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CHAPTER 5 INCIDENT INVESTIGATION AND REPORTING

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Presentation on theme: "CHAPTER 5 INCIDENT INVESTIGATION AND REPORTING"— Presentation transcript:

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 2005/1

4 Scope Principles of loss prevention Causes of incidents
Incidents and productivity Approach to loss prevention 2005/1

5 Principles of Incident Prevention
Incident prevention is good management Management and workers must fully cooperate Top management must lead 2005/1

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 2005/1

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. 2005/1

8 Why Prevent Incidents? Legal Human Rights Business
2005/1

9 Causes Of Incidents 2005/1

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 2005/1

11 Early Theory Of Accidents (Heinrich (1930's))
Ancestry/social environment Fault of a person Unsafe act/condition Accident Injury 2005/1

12 Heinrich’s Five Stage Sequence
Ancestry/social environment Fault of a person Unsafe act/condition Accident Injury 2005/1

13 Accident Causation Model (1974)
2005/1

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 2005/1

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 2005/1

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 2005/1

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. 2005/1

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? 2005/1

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? 2005/1

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 2005/1

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. 2005/1

22 Accepted Accident Theory
Heinrich’s theory is weak and negative Blaming victim and lack system thinking, continual improvements, upstream control and worker participation. 2005/1

23 Productivity Aspect Of OSH
2005/1

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 2005/1

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 2005/1

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) 2005/1

27 Cost- Benefit Analysis Of Control Measures
Compare specific incident costs with cost of specific improvement being suggested. 2005/1

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 2005/1

29 Why Investigate an Incident
To prevent repetition of the same work- related injuries, ill health, diseases and incidents Legal Requirement 2005/1

30 Why Investigate an Incident
Accurate record (for insurance, legal prosecution, public enquiries) Organisation’s own policy and business reasons 2005/1

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 2005/1

32 Who Should Investigate? Depends On Severity Of The Incident
External agency involvement DOSH and / or DOE, Police, etc. 2005/1

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 2005/1

34 Principles Of Incident Investigation
2005/1

35 Principles of Investigation
Carried out according to procedure: For all incidents By competent persons with participation of workers. 2005/1

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 2005/1

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 2005/1

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 2005/1

39 Be Prepared – Before The Incident
Designated trained and competent investigator Only be responsible for investigating 2005/1

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 2005/1

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) 2005/1

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 2005/1

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 2005/1

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 2005/1

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 2005/1

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 2005/1

47 On-Site Investigation Strategy
2005/1

48 Steps In Incident Investigation
Gather information Search for and establish facts Isolate essential contributing factors Determine the causes & root cause 2005/1

49 Steps In Incident Investigation
Determine corrective actions Report, review the findings Analyze incidents Implement corrective actions 2005/1

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? 2005/1

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.


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