Transcript Knocking out the term “accident” from webcare

Accident Investigation –
Key Concepts
Dr Stephen Peckitt
Head of H&S CEMEA
Bovis Lend Lease
Content
 Meanings & Paradigms
 Accident causation
theories
 What is an investigation
and why do it?
 Interviewing witnesses
 Analytical Methods
 Case study
Incident Investigations – Key Concepts
Meanings & Paradigms
What does the word accident mean?
1)
2)
3)
A worker drops his hammer whilst working on a roof. The
hammer falls off the roof (under gravity (E)) and hits (IB):
a person on the head (V) and cracks their skull
a car (P) denting the roof
the path next to the person
Accident as a simple equation –
E + IB + V = Injury (+/-P)
E + IB +/- P = Near Miss
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E = Energy - electricity, gravity, heat, mechanical, virus, wind, etc.
IB = Inadequate Barrier – physical guard to protect against energy
emission or provide personal protection, distance, time,..
V = Victim P = Property
Are these accidents?
Incident Investigations – Key Concepts
Meanings & Paradigms
Definitions of Accidents:

specific, unidentifiable, unexpected, unusual and
unintended external action which occurs in a particular
time and place, with no apparent and deliberate cause
but with marked effects (Wikipedia, 2010).

unplanned loss events which result in physical harm to
people or property or the environment (Ridley, 1990)

unplanned damage incidents.
Incident Investigations – Key Concepts
Meanings & Paradigms
Causation

What causes accidents?


bad luck, carelessness, risk taking, failure of management
processes, natural products of the very complex world we live in,
etc.
Four general accident causation paradigms:

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Fatalist – acts of god, destiny or bad luck,
Individualistic – carelessness, risk taking and rule breaking
Modernist – accidents are inevitable and unimportant byproducts of industrial age, and
Postmodernist – accidents are failures to manage risk.
Incident Investigations – Key Concepts
Meanings & Paradigms
Blame

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Accident victims often blame themselves; while managers are quick to
blame the victim or immediate supervisor, and are reluctant to place
any blame on themselves for accidents.
It is a form of denial, a self-protective mechanism and a way of
simplifying a complex phenomena. It is a deep rooted human
psychological characteristic known as fundamental attribution error.

We need to keep the blame bias out of investigations in order to get at
the facts and identify the root causes of incidents

Only apportion blame where it is clearly proven to be due, eg for
sabotage and violations.
Incident Investigations – Key Concepts
Meanings & Paradigms
Incident v Accident
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Risk management experts generally avoid use of the term 'accident' to
describe events that cause injury and loss to highlight the predictable
and preventable nature of most damage incidents.
The term incident is preferred as it implies a generally negative
probabilistic outcome which may have been avoided or prevented had
circumstances leading up to the accident been recognized, and acted
upon, prior to its occurrence.
Such incidents are viewed from the perspective of epidemiology, (i.e
they are predictable and preventable). Preferred words are more
descriptive of the event itself or severity of the damage, rather than of
its unintended nature (e.g. drowning, fall, first aid, lost time, major,
fatal, catastrophic, major and minor damage, etc.)
Source: Wikipedia
Incident Investigations – Key Concepts
Causation Theories

Domino – Heinrich, Bird & Loftus

Human Error – HSE, Rassmussen

Swiss Cheese Model – Reason
Incident Investigations – Key Concepts
Heinrich’s Domino Theory
Unsafe Acts and Unsafe Conditions Paradigm


Herbert Heinrich is credited with the first accident causation theory. He
analysed 12,000 accident insurance claims and over 50,000 injury reports
in the 1930s, and identified unsafe acts by workers as the primary cause
of 88% of accidents.
Heinrich developed a domino theory of accident causation where a single
sequence of events results in an accident:
 the first domino is concerned with the accident victim’s personal
traits;
 the second – victims actions;
 the third - unsafe acts and conditions;
 the fourth - the accident;
 the fifth - the injury.
Incident Investigations – Key Concepts
Loss Control Domino Models
Incident Investigations – Key Concepts
HUMAN ERROR – To Err is human
We all make mistekas
Slips & Lapses Skill based
Errors
Human
failure
Mistakes
Rule-based
Knowledge
based
Routine
Violations
Exceptional
Situational
HSE 1999
Incident Investigations – Key Concepts
Prof. James Reason


Rather than being the main instigators of an
accident, operators tend to be the inheritors of
system defects created by poor design, incorrect
installation, faulty maintenance and bad
management decisions.
Their part is usually that of adding the final
garnish to the lethal brew using ingredients that
have already been long in the cooking.

Reason (1990) p173.
Incident Investigations – Key Concepts
Reason’s Swiss Cheese Model
Latent Pathogens
Errors made at
business planning
stage
Errors made during
task planning
Active
failures
Active Errors at the
workface – lapse,
mistake, short cuts
INCIDENTS
Incident Investigations – Key Concepts
Key concepts from causation
theories

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Incident causation is a complex dynamic process, not a
simple linear process.
Everyone makes mistakes so activities and equipment
need to be designed to take account of human error.
The negative impact of incidents and injuries is wider
than the victim – includes their family, worker morale,
production, profitability, and both personal and corporate
reputation (BP, Toyota!).
Employers and those who control activities have a duty of
care towards workers and others who may be impacted
by their activities, so must ensure they effectively
manage the risks involved in their undertaking to prevent
incidents occurring.
Incident Investigations – Key Concepts
Why Investigate Incidents?
An investigation is a systematic and thorough attempt to learn the facts
about something complex or hidden; an inquiry to ascertain facts based
on the detailed and careful examination of evidence.
There are four main reasons for investigating accidents:
 Identify causes – immediate and underlying;
 Assess weaknesses - legal compliance and risk management;
 Define remedial actions - corrective & preventative;
 Share lessons learnt – prevent similar incidents occurring by
encouraging learning, change and improved risk management.
The focus and depth of the investigation will vary depending on the role
and expertise of those undertaking the investigation.
The ultimate goal is to prevent similar events occurring again!
Incident Investigations – Key Concepts
What Incidents should be
Investigated?


