Incident Prevention
Incident prevention is good management
Management and workers must fully cooperate
Top management must lead
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6. Principles of Incident Prevention
There must be an OSH policy
Must have organisation and resources to implement the OSH policy
Best available information and technology must be applied
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7. What Is An Incident? An 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,
Any combination of these effects.
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8. Why Prevent Incidents? Legal Human Rights Business
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9. Causes Of Incidents
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10. Types of Incidents
Cause immediate injury or damage to equipment or property:
A forklift dropping a load
Someone falling off a ladder
That occur over an extended period:
Hearing loss
Illness resulting from exposure to chemicals
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11. Early Theory Of Accidents (Heinrich (1930's))
Ancestry/social environment
Fault of a person
Unsafe act/condition
Accident
Injury
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12. Heinrich’s Five Stage Sequence
Ancestry/social environment
Fault of a person
Unsafe act/condition
Accident
Injury
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13. Accident Causation Model (1974)
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14. The Three Basic Causes of Accidents
Poor Management Safety Policy &
Decisions
Personal Factors
Environmental Factors   
Basic Causes
Unsafe
Condition
Unsafe Act
Indirect causes
Unplanned Incidence
ACCIDENT
Personal Injury,
Property Damage
Direct Causes
Three Basic Causes Of Accident
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15. Contributing Factors To Accidents – Immediate Causes (Symptoms)
The unsafe acts and unsafe conditions can be categorised as follows:
Human behaviour
Design of equipment and plant
Systems & procedures including use of materials
Environmental surroundings
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16. 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, sub- standard 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
This is the area where most causes can be located and where effective Quality Assurance programs are in place, may of these causes have the potential to be eradicated
Organisation policy and procedures should identify and outline specific safety requirements and ensure compliance
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17. Multiple Cause Of Accidents
Cause A
(Poor lighting)
Cause B
(Not look where going)
Accident
(Trip)
Cause C
(Wood in walkway)
Compatible with Loss Causation Theory.
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18. Fall From a Defective Ladder
Why was the defective ladder not found during normal inspection?
Why did the supervisor allow its use?
Didn't the injured employee know it should not be used?
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19. Fall From a Defective Ladder
Was the employee properly trained?
Was the employee reminded not to use the ladder?
Did the superior examine the job first?
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20. 1 3 50 80 400 The Accident Pyramid TYE/PEARSON/BIRD 1969-1975
Near misses 80
Property 50
First aid 3
Lost days 1
Fatal / Serious injury
TYE/PEARSON/BIRD
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21. Accepted Accident Theory
Multiple Causation Theory
A single unsafe act or condition may or may not cause an accident but both are caused by lack of management control.
Bird Loss Causation Model
In line with Schewhart(1930’s) theory of quality control.
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22. Accepted Accident Theory
Heinrich’s theory is weak and negative
Blaming victim and lack system thinking, continual improvements, upstream control and worker participation.
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23. Productivity Aspect Of OSH
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24. Direct Vs. Indirect Incident Cost Iceberg
It is estimated that for every $1 in direct incident costs, there are anywhere from $4 to $11 in indirect or “hidden” costs.
Direct
Costs
Indirect
Costs
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25. Insured Costs -- covering injury, ill health, damage.
The Hidden Costs
Insured Costs -- covering injury, ill health, damage.
Hidden Uninsured – 8-36 times as much as insured costs
Investigation time
Supervisors time diverted
Clerical Effort
Overtime working
Temporary labour
Loss of expertise / experience supplies
Clearing site
Production delays
Product and material damage
Plant and building damage
Tool and equipment damage
Expenditure on emergency
Fines
Legal costs
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26. Incident Prevention Costs
DESIGN COSTS (e.g to install machine guards)
OPERATIONAL COSTS (training costs, PPE, etc.)
SAFE GUARDING THE FUTURE COSTS (health surveillance, audits etc)
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27. Cost- Benefit Analysis Of Control Measures
Compare specific incident costs with cost of specific improvement being suggested.
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28. 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 organisation’s Occupational Safety And Health management system can be continually improved
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29. Why Investigate an Incident
To prevent repetition of the same work- related injuries, ill health, diseases and incidents
Legal Requirement
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30. Why Investigate an Incident
Accurate record (for insurance, legal prosecution, public enquiries)
Organisation’s own policy and business reasons
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31. 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
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32. Who Should Investigate? Depends On Severity Of The Incident
External agency involvement
DOSH and / or DOE, Police, etc.
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33. What & When to Investigate
All serious and long-term incidents & near misses
As soon as possible to prevent:
Scene interference
Deterioration of evidence
Losing people’s recollection of the incidence
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34. Principles Of Incident Investigation
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35. Principles of Investigation
Carried out according to procedure:
For all incidents
By competent persons with participation of workers.
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36. Principles of Investigation
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
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37. Principles of Investigation
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
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38. 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
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39. Be Prepared – Before The Incident
Designated trained and competent investigator
Only be responsible for investigating
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40. 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
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41. Notification Procedure
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)
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42. Investigation Procedure
For recording evidence
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
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43. 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
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44. Responsibilities Employee Supervisor / Manager
Record in incident book (supervisor checks)
Supervisor / Manager
Initiate risk control response: first-aid, fence area, etc. other preventive action
Inform SHO
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45. Responsibilities Organise camera, tape and report form
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
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46. Responsibilities Visit and survey incident scene
Investigator
Visit and survey incident scene
Eliminate the hazards:
Control of chemicals
De-energise
De-pressurise
Light it up
Shore it up
Ventilate
Obtain authority to investigate (this should not be a problem)
Where possible obtain video, photographic or graphical support which will be an invaluable tool later on to refresh memories and allow third parties to have an intimate knowledge of the accident and the environment at that time.
The investigator must be alert enough to include as much information as possible in relation to:
machinery readings and possible faults,
particular damage to machinery,
hazardous substances
environmental particulars
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47. On-Site Investigation Strategy
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48. Steps In Incident Investigation
Gather information
Search for and establish facts
Isolate essential contributing factors
Determine the causes & root cause
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49. Steps In Incident Investigation
Determine corrective actions
Report, review the findings
Analyze incidents
Implement corrective actions
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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
Target the reader - Who is the reader?
Discuss the “Queens Street Accident” (Concrete slab kills 3 members of the public)
multi volume report
Target audience was:
Public prosecutor
Principal Contractor
Site owner (Bank)
Victims representatives
Government
Div WH&S
Police
It would be a distinct advantage if the investigator or person(s) producing the report have undergone formal training in report writing techniques
Set out in an appropriate format to be easy to read and understand (ABC)
Don’t get too technical, it may confuse the reader (KISS)
Recommendations must have time frame priorities and there MUST be a method of reviewing any control measures - Did they actually work?
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51. 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

52. 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.