004 Incident Investigations PDF

UTAS EH&S INSTRUCTION No.
004
October 2013 Revision 05
EH&S Incident Investigations

APPLICABILITY: This EH&S Instruction is mandatory at all UTAS sites worldwide and applies to EH&S-related
incidents involving employees or contractors.
SUMMARY:
This EH&S Instruction contains reporting requirements and general instructions for completing incident investigations,
as well as a sample incident investigation form. The sample form in Attachment 1 can be used to gather required data.
For all work related injuries/illnesses the ‘Recordkeeping Rationale Form’ (Attachment 2), must also be completed.
The following incidents must be reported in the UTC EH&S Reporting System using the Incident Investigation module:
• Fatality/serious injury/serious near miss (UTC Policy 33 Reportable Incident)
• Fatality/serious injury/serious near miss for contractor employees (UTC Policy 33 Reportable Incident)
• Recordable injuries/illnesses
• First Aid Cases
• Cardinal Rule Violations2
The following adverse events must be reported in the UTC EH&S Reporting System using the Compliance module1.
• Serious environmental incident / Serious environmental near miss (UTC Policy 52 Reportable Incident)
• Discovery of any chemical spill or release, fire, etc.
• Government notice of violation or receipt of any government agency correspondence that suggests or alleges non-
compliance with any EH&S legal requirement
• Permit / regulatory non-conformance
For an overview and guidance of reporting requirements for EH&S Incidents, see Attachment 7.
The Tap Root® investigation process is required for all Cardinal Rule violations, recordable incidents, serious near
misses, government enforcement actions, serious environmental incidents, and reportable releases.
Cardinal Rule Violations are required to be reported using the process outlined in Attachment 3.
All first aid and near miss incidents require some level of incident investigation to establish root cause using the
appropriate ACE Relentless Root Cause Tool(s) (see Attachment 6).
For trending purposes, root cause and corrective action data shall be entered in the ERS system Incident Investigation
Module for all near miss and first aid cases.
DEFINITIONS:
Cardinal Rule: See the UTC EH&S Management System, Appendix C.
Near Miss: See EH&S Instruction 037 “Reporting of EH&S Serious Incidents.”
Serious Injury: See EH&S Instruction 037 “Reporting of EH&S Serious Incidents”
Serious Near Miss: See EH&S Instruction 037 “Reporting of EH&S Serious Incidents”
1
See UTAS Instruction 001 for a detailed list of additional reporting obligations that must be made to UTAS EH&S
relative to the compliance program.
2
Cardinal Rule Violations must be evaluated for appropriate disciplinary action in accordance with UTAS DP126 and
documented in the EH&S Reporting System in the Safety / Recognition and Discipline module.
This document or file contains no EAR technology or ITAR technical data. iClass Identifier: CLS01143529.
G:\Management Systems\Procedures\EH&S Instructions Page 1 of 17
UTAS EH&S INSTRUCTION No. 004
KEY ELEMENTS:
The main purpose of an EH&S incident investigation is to determine the underlying root cause or causes of the incident
and to ensure appropriate corrective actions are identified. The investigation process must provide answers to the
following questions: Who? What? When? Where? How? Why?
The following process provides a framework suitable for use in conducting incident investigations.
Classify significance of
Incident / incident / near miss & report Form Cross Site Evaluation/Data
Near Miss Functional Team Collections
Occurs -Cardinal Rule Violation?
-Recordable Incident?
-Serious Near Miss?
-Government Enforcement Actions?
-Serious Environmental Incidents
-Reportable Releases?
YES - Conduct NO - Use
TapRoot Investigation ACE Tools
Analyze Verify Root Implement Review/Update Document Lessons

Data Cause Corrective Action All-Risk Program Learned
Fishbone On-line Report System JHA Gold, HAZOP, Incident Management
RRCA, 5 Why’s, TapRoot CA Worksheet Contractor Program, Review,
TapRoot TapRoot Root Field Work, EH&S Incident
SnapChart Cause Tree Design Process Review Notification; UTAS
Alert
The following instructions provide a sample framework suitable for use in conducting incident
investigations. Refer to pages 9 and 10 for instructions on how to complete the incident investigation report.
Incident/Near Miss
Accident or near miss has occurred. Injured employees must be attended to and the scene secured.
Applicable supervisor / manager shall initiate the investigation by identifying who, what, where and when.
Refer to questions 1-25 of the incident investigation report (Attachment 1).
Classify significance of incident / near miss & report

All incidents that result in a UTC reportable incident per EH&S Instruction No. 37 must be reported and
input into UTC EH&S online system (ERS) using the Incident Investigation module. Any Cardinal Rule
violation or any Near-Miss that could have resulted in a serious injury must also be reported in the EH&S
online system (ERS) using the Incident Investigation module (see attachment 3 for reporting Cardinal
Rule violations). First aid cases and OSHA recordable cases must be reported into the UTC EH&S online
system (ERS).
Form Cross Functional Team