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Fatal Incidents
Major Injury Incidents
Legally Reportable Incidents - > 3 day
Lost Time Injury Incidents
First Aid Injury Incidents
Near Misses – no injury
Incident Investigations – Key Concepts
The Injury Pyramid – where to
focus our efforts?
Injury statistics
are commonly
the sole focus
of safety
initiatives
Fatal
Major injury
Become reality here in
the form of damage to
people, property and
the environment…
Lost time injury
First aid injury
To prevent
incidents we
need to focus
on making the
right decisions
Near miss / near hit
At risk behaviour & unsafe conditions
Unsafe decisions & choices
What you
permit to
happen here…
bad practice,
poor decisions,
unsafe acts &
conditions
Incident Investigations – Key Concepts
Who should be involved?
Dictated by severity of incident, speed of investigation,
technical complexity, processes, etc.

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Investigation Team – number of people, skills, experience,
availability, consultants, police, lawyers;
Timing - ASAP to examine and record scene, collect witness
details and statements, consider wider implications,
reporting timescales;
Reporting – to who, by when, what format, regular
updates, legal privilege;
Management – who, roles and responsibilities
Review – factually correct, technical issues, lessons learnt;
Implementation of remedial measures – by who and when,
tracking and verification;
Incident Investigations – Key Concepts
Investigations - Common Errors

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Stating the apparent, immediate cause rather than the root cause.
 Slip on oil spot on floor.
Cause is related to outcome rather than the incident itself.
 Chemical leak spray in face - “employee not using face shield”
Stopping investigation too soon not going far enough.
 Facility equipment failure
 “Be more careful”
Blaming the victim
 Operator was attempting to pick up parts that were on floor
while not leaving their stool
It is easy and quick to identify the immediate causes but to get to
underlying causes to really understand how an incident occurs and
how to prevent a repeat – we need to get deeper into the chain of
events which ended in the injury.
Incident Investigations – Key Concepts
Importance of Analytical Approach to
Investigations

Avoid investigators’ personal assumptions

Logical approach to gathering evidence

Co-ordinate investigation activities

Identify Root Causes

Verify findings

Clearly communicate findings

Implement actions taken to prevent future incidents
Incident Investigations – Key Concepts
Evidence Gathering
•
•
•
•
•
•
•
Gather the known facts about the incident to understand
the nature, scale, technical complexity, etc.
Allocate appropriate resources to conduct investigation.
Collect physical evidence at the scene.
Identify witnesses and the organisations involved.
Conduct interviews to establish:
• Who, What, Where, When, Why & How
• Keep probing for more information with open questions.
• Clarify understanding of the key issues with interviewees
Don’t jump to conclusions and recommendations too quickly
Go back and collect more evidence and statements if
needed
Incident Investigations – Key Concepts
Evidence Gathering

Physical Evidence

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
Interviewing People

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take pictures, copies of documents, measurements,
drawings, etc.
take possession of items for detailed examination or
evidence for legal case
obtain expert analysis of equipment
Informal - information gathering
Formal - statement taking
Chain of evidence

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Give receipts for all physical evidence obtained
All statements should be signed
Keep secure where they cannot be tampered with
Incident Investigations – Key Concepts
Evidence Gathering –
Investigator's Tools

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Personal Protective Equipment
Digital Camera
Logbook
Statement forms
Evidence bags & tags
Tape measure
Spare batteries, pens, SD card, etc
Video recorder
Incident Investigations – Key Concepts
Who to Interview?

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Injured Person
Witnesses of the incident
Witnesses Pre-Accident
Witnesses Post-Accident
Supervisors
Managers
Maintenance, Housekeeping,
Engineering, Purchasing……...
Incident Investigations – Key Concepts
Interviewing Techniques
An interview is a structured conversation with a
purpose – to establish facts.
 Respect
 Empathy
Developing a rapport
with the witness
 Supportive
is crucial to
 Positive
effective interviewing
 Open
 Non-Judgemental
 Straight forward
 Equal
Incident Investigations – Key Concepts
Interviewing Techniques

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Put person at ease - Assure “no blame”
Listen carefully
Repeat the story back and check understanding
Be polite and thank the witness
Questions should be:

Clear - short and simple using easily
understood language, one point at a time

Logical - follow lines of enquiry, ask only
relevant questions

Polite but firm tone – establish status
Interview Techniques –
Key Information

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Personal details;
Confirm employer, profession and role;
What they were doing at the time of the
incident;
What relevant information they remember:

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Use open questions about what they saw
happen?, where they were?, who was
involved?, what they did, etc.
Probe issues of concern for clarity or to
check validity and compare with other
evidence;
Use closed questions to confirm specific
details
Witness signature and date
Avoid using

