> Introduction
Incident Investigation and Analysis
General
Before we begin
General
Trainer Profile
Md Al amin Hossain
NEBOSH U.K, IOSH U.K,EOSH U.K, AOSH U.K & OSHA
U.S.A Approved Trainer.
Lead Auditor ISO 45001:2018 , 9001:2015 , 14001:2015 .
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> Introduction
Disclaimer
• This training material presents very important, • Your organization must do an evaluation of all
pertinent information. It should not be assumed, exposures and applicable codes and regulations. In
however, that this program satisfies every legal addition, establish proper controls, training, and
requirement of every state. Some states require the protective measures to effectively control exposures
training be developed and delivered by an individual and assure compliance.
with specific training and experience.
• This program is neither a determination that the
• This training is AWARENESS LEVEL and does not conditions and practices of your organization are safe,
authorize any person to perform work or validate the nor a warranty that reliance upon this program will
level of their competency; it must be supplemented prevent accidents and losses or satisfy local, state, or
with operation and process-specific assessments and federal regulations.
training, as well as management oversight, to assure
that all training is understood and followed.
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> Introduction
Course Outline
1. Introduction
2. Part 1: Overview
3. Part 2: Preparation and Response
4. Part 3: The Investigation
5. Part 4: Analysis
6. Part 5: Follow-Up
7. Summary
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> Introduction
Save lives and money by investigating
all incidents in your organization. Even
a minor incident or near miss can be a
warning of a major risk.
Investigate incidents in order to
pinpoint the root causes. Addressing
these underlying issues allows you to
prevent similar incidents from recurring.
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> Introduction
Definitions
• Incident: Also referred to as an accident, an incident • Direct cause: This is the most obvious reason that
is an event that causes injury or death to people or an incident occurred when the circumstances of the
damage to property. incident are considered.
• Near miss: A near miss is an event that almost • Root cause: This is a factor that underlies the other
results in injury, death, or damage. A near miss is a contributing causes. It could eliminate recurrence of
warning sign that an incident is likely to occur, so the problem if it is addressed.
near misses should also be investigated.
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> Introduction
Respond, Investigate, and Analyze
The following slides look at organizational preparation for and response to
incidents, some basic causes, how to conduct an investigation, and analysis
methods.
Benefits of investigating and analyzing incidents:
• Identifying unsafe conditions and behaviors
• Identifying needed organizational changes
• Providing constructive feedback
• Reinforcing best practices
• Reducing future incidents
• Prioritizing the safety and well-being of everyone in the organization
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Overview
What you need to know:
1. The safety pyramid
2. The importance of investigating and
documenting near misses and unsafe working
conditions
3. Unsafe acts or conditions that can lead to
incidents
4. Organizational causes of incidents
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1 Overview
The Safety Pyramid
1 Serious Injury or Fatality
10 Lost Time
100 Medical Only
1,000 Near Misses
10,000 Unsafe Behaviors/Hazards
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1 Overview
The Safety Pyramid
1 Serious Injury or Fatality
10 Lost Time
100 Medical Only
1,000 Near Misses
10,000 Unsafe Behaviors/Hazards
General
1 Overview
The Safety Pyramid
1 Serious Injury or Fatality
10 Lost Time
100 Medical Only
1,000 Near Misses
10,000 Unsafe Behaviors/Hazards
General
1 Overview
The Safety Pyramid
1 Serious Injury or Fatality
10 Lost Time
100 Medical Only
1,000 Near Misses
10,000 Unsafe Behaviors/Hazards
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1 Overview
The Safety Pyramid
1 Serious Injury or Fatality
10 Lost Time
100 Medical Only
1,000 Near Misses
10,000 Unsafe Behaviors/Hazards
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1 Overview
The Safety Pyramid
1 Serious Injury or Fatality
Typically
Documented 10 Lost Time
100 Medical Only
1,000 Near Misses
Typically
Undocumented 10,000 Unsafe Behaviors/Hazards
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1 Overview
The Safety Pyramid
1 Serious Injury or Fatality
10 Lost Time
100 Medical Only
1,000 Near Misses
10,000 Unsafe Behaviors/Hazards
General
1 Overview
The Safety Pyramid
1 Serious Injury or Fatality
10 Lost Time
100 Medical Only
1,000 Near Misses
10,000 Unsafe Behaviors/Hazards
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1 Overview
The Safety Pyramid
1 Serious Injury or Fatality
10 Lost Time
100 Medical Only
1,000 Near Misses
10,000 Unsafe Acts/Conditions
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1 Overview
Unsafe Acts
Unsafe acts are activities that create or increase the risk of injury
or property damage. They result from behavior rather than a lack
of skill.