The applicable supervisor / manager shall assemble a cross functional team to investigate the incident. The
team should include, at a minimum: the Area Supervisor, an EH&S representative, injured employee (if
possible), witnesses, area Safety Coordinator (if applicable), and other employees who are knowledgeable on
the process/task being investigated. Give consideration as appropriate to including additional subject matter
experts (i.e., trade union representative, electrical engineer, machine guarding resource, etc.).
Site Evaluation/Data Collections

Visit the accident scene and document the conditions. Gather all possible information regarding who, what,
when, where, how, and why. Look for all possible contributing factors. Refer to questions 11-19 of the
incident investigation report.
Analyze Data
Evaluate the collected data utilizing brainstorming and relentless root cause analysis techniques. Define the
problem, document ideas, clarify and combine, prioritize, and discard those that did not contribute to the
incident under investigation. A fishbone diagram is one method to perform this process. Use Tap Root®
investigation process to identify causal factors and root causes for OSHA recordable, Policy 33 incidents,
Cardinal Rules violations, serious near misses, and government enforcement actions. Root causes for first
aid cases must be identified through Tap Root® or other appropriate root cause methodology (i.e., 5 Why’s,
Fishbone diagram, etc.).
Verify Root Cause (when not a Tap Root required event. See pp 1-2)
When a final cause (or causes) have been determined, apply a root cause test. Is the cause a management
system failure? Is it controllable? Apply the 5 Why’s test. Will corrective action prevent recurrences?
Implement Corrective Action

Corrective actions for all incidents entered into ERS must be assigned, tracked and closed. Implement the
corrective action and monitor effectiveness. Refer to questions 39-40 of the incident investigation report.
Review/Update All-risk program

Update the site risk assessment data (e-g, JHAG screening tool, JHAG protocol, process safety rules,
HAZOP, contractor management program…) for the process/activity/product involved in the incident by
taking into account the corrective actions implemented. The purpose is to verify that corrective actions are
deep enough to ensure the risk is now controlled.
Document Lessons Learned

Summarize lessons learned and share information with others. Use the UTAS Incident Review / TapRoot
template (Attachment 4) to document the incident, investigation process, causal factors, root causes, and
corrective actions. Conduct a management incident review that includes site and business leadership, as well
as UTAS EH&S (region lead, UTAS safety, and segment EH&S). Include a description or picture of the
incident, the root cause(s) and any planned corrective action(s). The EH&S Incident Notification (slide 14)
should be used (Attachment 4) for general communication of learning within UTAS business units. Ensure
all notification communications are in compliance with ITAR and export requirements and coordinated with
UTAS EH&S Communications.
INCIDENT MANAGEMENT TIMELINE:
Incident investigations should be conducted as soon as possible after the incident occurs or is reported.
Investigations rely on obtaining the facts of the case from involved parties and important details may be lost
as time progresses. Also, prompt investigation is consistent with the UTC and UTAS commitment to
providing a safe workplace for our employees.
The significant milestones are as follows (see Attachment 5 for an example of a site-specific incident
protocol checklist):
Immediately: Provide treatment / clean-up activities
Within 24 hours: Determine initial severity / significance; verbally report incident as applicable
First 48 hours: Enter initial incident information into ERS
First 14 days: Conduct incident investigation; develop CAPA; prepare incident review
14th day: Send incident review report to UTAS Safety Manager (Attachment 4)
14th – 30th day: Report out on incident review with site & business leadership and Central EH&S
Document
Changes
Revision No. Date Description of Change
0 5/01/07 Initial release
1 6/2/09 Required online reporting of:
• any Cardinal Rule violation (w/ associated TapRooT)
• Near Misses which could have resulted in a serious injury
2 7/1/09 Use of the Tap Root® investigation process is required for all cardinal
rule violations, recordable incidents, serious near misses, government
enforcement actions, serious environmental incidents, and reportable
releases.
3 9/30/11 Amended Incident Investigation Process and amended flow chart (p.1)
Amended paragraph; Classify significance of incident/near miss and
report to include Cardinal Rule violation reporting process
Revised and added as attachment 1, Incident Investigation Report (

p.4-7)
Added Instructions for Incident Investigation Report (p.8-9)
Deleted ACE Tools; Fishbone/5 Why (pp 1-2)
Added Attachment 2 OSHA Recordkeeping Rationale Form
Added Attachment 3 Cardinal Rule violation reporting flowchart
Added Attachment 4, EH&S Alert Model
4 7/01/12 Formalized requirement to enter all First Aid incidents in UTC
Reporting System.
5 10/17/13 Clarified responsibilities of applicable supervisor / manager in

initiating and coordinating the investigation
Added requirements for reporting adverse events
Clarified types of incidents for which TapRoot is required
Added requirement for root cause identification for first aid cases and
near miss incidents
Added examples of ACE RRCA tools
Added requirement for management incident review
Provided clarification on distribution of EH&S incident notifications
Added incident management timeline
Added TapRoot template
Added Z-Chart to TapRoot template
Removed EH&S Alert Model
Added Incident Reporting Guidance Matrix
Incident ID:___________
Attachment 1 Assigned by On-Line Reporting System
Incident Investigation Report/Instructions
Severity/Incident Type (Select at least one)

