1. Avoiding Incident Investigation Pitfalls Pursue the Right Trail Presented by: Wally Cook P. Eng. CRSP CHSMSA President – Kestrel Resources Ltd.

2. What Frustrates you About Incident Investigations?  Repeat incidents?  Poor analysis?  Lack of commitment to action?  Fear of reprisal?  Apathy?

3. Do Investigations Make You Feel……?

4. Let’s Look at Incident Investigation …….  Process  Pitfalls  Pointers

5. The Investigative Process  Reporting  Data gathering  Analysis  Recommendations  Corrective actions  Follow-up

6. Reporting Gaps  Lack of reporting  Late reporting  Incomplete information Possible Causes  Didn’t know I needed to report  Didn’t seem important  Too busy to complete information - production pressure  Pushback – retribution, job security  Afraid of medical treatment  “Red tape” involved with forms – too complicated

7. Solutions to Reporting Gaps  Explain the “what and why” to all personnel  Orientations  Feedback on actual reports  Streamline reporting  Give timely feedback on actual reports  Push back on the push back mechanisms

8. Data Gathering Gaps  Information inaccessible  Site already cleaned up  Witness went home to Newfoundland  Witnesses hesitant to provide information  No interviews, using witness statements only  Hearsay vs. facts Possible Causes  Inadequate site securement  Misunderstanding of data required  Improper scene management  Witness perceptions - blame agenda  Easier to review statements than speak to witnesses  Time requirement  Comfort with conducting an interview  Poor interview technique

9. Solutions to Data Gathering Gaps  Clear incident response roles and responsibilities – line vs. “safety guy”  Assign scene commander/lead investigator  Identify data sources early – scene, witnesses and relevant documents  Formal training - incident data preservation, interviewing etc.  Clearly communicate purpose of investigation to interviewees  Always seek witness interviews in addition to written statements  Separate fact from opinion

10. Analysis Gap  Corporate policy – We only do immediate cause analysis on low risk events  95% of incidents rated low risk  Mars vs. Venus risk perception  Focus on human (victim) behavior  Can’t find a cause in the pull down menus  Lack of detail – cause type vs. actual cause Possible Causes  Corporate commitment  Rating based on actual loss not loss potential  Task familiarity - perception that risk is lower than actual  Single individual defines risk of event  Easier to focus on injured rather than system issues  Model limitations or restrictions

11. Solutions to Analysis Gaps  Develop investigator skills  Critical thinking  Interviewing  Writing  Tune investigation model  Don’t be a slave to the model  Risk rate based on loss potential  Use an investigation team

12. Recommendations Gap  Corporate culture  They’ll never buy that!  Saying that would be career limiting  Difficulty speaking truth to power  Suggesting what is easy to fix  Favorite recommendation(s)  Recommendations don’t relate to identified causes  Need to get an answer to company or client ASAP Possible Causes  Corporation has no interest in learning or improvement  Investigators afraid or unable to speak to management  Interest in closing out a file promptly  Poor use of process – training, attention to detail etc.  Unrealistic expectations – corporate or client contract documents

13. Solutions to Recommendation Gaps  Confirm corporate culture  Line management needs to own the process  Willingness to learn from mistakes  Commitment to continuous improvement  Learn to speak to management  Engage management on the investigative team  Align recommendations to causes  “Acid test” recommendations  Manage final reporting expectations

14. Corrective Actions Gap  Actions do not actually address the causes  Corrective actions vague Possible Causes  Easier to “do something” than address the issue  Filling out a CAR keeps the corporation happy  Inadequate oversight of suggested corrective actions  Easy to sign-off on a non- specific action

15. Solutions to Corrective Action Gaps  Quality Assurance  Design and use an effective review process  Seek specific details in CARs  Discuss improvements

16. Follow-up Gap  Actions not completed  Action completed, problem still remains Possible Causes  Undefined progress and completion times  Actions not assigned to specific individuals  Cause analysis inadequate

17. Solutions to Follow-up Gaps  Set corrective action completion targets  Ask  Are corrective actions completed? AND  Did actions resolve the issue? AND  What “baggage” is attached to the action?  Re-analyze if action did not solve problem  Address the “baggage”

18. What are the Root Factors Behind These Pitfalls and Traps?

19. Key Target Areas – Effective Investigations  Enhance corporate culture  Tune investigation tools  Realign software packages  Invest in skills for investigators  Engage management  Quality-check investigation results  Follow-up  Did we do what we said we’d do?  Did it resolve the problem?  What “baggage” comes with the action?

20. Wally Cook P. Eng. CRSP CHSMSA President – Kestrel Resources Ltd. wcook@kestrelresources.com 1.780.720.1954