Examples:
• Disregard for proper procedures or training
• The bypassing or disabling of safety devices
• Failure to use proper personal protective equipment (PPE)
• Careless, distracted, or unauthorized operation of equipment
• Working under the influence of drugs or alcohol
• Horseplay
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1 Overview
Unsafe Conditions
Unsafe conditions are present when features of Examples not inherent to the worksite:
the worksite create or increase the risk of injury or
property damage. • Uneven or slick walking surfaces
• Damaged or improperly maintained equipment
or PPE
Examples inherent to the worksite:
• Ergonomic hazards
• Extreme temperatures
• Improper storage
• Heights
• Inadequate machine guarding
• Air quality
• Other environmental or atmospheric
conditions
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1 Overview
Organizational Causes
Accidents may stem from organizational causes that go
beyond the actions or conditions at the scene of the Unsafe acts, unsafe conditions, and
accident. organizational causes are not mutually
exclusive: they may all be contributing factors.
Examples:
• Inadequate training
• Inadequate communication
Minimize incidents caused by unsafe
• Inadequate supervision or accountability processes behaviors by fostering a culture of safety
in the workplace.
• Inadequate safety programs or procedures
• Lack of safeguards, resources, or equipment
• Lack of preventative maintenance
• Non-enabled tasks
• Poor hiring or placement procedures
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Preparation and Response
What you need to know:
1. Organizational preparation for incidents
2. Initial incident response
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2 Preparation and Response
Organization Preparation
Make sure that your organization is prepared:
• Implement effective and reliable methods of
communication throughout your facilities.
• Create contingency plans that cover what to do:
– If managers or supervisors are unavailable.
– If primary communication channels fail.
• Train employees:
‒ To properly report incidents and near misses.
‒ To recognize and respond to emergencies.
‒ To follow safe practices and proper procedures at all
times.
• Determine internal procedures to be followed during
all investigations.
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2 Preparation and Response
Initial Incident Response
1. Secure the area if necessary to prevent further injury or disruption
of evidence.
2. Control or eliminate hazards created in the incident.
3. Contact the appropriate people immediately:
‒ Management or supervisors
‒ Emergency personnel if necessary
4. Provide first aid if necessary and able.
5. Start preserving evidence that may be needed for the subsequent
investigation.
‒ Photograph details of the scene before removing any evidence.
‒ Take measures to isolate any evidence that may not be able to
be removed from the scene (e.g., damaged heavy machinery).
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The Investigation
What you need to know:
1. Investigation guidelines
2. Proper interview techniques
3. Person-focused vs. system-focused investigations
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Investigation Guidelines
• Include both management and employees in the • Collect as much data as possible. The more
investigation. Multiple perspectives are invaluable. information you have, the easier it will be to see the
big picture.
• Make sure that the investigation team includes or has
‒ Interview personnel involved in the accident, as
access to technical expertise in safety, engineering,
well as any witnesses.
operations, or any other subjects that might be
helpful. ‒ Document the site of the incident. For example,
take photographs or video.
• Focus on finding causes for the issue rather than
placing blame.
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3 The Investigation
Collecting Data
Look for the following information: Information sources:
• Who was involved, including all witnesses • Witness accounts
• The time, date, and location of the accident • Photos and evidence collected at the scene
• The activities being performed when the • Surveillance videos
accident occurred
• Maintenance records, work orders, or any other
• All equipment being used when the accident documentation regarding the personnel or
occurred equipment involved
• Existing safety policies for the activities and
equipment
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3 The Investigation
Interview Techniques
• Conduct interviews in private.
• If possible, conduct interviews close to the scene of the incident.
• Plan the questions ahead of time, but allow the subject’s answers
to guide what is asked next.
• Do not make assumptions about what you expect the answers to
be: keep an open mind.
• Ask open-ended questions, allowing the subject to tell the story in
their own words.
• Ask who-what-when-where-why-how questions.
• Do not interrupt or try to assist with an answer.
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3 The Investigation
Focus on the System
In order to discover root causes, the analysis should be
system-focused rather than person-focused.
Person-Focused System-Focused
Considers the incident to be the starting Recognizes that an incident may be the result
Perspective point of the issue and investigation of an inherent risk in the system
The direct cause of the incident and The system as a whole, in order to identify risk
Scope its aftermath or failures
Outcome Damage control Process control and improvement
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3 The Investigation
Example: Investigation Focus
Incident:
A warehouse worker’s ankle is seriously injured
when he is struck by a turning forklift.
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3 The Investigation
Example: Investigation Focus
Incident:
A warehouse worker’s ankle is seriously injured
when he is struck by a turning forklift.
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3 The Investigation
Example: Investigation Focus
Person-focused questions:
• How was the operator at fault?
‒ Was he paying attention?
‒ Was he driving recklessly?
• How serious is the damage?
• What are the financial implications?
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3 The Investigation
Example: Investigation Focus
The Operator
Damage Liability Blame
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3 The Investigation
Example: Investigation Focus
The Operator
Damage Liability Blame
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3 The Investigation
Example: Investigation Focus
The System The Operator
Process Inherent Variance Damage Liability Blame
INCIDENT
Failure Risk
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3 The Investigation
Example: Investigation Focus
The System The Operator
Process Inherent Variance Damage Liability Blame
INCIDENT
Failure Risk
CAUSE
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3 The Investigation
Example: Investigation Focus
The System The Operator
Process Inherent Variance Damage Liability Blame
INCIDENT
Failure Risk
CAUSE EFFECT
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3 The Investigation
Example: Investigation Focus
The System
Process Inherent Variance INCIDENT
Failure Risk
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3 The Investigation
Example: Investigation Focus
System-focused questions:
• Was the injured worker wearing high-
visibility clothing?
