1. Incident Reporting and Investigation College of Engineering Team 2: Joseph Duffy, Andrew Sullentrop and Zlatko Sokolikj March 29, 2013 Revised April 2, 2014, L. Schreiber

2. Incident or Accident - Although both of the terms incident and accident are used to describe any unforeseen occurrence in the lab, regardless of the severity, the National Safety Council has defined the appropriate boundaries in which these terms are used. NEAR MISS - describe incidents where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have occurred. INCIDENT - an unplanned, undesired event that adversely affects completion of a task Accident - an undesired event that results in personal injury or property damage.

3. Contain the Accident/ Incident - After an accident has occurred, the first thing to do is to contain the accident making sure it can no longer cause more harm to the already injured or others & so that it cannot evolve into something more serious - ENSURE any injured personnel is receiving medical attention - ENSURE that any hazards generated by this accident have been contained or removed - REMOVE the equipment and any other items associated with the accident/incident out of access, so they may not cause harm to other operators in the vicinity - ENSURE that all the proper agencies have been informed

4. Report all accidents/incidents !!! - no matter how insignificant the damage or how evident the cause, all accidents must be reported WHY? What you don’t report, you can’t investigate. Legal requirements. Develop database of incident reporting and investigation history for future analysis. Identify problems in the operation before they lead to major incidents. Where? - Specified Incident/Accident report form To Whom? - Appropriate Authority

5. Accident/Incident Report

6. The Investigation To recognize the unsafe acts and/or conditions that caused the incident. To identify the management system that failed to prevent it from happening. To recommend remedial actions that will prevent it from happening again. WHY? WHO? - The team that performs the investigation is composed by the governing authority and may consist of an expert that has demonstrated knowledge in the field in which this incident falls onto

7. The Evidence - effective preservation of evidence is the key building block to a successful investigation. The Four types of Evidence (The four P’s) Position Evidence – describes the position of each apparatus at the time of the occurrence of the incident/accident. As the positions of the apparatuses might change after the experiment, it is the most fragile of all evidence and therefore should be gathered as soon as possible after an incident has occurred. - There are several easy ways to record position evidence photographs position maps

8. People evidence - is the second most fragile type of evidence we can gather in an incident / investigation. - The primary method we use for gathering people evidence is personal interviews. - Relevant information is not restricted to the incident itself, but includes the standards and practices of the work group, the normal operating conditions and any past incidents of a similar nature. An interviewer should be able to extract useful information of that nature. - People's ability to remember details regarding a situation diminishes quickly; therefore it is imperative that witnesses are interviewed as quickly as possible. - In addition, most people are not trained observers. They tend to interpret or rationalize what they have seen and “fill in” missing gaps with assumptions or pieces of information they have heard from others associated with the incident.

9. Interviewing People Interview one individual at a time (one on one). Neutral, private setting. Depersonalize. Use open-ended questions to gather information. Use close-ended questions to confirm information. Follow; don’t lead. Listen and record; do not comment. Encourage follow-up.

10. Parts Evidence - Parts must be retrieved, labeled, and protected against damage so that analyses can be conducted. - All too often critical parts are thrown away or damaged, resulting in the loss of valuable evidence. - If a part is moved, it first should be photographed where it was found and then placed in an appropriate container. - Each part should be labeled to identify what it is and where it was found. - This also applies to material or liquid that has been spilled or discharged as a result of the incident. - It is important to be careful when handling these parts and materials, as fractured surfaces may be jagged or spilled material may be hazardous.

11. Paper Evidence - Paper evidence is the least fragile of all types of evidence. - Most paper evidence will be available for analysis several days or weeks after the incident. - Some computer evidence, such as process data, will need to be retrieved soon after an incident has occurred, as these systems often download or dump data every twenty-four hours.

13. Incident/Accident Analysis - Once all the evidence has been gathered, it can be analyzed using different models of Accident/Incident Analysis Models of Incident/Accident Analysis - Root Cause Analysis - Incident Trajectory Model

14. Root Cause Analysis

15. - Is an approach for identifying the underlying causes of why an incident occurred so that the most effective solutions can be identified and implemented. - Typically used when something goes badly, but can also be used when something goes well. Within an organization, problem solving, incident investigation and root cause analysis are all fundamentally connected by three basic questions: - What's the problem? - Why did it happen? - What will be done to prevent it?

16. Multiple Root Causes The word root, in root cause analysis refers to the causes that are beneath the surface. Most organizations mistakenly use the term "root cause" to identify the one, main cause. Focusing on a single cause can limit the solutions set, resulting in better solutions being missed. The root is the system of causes that reveals all of the different options for solutions.

17. Simple Example Worker falls off ladder Ladder Absence of Inspection Absence of training Misinformed Employee Worker Lacking Operational Readiness or Physical Strength Prevention: - mandatory physical training - more regular inspections - proper distribution of hazards – related information - clear definition of responsibilities

18. References - Incident/ Accident Investigation and Root Cause Analysis NPC Training Program Student Handout by Ron Rosser and Mike Breward - Think Reliability - Root Cause Analysis http://www.thinkreliability.com/Root-Cause-Analysis-CM-Basics.aspxhttp://www.thinkreliability.com/Root-Cause-Analysis-CM-Basics.aspx -http://www.osha.gov/SLTC/etools/safetyhealth/mod4_factsheets_accinvest. htmlhttp://www.osha.gov/SLTC/etools/safetyhealth/mod4_factsheets_accinvest. html