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Leading & Hypothetical questions
Statements
Incident Investigations – Key Concepts
Interview Techniques
FUNNELLING
General Open Question
leads to an account of
several smaller sections
Specific Open Questions
to focus on specific
areas of the account
Journey to
work
At home
Day at
work
Journey
home
Open
Questions
Open
Questions
Use 5 Whys
probe every
key issue
Closed
Questions
LINK
clear-up
issues or
close out
line of
enquiry
Closed
Questions
Closed
Questions
LINK
Process is
repeated
for every
section
Process is
repeated
for every section
LINK
Process is
repeated
for every
section
Incident Investigations – Key Concepts
Interviewing Techniques
Questions & Perceptions
Incident Investigations – Key Concepts
Interviewing Techniques
Cognitive Interviewing
Memory is selective and stored in isolated fragments
which fade and become influenced by attitudes and
beliefs. Cognitive interview techniques can help
increase memory recall by 10%.
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Free recall – ask the witness to recall everything
they can remember – don’t question
Mental reconstruction – describe the scene by
describing everything they felt and saw
Reorder recall – question issues in different order
Different perspective – ask how other witnesses may
have perceived the incident
Focus on specifics - conversations, reactions, noises,
numbers, smells, etc.
Incident Investigations – Key Concepts
Interview Tips

Actively listen - concentrate, comprehend and sustain

Encouraging cues – open posture, eye contact, nod head, open hand
gestures, “uh huh”

Pauses and silence - encourage responses

Echoing – repeating witness phrases to prompt further elaboration;

Summarise regularly - to keep focus, revisit issues if necessary and agree
statements

Avoid misleading the witness – do not use leading questions, and opinion

Observe Body Language – deception indicated by, shuffling feet and
crossing legs, touching face and licking lips, drumming and gripping,
blushing and perspiring.
Incident Investigations – Key Concepts
Interviewing Techniques
Formal Statement Taking
P
E
A
C
E
Plan & Prepare
Engage & Explain
Account
Closure
Evaluate
Incident Investigations – Key Concepts
INTERVIEWING Techniques
P - Plan & Prepare
Venue – Your place or theirs?
Timing – Too soon, too late?
Witness Support – accompanied?
Agenda – what do you need?
Prepare key questions
Physical evidence verification
E - Engage &
Explain
Introductions - reason for interview,
their role, subsequent actions
Explain format of interview
Any questions before starting?
A - Account
Their account of what they witnessed
Introduce evidence
Ensure key questions answered
Go back to issues which need clarifying
Incident Investigations – Key Concepts
INTERVIEWING WITNESSES
C - Closure
E - Evaluation
Check understanding of key issues
Go through statement to agree content
Witness to sign any changes and at end of
statement
Give them a copy
Ask if they have any questions?
Clarify what happens next
Thank them for their cooperation
What have you learned?
How does this fit with other evidence?
Anything missing – to follow up?
How did you perform?
Next actions
Incident Investigations – Key Concepts
Interview Techniques Summary
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Conduct the interview as soon after the incident as possible.
Create a relaxed atmosphere, avoid blame, get all sides and
request ideas for prevention.
Keep the interview private to avoid group biases.
Focus on establishing facts, avoid irrelevancies, assumptions,
and smoke screens.
Ask open-ended non-leading questions to explore lines of
enquiry.
Listen, test understanding and validate key evidence with
closed questions.
Repeat the story back, probe into all aspects of the nonconformance or accident, get all sides of the story.
Incident Investigations – Key Concepts
Examples of Analytical Methods
Root Causes Analysis

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Fishbone
5 Whys
Decision / Event Trees
Management Oversight Risk Tree
Incident Investigations – Key Concepts
Fishbone Diagram
Problem

