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1. Objectives  Describe the responsibilities and procedures for reporting and investigating ◦ incidents / near-miss incidents ◦ spills, releases, ◦ injuries,

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Presentation on theme: "1. Objectives  Describe the responsibilities and procedures for reporting and investigating ◦ incidents / near-miss incidents ◦ spills, releases, ◦ injuries,"— Presentation transcript:

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2 Objectives  Describe the responsibilities and procedures for reporting and investigating ◦ incidents / near-miss incidents ◦ spills, releases, ◦ injuries, occupational illnesses, ◦ equipment or property damage, ◦ transportation incidents, ◦ fires or explosions ◦ security issues 2

3 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. 3

4 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. 4

5 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 5

6 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. 6

7 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. 7

8 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. 8

9 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. 9

10 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. 10

11 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. 11

12 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: 1.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. 12

13 Preparation for investigation 2.ASSEMBLE AN INVESTIGATION KIT. ◦ This kit may include a camera, paper/pens, reporting forms and any information such as notes on investigation. 3.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.  13

14 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. ◦ Sketch ing the accident scene –  Will provide information that a photo will not. 14

15 Doing the investigation: ◦ Writing notes –  Notes should be written as soon as possible while information is fresh.  Notes, emails, communications should be initiated as soon as possible by personnel involved in the incident  Consider who, what, when, where, how and why. 15

16 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. 16

17 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. 17

18 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. 18

19 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. 19

20 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. 20


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