1. Incident Reporting And Investigation Program
CSP
Incident Reporting And Investigation Program
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2. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Objectives
Describe the responsibilities and procedures for reporting and investigating
Incidents / near-miss incidents
Spills, chemical releases
Injuries, occupational illnesses
Equipment or property damage
Transportation incidents
Fires or explosions
Security issues
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3. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Objectives
Describe the importance of investigations in:
Determining the root causes of incidents
Determining corrective and preventive actions to prevent similar incidents.
Describe the importance of initiating investigation immediately after the incident situation is under control.
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4. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Definitions
Incident –
Any unplanned event or near miss occurring inside the facility boundaries affecting employees, processes, contractor employees, or visitors.
Any off-site events involving company products or equipment in transit or at customer sites
Incident Owner –
The manager, supervisor or designated person responsible for the facility, area or activity where the incident occurred.
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5. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Definitions
OSHA Recordable Cases –
All work related illnesses and deaths, and those work related injuries which result in:
Loss of consciousness,
Restriction of work or motion, transfer to another job, or require medical treatment beyond first aid and/or use of prescription medications.
Initial Notification–
A brief communication providing basic details of an incident
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6. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Definitions
Investigation Team –
Consist of personnel who shall investigate and analyze the incident.
If an incident involves contractor personnel, then non- involved contractor employees may be included as team members.
Management personnel knowledgeable of investigation methodologies and techniques shall be included in the incident investigation.
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7. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Definitions
First Aid –
Any treatment and subsequent observation of minor scratches, cuts, burns, splinters, and so forth, which do not ordinarily require medical care or use of prescription medications.
Such treatment and observation are considered first aid even though provided by a physician or registered professional personnel.
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8. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Responsibilities
All personnel are responsible for:
Notifying their immediate supervisor of all incidents immediately.
Participating in generating the initial notification
Participating in incident investigations as needed.
Participating in generating the investigation report
Completing corrective and preventive actions as assigned.
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9. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Responsibilities
Facility Manager or Shift Leader, or Control Room Operator is responsible for:
Being the Incident Owner for all incidents that occur within their area of responsibility.
Documenting initial incident details.
Contacting regulatory agencies if necessary.
Assigning personnel to the incident investigation team.
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10. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Responsibilities
Facility Manager or Shift Leader, or Control Room Operator is responsible for:
Leading and conducting incident investigations.
Communicating with Maintenance when design issues or equipment failures may be involved in the incident.
Defining and recommending corrective and preventive actions.
Verifying all corrective and preventative actions assigned during the incident investigation are completed.
Communicating to employees incident summaries.
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11. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Procedure for Investigation
An Incident Investigation shall begin immediately after securing the scene.
If the area is quarantined, the investigation shall not commence until release of the quarantine.
Documents associated with the incident should be attached to incident file.
The Investigation Team shall produce an Investigation report including corrective and preventive actions.
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12. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Preparation for Investigation
An effective incident investigation starts before an incident occurs with a well designed investigation procedure. The following information will provide guidance when conducting an investigation:
ORGANIZE AN INVESTIGATION TEAM.
As few as two or as many as four employees.
The size of the team may vary based on the type of incident.
Must include at least one employee of supervisor responsibility.
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13. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Preparation for investigation
ASSEMBLE AN INVESTIGATION KIT.
This kit may include a camera, paper/pens, reporting forms and any information such as notes on investigation.
SECURE THE ACCIDENT SCENE.
Asses the situation to prevent additional accidents from occurring based on hazards.
Attend to any immediate medical emergencies.
Preserve any evidence at the scene. DO NOT ENTER AN ACCIDENT SCENE UNTIL IT HAS BEEN CLEARED FOR SAFETY.
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14. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Doing the investigation:
Identifying and collect evidence –
This must be done quickly.
Identifying contributing factors –
Can include procedure violations or employee knowledge.
Photographing the accident scene –
Take pictures necessary to reconstruct the scene. Take close and long range.
Sketching the accident scene –
Will provide information that a photo will not.
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15. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Doing the investigation:
Writing notes –
Notes should be written as soon as possible while information is fresh.
Notes, s, communications should be initiated as soon as possible by personnel involved in the incident
Consider who, what, when, where, how and why.
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16. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Doing the investigation:
Interviewing affected parties or witnesses –
Prepare interview questions. Ask questions but let the employees describe their observations. Take notes during the interview. Get facts, don’t assign blame or criticize. Don’t focus on expense of the damages or legal issues. End the interview on a positive note.
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17. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Determining root cause
1. REVIEW ALL EVIDENCE.
This will include all information collected
2. DETERMINE THE ROOT CAUSE.
To determine the root cause, you must first identify contributing factors (symptoms). As an example, an employee’s action may have caused the accident, but why did the employee perform this action.
This could have been the result of procedural violations or lack of training.
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18. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Determining Corrective Actions
3. DEVELOP CORRECTIVE AND PREVENTIVE ACTIONS.
A root cause may be a mechanical problem or personnel issue.
Corrective and preventive actions are implemented to eliminate or reduce the chance of another accident.
Actions are determined by the following methods; input from employees, hazard assessments, safety committees.  
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19. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Communicating to others in the organization 
4. COMMUNICATE RESULTS.
To effectively communicate the findings of the investigation, a final report must be completed.
The Company will communicate investigation reports through a safety meeting.
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20. INCIDENT REPORTING AND INVESTIGATION PROGRAM
Approval & Closure 
An Incident Report is ready for approval and closure when
The investigation is completed,
The root cause has been identified
Corrective actions have been implemented.
The Facility Manager is responsible for final closure of the incident record.
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21. CSP Procedure for Completing Incident Report
EMPLOYEE REPORT OF INCIDENT OR INJURY
Always: Fill this form immediately after the incident.
Fill all the sections of the form electronically:
“Report Completed by” (Employee involved in incident/Accident. If not available, the Shift Lead or the CR operator must fill a preliminary report)
“Report Received by” (Shift lead or CR operator. If not available, the name of next operator in line)
“Date / Time Received” (Date/time when SL or CR operator received the report)
Save electronic copy under:
Dropbox/Safety/Incident report/In progress
Send with electronic copy to:
Lead Compliance
Plant Manager
Print the report
Obtain signature from SL or CR operator
Place hard copy in Lead Compliance Mailbox
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22. CSP procedure for completing Incident Report cont..
INCIDENT INVESTIGATION REPORT SECTION I & II
Always:
Involve a supervisor and the employee involved in the incident / accident
Fill Sections I & II being selective of the sub-sections that apply
COMPLETE THIS SECTION IF THE INCIDENT INVOLVES AN INJURY
This section applies only in circumstances where the employee involved resulted injured.
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