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People
Methods
Environment
Equipment
Roots
Tool for systematic review of cause and effects.
Assists in categorizing many potential causes of problems in
orderly way.
Start with categories – people, methods, environment,
equipment, etc.
Review causes within each category.
Incident Investigations – Key Concepts
Example Flow/Decision Tree
WAS THE HAZARDOUS
YES
CONDITION(S) OF EQUIPM ENT
NO
A CONTRIBUTION FACTOR?
POSSIBLE CORRECTIVE ACTIONS
REVIEW PROCEDURES FOR
INSPECTING, REPORTING, M AINPOSSIBLE CORRECTIVE ACTIONS
TAINING, REPAIRING, REPLACING,
REVIEW JOB PROCEDURE FOR
OR RECALLING DEFECTIVE EQUIP-
HAZARD AVOIDANCE. REVIEW
M ENT, TOOLS, OR M ATERIALS.
YES
DID ANY DEFECTS IN EQUIPM ENT,
WAS THE LOCATION/POSITION OF
TOOLS, OR M ATERIAL CONTRIBUTE
EQUIPM ENT, M ATERIAL, EM PLOYEE
TO HAZARDOUS CONDITIONS?
A CONTRIBUTING FACTOR?
NO
YES
NO
SUPERVISORY RESPONSIBILITY &
SUPERVISOR-EM PLOYEE
POSSIBLE CORRECTIVE ACTIONS
COM M UNICATIONS
YES
POSSIBLE CORRECTIVE ACTIONS
NO
WAS THE HAZARDOUS
CONDITION REPORTED?
YES
WAS THE HAZARDOUS CONDITION
DID THE LOCATION/POSITION OF
RECOGNIZED?
EQUIPM ENT, M ATERIAL, EM PLOYEE
PERFORM JOB SAFETY ANALYSIS.
YES
CAUSE HAZARDOUS CONDITION?
TRAIN EM PLOYEE IN REPORTING
NO
NO
WAS THE JOB PROCEDURE USED
REVIEW JOB PROCEDURE. CHANGE
A CONTRIBUTING FACTOR?
LOCATION/POSITION OF EQUIPM ENT
POSSIBLE CORRECTIVE ACTIONS
OR EM PLOYEE. PROVIDE GUARD
REVIEW JOB PROCEDURE FOR
PROCEDURES. STRESS INDIVIDUAL
POSSIBLE CORRECTIVE ACTIONS
ACCEPTANCE OF RESPONSIBILITY.
PERFORM JOB SAFETY ANALYSIS.
SUPERVISORY RESPONSIBILITY &
IM PROVE EM PLOYEE ABILITY TO
SUPERVISOR-EM PLOYEE
RECOGNIZE EXISTING OR
WAS THE HAZARDOUS
POTENTIAL HAZARDS.
CONDITION RECOGNIZED?
RAILS, BARRIERS, SIGNS, ETC.
WAS THE HAZARDOUS
YES
TO DETECT HAZARDOUS
NO
WAS THERE EQUIPM ENT INSPEC-
NO
CONDITIONS. CONDUCT TEST.
POSSIBLE CORRECTIVE ACTIONS
COM M UNICATIONS
NO
POSSIBLE CORRECTIVE ACTIONS
TRAIN EM PLOYEE IN REPORTING
FOR THIS JOB?
PROCEDURES. STRESS INDIVIDUAL
NO
WAS THERE A WRITTEN OR
KNOWN PROCEDURE (RULE)
DID JOB PROCEDURES ANTICIPATE
YES
WAS EM PLOYEE SUPPOSED TO BE
WAS LACK OF PPE OR EM ERGENCY
EQUIPM ENT A CONTRIBUTING
JOB PROCEDURE.
FACTOR IN THE INJURY?
NO
YES
YES
EQUIPM ENT/M ATERIAL?
NO
POSSIBLE CORRECTIVE ACTIONS
DID EM PLOYEE KNOW
INSTRUCTIONS. PROVIDE GUARD
THE JOB PROCEDURE?
NO
RAILS, BARRIERS, SIGNS, ETC.
POSSIBLE CORRECTIVE ACTIONS
IM PROVE JOB INSTRUCTION.
WAS APPROPRIATE PPE SPECIFIED
TRAIN EM PLOYEES IN CORRECT
FOR THE TASK OR JOB?
WAS APPROPRIATE PPE
YES
AVAILABLE?
NO
JOB PROCEDURE.
PROVIDE APPROPRIATE PPE.
WAS M ANAGEM ENT SYSTEM
REVIEW PURCHASING AND
A CONTRIBUTING FACTOR?
DISTRIBUTION PROCEDURES.
YES
NO
YES
YES
DID THE EXISTING EQUIPM ENT
NO
NESS. IM PROVE EM PLOYEE ABILITY
INSPECTION PROCEDURES DETECT
THE HAZARDOUS CONDITION?
WAS THE HAZARDOUS CONDITION
YES
CREATED BY LOCATION/POSITION
OF EQUIPM ENT/M ATERIAL VISIBLE?
TO DETECT DEFECT & HAZARDOUS
CONDITIONS.
POSSIBLE CORRECTIVE ACTIONS
NO
POSSIBLE CORRECTIVE ACTIONS
CHANGE LIGHTING OR LAYOUT TO
DID EM PLOYEE DEVIATE
INCREASE VISIBILITY OF EQUIPM ENT
FROM THE KNOWN JOB
PROCEDURE?
PROVIDE GUARDRAILS BARRIERS,
SIGNS, ETC.
SPECIFY CORRECT EQUIPM ENT,
YES
POSSIBLE CORRECTIVE ACTIONS
DETERM INE WHY. ENCOURAGE ALL
DID EM PLOYEE KNOW THAT
EM PLOYEES TO REPORT PROBLEM S
WEARING SPECIFIED PPE WAS
WITH ESTABLISHED PROCEDURE.
POSSIBLE CORRECTIVE ACTIONS
REVIEW JOB PROCEDURES.
WAS THERE A FAILURE BY SUPER-
IM PROVE JOB INSTRUCTION.
REQUIRED?
VISION TO DETECT, ANTICIPATE,
OR REPORT A HAZARD CONDITION?
YES
NO
NO
IM PROVE SUPERVISOR CAPABILITY
YES
PROVIDE CLOSER SUPERVISION.
REPORTING PROCEDURES.
WAS THE CORRECT
NO
EQUIPM ENT, TOOLS, OR M ATERIALS
USED?
PROCEDURES.
POSSIBLE CORRECTIVE ACTIONS
WAS THERE SUFFICIENT
WORK SPACE?
NO
YES
POSSIBLE CORRECTIVE ACTIONS
REVIEW WORK SPACE
WAS THE EM PLOYEE M ENTALLY
REQUIREM ENTS AND M ODIFY
AND PHYSICALLY CAPABLE OF
AS REQUIRED.
PERFORM ING THE JOB?
SELECTION. REM OVE OR TRANSFER
YES
OR PHYSICALLY INCAPABLE OF JOB.
NO
POSSIBLE CORRECTIVE ACTIONS
REVIEW EM PLOYEE REQUIREM ENTS
DID EM PLOYEE KNOW HOW TO USE
FOR THE JOB. IM PROVE EM PLOYEE
AND M AINTAIN THE PPE?
IM PROVE JOB INSTRUCTION.
YES
POSSIBLE CORRECTIVE ACTIONS
WAS THERE A FAILURE BY SUPERVISION TO DETECT/CORRECT DEV-
REVIEW JOB SAFETY ANALYSIS &
YES
IATION FROM JOB PROCEDURE?
CORRECT DEVIATIONS.
NO
WAS THE CORRECT
NO
CHASING SPECIFICATIONS &