• Were proper load-height restrictions
established and communicated?
• Are driving and walking zones clearly
defined and separate?
• Have additional traffic controls (e.g., signs,
mirrors) been implemented?
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3 The Investigation
Example: Investigation Focus
The System
Process Inherent
Variance INCIDENT
Failure Risk
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3 The Investigation
Example: Investigation Focus
The System
Inherent
Process Variance
Risk
Failure
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3 The Investigation
Example: Investigation Focus
The System
Inherent
Process Variance
Failure
Risk 1 Serious Injury or Fatality
10 Lost Time
Risk Control
100 Medical Only
Measures
1,000 Near Misses
10,000 Unsafe Behaviors/Hazards
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3 The Investigation
Example: Investigation Focus
1 Serious Injury or Fatality
10 Lost Time
100 Medical Only
1,000 Near Misses
10,000 Unsafe Behaviors/Hazards
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Analysis
What you need to know:
1. Analysis goals
2. Common misconceptions
3. Ishikawa diagrams
4. Why Method
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4 Analysis
Analysis Goals
Once all the data pertaining to the incident has been gathered, it must
be reviewed for clues as to what caused the accident.
A thorough analysis should:
• Seek to identify all root causes of the accident.
• Identify any possible contributory factors.
• Determine actions to eliminate all causes.
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4 Analysis
Common Misconceptions
Avoid making these assumptions:
• There can only be one true cause and solution for the accident.
• Incidents only occur when rules are broken.
• Someone must be held accountable.
• Given the same set of facts, everyone will come to the same conclusion.
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4 Analysis
Ishikawa (Fishbone) Diagrams
Ishikawa or fishbone diagrams help to identify
potential factors contributing to the incident.
The diagram allows you to break down your
organization into different categories, including
equipment used and procedures followed. Then
you can brainstorm possible causes for the
incident for each category.
For example, if machine failure was involved
in the incident:
• Was the operator sufficiently trained to use
the machine correctly?
• Was the maintenance schedule for the
machine correctly followed?
• Was the operator or machine negatively
affected by environmental factors?
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4 Analysis
Ishikawa (Fishbone) Diagrams
Tailor the categories to best fit the environment you are working in.
Common examples:
5 M’s for 5 S’s for the 6 P’s for office
manufacturing: service industry: environments:
• Machines • Surroundings • People
• Method • Suppliers • Process
• Material • Systems • Policy
• Manpower • Skills • Plant
• Measurement • Safety • Program
• Product
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4 Analysis
The Why Method
Often, the easiest way to get to the root cause of a problem is simply asking
“why did this happen?”
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4 Analysis
Example: The Why Method
An employee was injured when her hand got caught in the belt assembly of
a conveyer machine.
Question Answer
Why did the employee’s hand get caught? The machine’s safety guard was not installed.
Why was the machine’s guard not installed? The belt needs to be replaced frequently.
Why does the belt need to be replaced so The load limit of the machine is being
frequently? exceeded.
The products on the conveyor were redesigned
Why is the load limit being exceeded? to be larger.
Try to think of the next question that you might ask in this scenario. Each answer may lead to
multiple next questions, so be prepared to follow multiple paths of inquiry.
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Follow-Up
What you need to know:
1. How to apply corrective actions
2. Follow-up procedures
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5 Follow-Up
Corrective Actions
Recommendations for corrective actions should address each root cause
that was identified in the analysis.
• Be specific in your instructions for what the action entails and how it
should be implemented.
• Keep your recommendations constructive and objective.
• In situations where human error is determined to be a cause, clearly
point it out in your findings, but avoid recommending disciplinary
actions, which should be handled via normal Human Resources
proceedings.
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5 Follow-Up
Next Steps
After determining the appropriate corrective
actions, outline a follow-up plan to assure that the
actions are implemented correctly and work as
planned.
• Specify the responsible parties for
implementation and for assuring the
effectiveness of the corrections.
• If hazards or risks are not corrected, review
the prescribed corrective actions to assure
that everything has been implemented as
planned and revise the actions as necessary
to address any remaining issues.
• Once the issues have been verified as
adequately resolved, share your results with
other departments that may be subject to
similar issues.
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> Finish
Summary
• Incidents can occur due to unsafe acts, unsafe
conditions, or organizational failures.
• Investigating even the most minor incidents, near
misses, or unsafe behaviors can lead to the prevention
of more serious and costly accidents.
• Always look for and address root causes.
• Person-focused investigations use the accident as the
starting point, while system-focused investigations look
at the entire system to find root causes that might
have led to the accident.
• Make use of methods such as the Why Method and
Ishikawa diagrams.
• Always document and report incidents and near
misses.
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