Incident Investigation (2020)
Incident Investigation (2020)
Incident Investigation (2020)
Investigation
Reece Chahal HSE Manager
What Will Be Covered
Module 1
Introduction
Major Incidents
Employers' Duties
Employees' Duties
In Practice
What Should be Investigated
What Will an Investigation Achieve
Cultural Aspects
Investigation Process
Introduction
Investigation of workplace accidents and incidents is an
essential part of the proactive management of health and safety.
Undertaking investigations of both those accidents that result in
injury or death, as well as near misses, in a systematic and
organised way will benefit any organisation. Analysis of
accurate information about previous accidents and near misses
helps to prevent them recurring.
Major Industrial Accidents
Major Industrial Accidents
December 3, 1984: The Bhopal disaster in India is one of the largest
industrial disasters on record. Estimates of the death toll range from 3700
to 16,000.
January 30, 2000: Romania Baia Mare cyanide spill,100,000 tons was a
released into the rivers Although no human fatalities were reported, the leak
killed up to 80 percent of aquatic life in some of the affected rivers.
• Falls
• Electrocution
• Crush injuries
• Caught-between injuries
• Crane collapse
• Fires
• Asbestos, ionising radiation, and cancer-causing chemicals
• Slips and trips
• Exhaustion
• Heat strokes
What is an Incident
An incident is an unplanned sequence of events that includes:
• All Accidents
• All Near misses
• Dangerous occurrences
• Occupational Diseases
Therefor all accidents are incidents but not all incidents are
accidents
• Lifting equipment
• Pressure systems
• Overhead electric lines
• Collapse of scaffolding
• Explosions
Unsafe Act/Unsafe Condition
Unsafe
Unsafe
act
condition
Potential Incident
Unsafe Act/Unsafe Condition
Most Health and Safety Management Systems imply that investigating the
causes of workplace incidents is considered an essential part of good
health and safety management, and of the risk assessment review
process. It forms the “check” part of the Plan, Do, Check, Act approach in
the HSE’s HSG65 Managing for Health and Safety
Explicit Legal Requirements
Client requirements
Employees' Duties
• dangerous occurrences
• near misses
• incidents whether or not they resulted in injury, damage or
disease.
Gathering information.
Analysing information.
Identifying risk control measures.
Producing and implementing an action plan.
Annalise
Immediate Plan the Collect Organize Recommend Report
Action Investigation Information Information Information Solutions Outcomes
Accident
Investigation
Module 2
Incident
Investigation
Module 2
Accident Investigation
Policy/Procedure
Immediate Action
Who Should Investigate an incident
Planning the Investigation
Checklist for Accident Investigation
Evidence Collection
Accident Investigation Policy/Procedure
• Who to notify
• Investigation Depth.
• Investigation Team:
Level Of Investigation
What Should be Investigated
Electrician
Scaffold Inspectors
Confined Space
Fire Specialist
Doctors
Etc
Immediate Action
When appointed to undertake the investigation of an incident
dependent of the severity of the incident it will be necessary
to take some immediate action. If the incident has just
occurred, it is important to go immediately to the incident
scene to consider:
names
scene
sighted
• Camera equipment
• Tape recorder
• Tape Measure
• High visibility tape
• Scissors
• Scotch Tape
• Sample Container
• PPE
• First Aid
• Gloves
• Large Envelopes
• Report forms
• Graph paper
Incident Site
Problem
or Issue
Incident
or
or
or or
Broke
bad Incide
Lost Felt n Heavy traffic
Too ill weathe nt
keys sick down
r
Alarm Alarm
Late Late
not set fails
visitor film
Lost Wrong
interes setting
t s
Collect Information
Need to consider:
Incident Trends
HSE reports.
Collect Information
Record the scene
Napoleon Bonaparte once said: A picture is worth a thousand
words. Photographs are one of the most useful investigation
tools. Taking photos can eliminate the need for lengthy
written descriptions. Photographs can assist the
investigation by providing a permeant record of:
Processes
Environment
Management systems
Plant and equipment
People
Risk assessments
TBT
Training records
Induction records
Pre Start Briefing records
Procurement Process
Method statements
SOPs
HSE Plan
Env Plan
Remember you won't get
rid of the weeds by just
concentration on the foliage
we need to get to the roots
Accident
Investigation
Module 3
Accident Investigation
Module 3
Recording
Interviews Witnesses Statements
Organise
Information
Write the
Analyse Conclusion
Report
Information
Interviews
Should be conducted separately and
as privately as possible
Should be held as soon as is
practicable after the event being
investigated
Photographs of the scene so that
witnesses can relate themselves to
the incident.
Interviewer must bear in mind that
not all witnesses will be helpful and
cooperative
Some may be hostile, and deliberately
misleading
Thosebeing interviewed may wish to
be accompanied by a colleague or
representative
Witnesses
Anyone who has seen or partly seen the
events leading up to or taking place during
the accident should be interviewed to
determine what they saw and/or heard.
E.g. did you see the staircase tread break when Mr Bob was walking
down the stairs case carrying a box.
Email Response
Notes in a diary
Formal statement
Organise Information
Organise Information
Drawn in a notebook
On a white Board
Or created using Post IT stuck on a
wall.
The event should be arranged from
left to right
Organise Information
Event
Event
Why
Why
?
?
Why Why
? ?
Answe Answe
Answe Answe
r r
r r
Write the Report
Brainstorm all the possible causes of the problem. Ask “Why does this happen
Causes can be written in several places if they relate to several categories.
Again asks “Why does this happen?” about each cause. Write sub-causes
branching off the cause branches.
Continues to ask “Why?” and generate deeper levels of causes and continue
organizing them under related causes or categories.
Event Tree Analyses
(Application)
The Event Tree analysis method is
used to analyse event sequences
following after an initiating event.
or
or
or or
Broke
bad Incide
Lost Felt n Heavy traffic
Too ill weath nt
keys sick down
er
or or
Alarm Alarm
Late Late
not set fails
visitor film
Lost Wrong
interes setting
t s
SCAT(Systematic Cause
Analysis Technique)
Direct Cause is a substandard act or substandard conditions that
triggered the Event.
Inspection not performed by new employee
Failure to secure lift
Safety valve is broken
The Basic Causes include personal and job or system factors that
together made it possible for the Direct Cause to occur. Examples
are:
Maintenance department understaffed
High workload
Wear and Tear
A Lack of Control factor can be inadequate program standards or
compliance to standards that cause the Basic Causes to occur.
Examples are:
Inadequate leadership
No task or risk assessments
Lack of training
Incident Investigation Process