EQUIPM ENT, TOOLS, OR M ATERIALS
POSSIBLE CORRECTIVE ACTIONS
READILY AVAILABLE?
WERE ENVIRONM ENTAL CONDI-
YES
(LIGHTING, NOISE, TEM P, AIR, ETC)?
PROCEDURES. ANTICIPATE
TIONS A CONTRIBUTING FACTOR
FUTURE REQUIREM ENTS.
M ONITOR OR PERIODICALLY CHECK
YES
POSSIBLE CORRECTIVE ACTIONS
WERE ANY TASK IN THE JOB
ENVIRONM ENTAL CONDITIONS AS
PROCEDURE TO DIFFICULT TO
REQUIRED. CHECK RESULTS
PERFORM (M ENTAL OR PHYSICAL)?
YES
POSSIBLE CORRECTIVE ACTIONS
CHANGE JOB DESIGN AND
WAS THE PPE USED PROPERLY
PROCEDURES.
WHEN THE INJURY OCCURRED?
NO
AGAINST ACCEPTABLE LEVELS.
INITIATE ACTION IF NEEDED.
POSSIBLE CORRECTIVE ACTIONS
REVIEW PROCEDURES FOR STORAGE, ACCESS, DELIVERY, OR DIS-
NO
NO
TRIBUTION. REVIEW JOB PROCEDTOOLS, & M ATERIALS.
YES
AGAINST USE OF SUBSTITUTES
IS THE JOB STRUCTURED TO EN-
YES
COURAGE OR REQUIRE DEVIATION
FROM JOB PROCEDURES?
CHANGE JOB DESIGN AND
YES
WAS THE PPE ADEQUATE?
ESTABLISH A PROCEDURE THAT
& JOB PROCEDURES FOR TASK
ENFORCE USE OF PPE.
INFREQUENTLY?
PERFORM ED INFREQUENTLY.
YES
REVIEW PPE REQUIREM ENTS.
NO
PROCEDURES.
WAS SUBSTITUTE EQUIPM ENT,
CONTINUED
TOOLS, OR M ATERIALS USED IN
PLACE OF THE CORRECT ONE?
ON PAGE 1
POSSIBLE CORRECTIVE ACTIONS
INSTALL EM ERGENCY
EQUIPM ENT AT APPROPRIATE
ALTER EQUIPM ENT/TOOL TO M AKE
WAS EM ERGENCY EQUIPM ENT
NO
READILY AVAILABLE?
LOCATIONS.
WAS SUPERVISOR RESPONSIBILITY
TIONS, AND CERTIFICATION
& ACCOUNTABILITY ADEQUATELY
OF THE PPE.
DEFINED AND UNDERSTOOD?
DEFINE AND COM M UNICATE
NO
ACCOUNTABILITY. TEST FOR
POSSIBLE CORRECTIVE ACTIONS
OR ENCOURAGE ERROR?
INCORPORATE USE OF
EM ERGENCY EQUIPM ENT IN
NO
POTENTIAL HAZARD CONDITIONS.
(CONTINUED FROM PAGE 2)
YES
SPECIFIED FOR THIS JOB (eg EM ERGENCY SHOWER, EYEWASH)?
NO
WAS EM ERGENCY EQUIPM ENT
POSSIBLE CORRECTIVE ACTIONS
NO
PROPERLY USED?
JOB PROCEDURES.
YES
POSSIBLE CORRECTIVE ACTIONS
REVIEW CRITERIA IN STANDARDS,
DID THE GENERAL DESIGN OR
YES
QUALITY OF THE EQUIPM ENT OR
TOOLS CAUSE HAZARD CONDITION.
UNDERSTANDABILITY AND
ACCEPTANCE.
WAS EM ERGENCY EQUIPM ENT
YES
SUPERVISOR RESPONSIBILITY &
POSSIBLE CORRECTIVE ACTIONS
NO
WAS SUPERVISOR ADEQUATELY
TRAINED TO FULFILL RESPONSIBILITY
IN ACCIDENT PREVENTION?
TRAIN SUPERVISORS IN
NO
ACCIDENT PREVENTION
FUNDAM ENTALS.
YES
POLICY AND LEVEL OF RISK ACCEPTANCE. REVIEW PROCEDURE &
YES
TOOLS CREATE OPERATOR STRESS
COURAGE EM PLOYEES TO REPORT
REQUIRES A REVIEW OF HAZARDS
POSSIBLE CORRECTIVE ACTIONS
CHECK STANDARDS, SPECIFICA-
YES
DID DESIGN OF THE EQUIPM ENT OR
YES
CAPABILITY & LIM ITATIONS. EN-
POTENTIAL HAZARD CONDITIONS.
PROCEDURE FOR TASK
POSSIBLE CORRECTIVE ACTIONS
POSSIBLE CORRECTIVE ACTIONS
M ATERIALS REQUIRED FOR JOB?
NO
JOB INSTRUCTION.
REQUIRED.
OYEE REVIEW OF HAZARDS & JOB
NO
OBTAIN EQUIPM ENT, TOOLS, OR
IN JOB PROCEDURES AND IN
ESTABLISH NEW CRITERIA AS
WAS THERE A SUPERVISOR/EM PL-
YES
POSSIBLE CORRECTIVE ACTIONS
SPECIFICATIONS, & REGULATIONS.
DETERM INE WHY AND TAKE
PROCEDURES TO M ONITOR AND
YES
POSSIBLE CORRECTIVE ACTIONS
PROVIDE CORRECT EQUIPM ENT,
M ORE COM PATIBLE WITH HUM AN
POSSIBLE CORRECTIVE ACTIONS
APPROPRIATE ACTION. IM PLEM ENT
DID EM PLOYEE KNOW WHERE TO
URES FOR OBTAINING EQUIPM ENT,
TOOLS, & M ATERIALS. WARN
JOB PROCEDURES. INCREASE
SUPERVISOR M ONITORING.
EM PLOYEES WHO ARE M ENTALLY
YES
POSSIBLE CORRECTIVE ACTIONS
PROVIDE CORRECT EQUIPM ENT,
M ATERIALS, & TOOLS. REVIEW PUR-
IN HAZARD RECOGNITION AND
COUNSEL OR DISCIPLINE EM PLOYEE.
YES
POSSIBLE CORRECTIVE ACTIONS
TOOLS, & M ATERIALS IN JOB
PERFORM JOB SAFETY
ANALYSIS AND CHANGE
YES
REVIEW JOB PROCEDURES &
YES
REVIEW PROCEDURES. CHANGE
NO
TO THE ACCIDENT?
POSSIBLE CORRECTIVE ACTIONS
THE HAZARDOUS CONDITION?
POSSIBLE CORRECTIVE ACTIONS
THE FACTORS THAT CONTRIBUTED
ACCEPTANCE OF RESPONSIBILITY.
TION PROCEDURES TO DETECT
IN THE VICINITY OF THE
FREQUENCY OR COM PREHENSIVE-
(CONTINUED FROM PAGE 1)
YES
YES
CONDITION REPORTED?
M ENT, TOOLS, OR M ATERIALS.
POSSIBLE CORRECTIVE ACTIONS
DEVELOP & ADOPT PROCEDURES
HAZARD AVOIDANCE. REVIEW
(CONTINUED PAGE 2)
NO
POSSIBLE CORRECTIVE ACTIONS
PROVIDE EM ERGENCY
WAS THERE A FAILURE TO INITIATE
EQUIPM ENT AS REQUIRED?
CORRECTIVE ACTION FOR A KNOWN
HAZARDOUS CONDITION?
REVIEW M ANAGEM ENT SAFETY
RESPONSIBILITY TO CARRY OUT
CORRECTIVE ACTIONS.
POSSIBLE CORRECTIVE ACTIONS
ESTABLISH INSPECTION/M ONITORING SYSTEM FOR EM ERGENCY
EQUIPM ENT. PROVIDE FOR
IM M EDIATE REPAIR OF DEFECTS.
DID EM ERGENCY EQUIPM ENT
NO
FUNCTION PROPERLY?
Incident Investigations – Key Concepts
Event analysis trees


Management
Oversight
and Risk Tree logical, structured,
generic fault tree
based on equation
E+V+IB = Incident
Aims to identify and prevent - management
errors, control risks and optimise performance
Incident Investigations – Key Concepts
“5 Whys” Cause & Effect Analysis
Why?


Why?


A ‘5 Why’ analysis is a simple method which adds Why?
discipline to the incident investigation based on asking
“why” something occurred and answering with
“because” then repeating this up to five times
It ensures that the key relevant contributory factors
are fully considered and analysed.
Why?
It focuses on gaining a deep understanding of why an
incident occurred by analysing critical factors
It facilitates the identification of the root causes of an
incident
It facilitates the creation of remedial action plans
which focus on preventing the root causes occurring
again.
Why?
Incident Investigations – Key Concepts
Cause & Effect Analysis – “5 Whys”
•
The 5 Why’s analysis leads to a comprehensive
picture of the potential contributing factors of an
incident and ultimately their root causes
Root
Causes
Immediate
Causes
Incident
Why?
Why?
Irrelevant
Why?
Why?
Why?
Incident Investigations – Key Concepts
RCA findings from UK Govt Study of
construction fatal accidents (2009)
Equipment
Competence
Leadership
Planning
Supervision
Incident Investigations – Key Concepts
RCA
INVESTIGATION
PROCESS
Incident
Emergency Response:
Rescue, Treat, Make Safe, Preserve, Record
Phase 1
Phase 2
Gather the key information
Who, What, Where, When, Why
Analyse and identify the immediate
critical factors
Phase 3
Analyse and Identify underlying causes
and root cause of each critical factor
Phase 4
Validate findings, lessons learnt, and
corrective and preventative measures
Phase 5
Complete investigation report
Phase 6
All injury incidents
and near misses
should be
investigated to
determine 5 Ws
Close out investigation report by
validating implementation of improved
risk control measures.
Conduct Root Cause
Analysis for fatal and
major accidents,
major environmental
or property damage
and high potential
near miss incidents
LESSONS LEARNT
CORPORATE MEMORY
Incident Investigations – Key Concepts
Emergency Response:

Rescue and Treat Injured Persons

Make Safe

Preserve Scene – secure evidence

Record - witness details, etc.
Incident Investigations – Key Concepts
Evidence gathering
4Ps
When gathering evidence
it is useful to remember the 4Ps.
• Ensure that all relevant people
have been identified and
interviewed
Phase 1
People
• Review the equipment and parts
of machinery which may have been
involved
• Consider the positions of people
and equipment at the time of the
incident
• Examine and collect copies of
relevant documents
Positions
Who
What
Where
When
Why
Parts
Paper
Incident Investigations – Key Concepts
Evidence gathering - Phase 1
People
Parts
Who was injured, suffered ill health or was otherwise involved
What injury, ill health or damage was caused?
Who witnessed the incident?
Who was in charge of supervising the work?
What other people and organisations were involved?
Were any of the following involved - Plant / Equipment / Machinery
/ Tools / Equipment / Materials / PPE.
How was it being used and was it in good working order?
What activity was being carried out and was there anything
unusual in the work environment?
Were the shape / nature of the materials, etc., relevant to the
accident / incident?
Was difficulty / unfamiliarity in using the plant, etc. a contributory
factor?
Was safety equipment adequate?
Incident Investigations – Key Concepts
Evidence gathering - Phase 1
Positions
Paper
Where and when did the incident occur?
Was the immediate environment safe?
The position of all parties (injured party(s) / witnesses), any
machinery, materials, barriers, signs, protections, tools &
equipment are to be considered
Was there anything unusual about the working conditions?
Were maintenance, workplace layout or housekeeping relevant
factors?
Paper evidence includes all relevant documentation, e.g. risk
assessment and risk register / safety method statements / H&S
plans / drawings / instructions / permits / certification (test,
examination, training) / licenses / induction & toolbox talk
registers.
Was the method for completing task detailed in a written plan?
Are there records of inspections, training, etc.
What are the organisation’s processes and systems?
Incident Investigations – Key Concepts
Evidence gathering - Phase 1 Culture
Assess the impact of company culture:
- the way things are
done around here
- interplay of people,
systems, technology,
and power
- eg rule breaking, short cuts,
command and control
Culture
Incident Investigations – Key Concepts
When is Root Causes Analysis
required?



After fatal & major injury incidents
Other incidents, including near misses where
circumstances could have resulted in a fatal or
majory injury – eg falls from height above 2 metres
To be completed with 4 weeks (where possible).
Incident Investigations – Key Concepts
Investigation and RCA summary








Establish Investigation Teams – number, skills, etc.
Collect Evidence - 4 Ps + statement taking
Establish the time line and immediate causes of the
incident,
Identify the critical factors (ie which if eliminated would
prevent the incident) in the time line
Identify the underlying causes of each critical factor
using Why/Because analysis (5 Whys)
Label the key cause of each factor using the underlying
factors terminology
Identify key Corrective & Preventative actions
Identify the Lessons Learnt which need to be
communicated and implemented
Incident Investigations – Key Concepts
RCA Terminology
Immediate causes
• Actions – acts directly contributing to the incident
• Conditions – environmental/operational factors directly contributing to
the incident
• Critical Factor – an immediate cause which if taken away would have
prevented the incident
Underlying causes
• Job Factors – how the task was planned and executed
• Organisational Factors – effectiveness of policies and systems
• Personnel Factors – attitudes, competencies, personality, perceptions
ROOT CAUSES – the factors at the end of the causal chain for each
critical factor – the causes which need to be addressed
to prevent reoccurrence.
Incident Investigations – Key Concepts
Phase 2 – Analyse the information
1) Sift through all the evidence gathered to establish the facts.
- John had tip of finger amputated by v belt on compressor in paint
shop which was not guarded
2) Identify the IMMEDIATE CAUSES:
Conditions: (operating / environmental conditions)
- the air compressor was running.
Actions: (what people did immediately prior to the incident occurring)
- John’s hand slipped off the side of the machine and onto the drive
belt
3) Establish a ‘timeline’ of single, irreducible facts that describe the
key actions and conditions working backwards from the incident.
Incident Investigations – Key Concepts
Phase 2 – Analyse the information –
Timeline and Critical Factors
Establish a time line from
immediate causes backwards.
Then identify the ‘CRITICAL
FACTORS’, i.e. those factors in
the ‘timeline’ or sequence of
events leading up to the incident,
that had they not been present the
sequence of events would have
been broken and the accident /
incident would not have occurred
or at least its severity reduced.
As a guide the number of critical factors
identified for any incident should range from five
to ten
Critical Factors

The compressor was running

John was maintaining the compressor

The guard was missing to the “v”belt pulley
drive
Incident Investigations – Key Concepts
Immediate Causes
Actions
1 - Work at height (inc Access)
2 – Lifting (Manual or
mechanical)
3 – Use of safety devices and
equipment
4 – Use of tools, equipment,
plant and machines
5 – Use of PPE
6 – Method of work
7 – Communications
8 – Operator error
9 – Violation
10 – Horse play
11- other (specify)
Conditions
1 – Open / Exposed edge (ext., Int.,
platform, etc.)
2 – Guards, protective devices or
equipment
3 – Housekeeping
4 – Tools, equipment, plant
5 – Vehicle movements
6 – Lifting and Slinging
7 – Live systems or equipment (electrical /
mechanical)
8 – Exposure to chemicals, noise,
vibration, etc.
9 – Environment (heat, cold, ventilation,
weather, etc.)
10 – Structural failure
11 – Communications - instructions, signs,
barriers and warnings
Incident Investigations – Key Concepts
Phase 3 - Identify the Underlying
causes for each Critical Factor
For each Critical Factor – identify:
 Underlying Causes - the factors that resulted in or
allowed the immediate cause of each critical factor to exist
 Root Causes - the last factor identified in the causal
chain of each critical factor
By
 Examining each critical factor using the “why and
“because” question and answer technique.
 Asking “why” and “because” between 3 and 5 times to
identify the underlying causes.
 Choose the most relevant factor from the factors detailed
in the RCA topic headings which best describes the root
cause identified.
Critical Factors –
5 Whys Analysis

The compressor was running –
-

…… because
John was examining the compressor
-

Being used for spraying operation
Supervisor said do not switch off
Part of finishing an urgent order
Focus on production
why?
Supervisor asked him to look at it because it was not operating correctly
Not maintained and inspected regularly
Manager not aware of need for regular maintenance
New to role and not experienced
Inadequate training and instructions
The guard was missing to the “v”belt pulley drive
-
Removed and not replaced over a year ago when belt was replaced
Person who did it was not trained in safe maintenance operations
No formal machinery maintenance or safety systems in place
Incident Investigations – Key Concepts
Underlying Causes of Incidents:
Job Factors
1)
2)
3)
4)
5)
6)
7)
8)
Risk assessment and safe method of work (done,
adequate, appropriate, checked, etc.).
Task planning (complies with RA and SMW, adequate
resources, buy in, communication, etc.).
Supervision (numbers, communication, competence,
control, etc.).
Communications (shift hand over, changes, toolbox talks
language, induction, etc.).
Provision & maintenance of plant, tools, equipment.
Management of hazardous materials and emergency
response.
Maintenance of safe work environment (noise, layout,
interfaces, atmosphere, etc.).
Compliance (Law, procedures, permits, etc.).
Incident Investigations – Key Concepts
Underlying Causes of Incidents:
Organisation Factors
1 – Contractor management (selection,
standard setting, liaison,
monitoring, supervision)
2 – Programme (time, co-ordination,
progress, realism, change)
3 – Design & planning risk
management (elimination,
assessment, control HSE risks)
4 – Training (provided, adequate,
recent)
5 – Leadership (provided, adequate,
visible, followed, credible, trusted)
6 – Change Management
(communication, consultation
evaluation, implementation)
7 – HSE management system
(document control, investigation,
lessons learnt)
8 – Communication (Corporate,
project, business unit)
9 – Responses to emergencies and
previous incidents
10 – Allocation and fulfillment of
responsibilities (just culture
approach)
11 – Allocation of staff &
resources (competence, time,
cost, equipment)
12 – Community issues (lack of
liaison – neighbours /
regulators)
13 – Client demands (time, cost,
schedule, design, novated
contractors, etc.)
14 – External pressures (legal,
market, environment)
15 – Corporate values and
perceptions
16 – Reward and recognition
Incident Investigations – Key Concepts
Underlying Causes of Incidents:
Personnel Factors
1 – Competence (skill, knowledge, experience)
2 – Excessive demands (physical, mental, workload)
3 – Fatigue (Excessive work hours, personal issues)
4 – Error (lapse, slip, mistake)
5 – Violation (deliberate rule breaking)
6 – Rushing work (programme, catch up, bonus, etc.)
7 – Morale (bored, disheartened, personal issues)
8 – Perception of risk – (unaware, under estimate, macho)
9 – Perception of priorities (supervision, peers, site team)
10 – Distraction (by colleagues, others, personal issues)
11 – other (specify)
Incident Investigations – Key Concepts
Areas for Corrective and
Preventative Actions
New guard
fitted
Physical
Changes
Behavioral
New manager
Environment
Changes
Personnel
Procedure
Changes
Training on
maintenance and risk
assessment
Training
Program
Maintenance
and safety
systems
implemented
Incident Investigations – Key Concepts
Writing up the Investigation

Try to be as concise, factual and precise as possible










summarise findings at start and conclusion at the end
use neutral language “incident vs. catastrophe”
use referenced diagrams and pictures
put detailed evidence in appendices, eg statements
Describe the 5Ws
State RCA findings
Identify corrective and preventative actions
Do not draw legal conclusions, e.g., “the negligence of the two
electricians caused the accident”
Avoid speculation on facts, motives, causes, and outcomes,
unless absolutely essential for the report. Personal opinion
should be kept out of the factual report – should put in a
separate section
Consider carefully to who should be sent the report
Incident Investigations – Key Concepts
Investigation Report
Business Unit:
Investigation Completed by:
Date of Incident:
Severity of Incident (from list below):
Fatal/ Major Injury/High Potential Incident (minor injury or near hit)/ Ill health
Nature of Incident (from list below):
fall,of person(s)
lifting equip or plant failure
vehicle,
fall of material
release
violence
collapse
exposure,
viral
electrical
fire / explosion
other
Description of Incident
Who:
What:
Where:
When:
Why:
Incident Investigations – Key Concepts
Investigation Report pt2
Immediate Causes
(see terminology – pick most relevant factors):
Actions:
Conditions:
Underlying Causes
(see terminology - pick most relevant factors):
Job factors:
Organisational factors:
Personnel factors:
Corrective Action(s) (ie actions to correct deficiencies - inc responsibilities, resources and timescales)
Preventative Action(s) ( ie actions to prevent situation occurring again Lessons Learnt
inc responsibilities, resources and timescales)
(i.e. what are the key learning points for the business to prevent this type of incident happening again)
Incident Investigations – Key Concepts
Corrective & Preventative Actions

Identify the corrective/remedial actions necessary to
eliminate the root cause of each critical factor following the
hierarchy of control:






Measures that eliminate the causal factor, e.g. a change of process,
equipment, sequence, materials, etc.
Measures that control the causal factor, e.g. the provision of physical
barriers, guarding, protection, etc.
Measure which protect people from the risk, e.g. PPE, etc.
Action By Whom, By When
Date to be completed by – verification/sign off by who?
Capture lessons learnt for the organisation – communicate,
revise process and standards.
Incident Investigations – Key Concepts
INVESTIGATION SUMMARY

When undertaking an incident investigation, think
carefully about who to involve and when – then act
quickly





Gather the evidence to answer – who, what, where,
when why and how
Stick to the facts and follow chains of evidence.
Analyse the evidence methodically using “5 Whys”
approach to identify root causes
Take the time to write the report correctly excluding
personal opinion. Avoid derogatory remarks, legal
buzzwords and jargon that can be misinterpreted or
difficult to explain.
Ensure corrective and preventative actions are identified
and implemented