1) Near Miss Property Damage Environmental/Permit Issue Spill/Release
2) Medical Treatment, Indicate Where and by Whom:__________________________________________________
First Aid Only Medical Treatment Only Restricted Duty Only Lost Time
Fatality Work Related Fatality Not Work Related
Other:_____________________________________________________________________________________
Person Involved in Incident (Complete for all incident types)

3) Last Name: ______________________________First Name: ________________________________________
4) Employee Identifier (Optional):_______________________________________________________________________
Person Involved in Incident Cont. (Complete for Injuries/Illnesses Only)

5) Employee Age:
<20 20-29 30-39 40-49 50-59 60+ Unknown
6) Years of Service:
<1 Yrs 1-4 Yrs 5-10 Yrs 11-15 Yrs 16-20 Yrs 26-30 Yrs 31+ Yrs
Unknown
7) Work Shift (Optional):
1st Shift 2nd Shift 3rd Shift Long Day Shift Long Night Shift
8) Employee Type:
Contractor (Directly Supervised by UTAS) Contractor/Subcontractor (Not Supervised by UTAS)
Direct/Hourly Employee Indirect/Hourly Employee
Indirect/Salary Employee Unknown
9) Employment Status:
Permanent Full Time Permanent Part Time
Temporary (Casual) Full Time Temporary (Casual) Part Time
Not Applicable Unknown
10) Employee Department Number:_________________________________
11) Supervisor Name (Optional):____________________________________
Timing of Incident (Complete for all incident types)
12) Incident Date: ______________
13) Incident Time: ___________ am/pm
14) Date Incident Was Reported: ___________________
15) Reported By: _________________________________
Information About What Happened

16) Brief Incident Description (What Occurred?):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
____________________________________________________________________________________________________
17) Full Incident Description (Describe Sequence of Events):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
___________________________________________________________________________________________________
Information About What Happened (Continued)

18) Activity Performed (Provide activity being performed that resulted in the incident)
Access Egress Hot Work Painting Other
(Specify):______
Confined Space Entry Inspection Passenger in Vehicle
______________________
Cutting, Shearing Installation of Equipment System Pipe Work
Electrical Work Machine Operation (Guarding) Pressurized Cylinder Work
Emergency Response Maint./Service of Equipment System Repair of Equipment/System
Forklift Operation Not Performing Task Testing of Equipment/System
Handling/Lifting Office or Sales Task Unknown/Undefined
Handling Tools Operating Machinery Working At Height
Hazardous Waste Operating Vehicle Working W/Handling Toxic Substances
19) Employees Experience Performing Activity: <3 Months 3-12 Months >12
Months
20) Is there a written SOP for the Task? Yes No
Complete for Injury/Illness Only
21) Source of Injury/Incident
Asphyxiation Bite-Animal Bite- Insect
Burn/Scald Contact Hot Object Burn/Scald Corrosive Chemical Burn/Scald Extreme Temp
Burn/Scald Misc. Burn/Scald Weld Burns to Eyes Caught In, Between,Under Collapse Material
Caught In, Between, Under Machine Caught In, Between, Under Object Caught In, Between, Under Mechanical
Chemical Poisoning Cut, Puncture, Scrape by Tool Cut, Puncture, Scrape by Misc.
Cut, Puncture, Scrape by Lifted Obj. Cut, Puncture, Scrape by Power Tool Electric Shock or Burn Misc.
Explosion/Fire Foreign Body in Eye Misc.
Motor Vehicle – Auto Accident Occupational Skin Disease/Disorder Repetitive Motion
Slip, Trip, Fall from Ladder/Scaffold Slip, Trip, Fall on Same Level Slip, Trip, Fall from Different Level
Slip, Trip, Fall from Stairs Strain/Injured by Continual Noise Strain/Injured by Lifting/Carrying
Strain/Injured by Misc. Strain/Injured by Pushing or Pulling Strain/Injured by Reaching
Strain/Injured by Twisting Strain/Injured by Using Tool Striking Against/Stepping On Misc.
Striking Against/Stepping On Part Struck or Injured by Malicious Intent Struck or Injured by Escalator
Struck or Injured by Hand Tool Struck or Injured by Lift/Elevator Struck or Injured by Machining
Material
Struck or Injured by Motor Vehicle Struck or Injured by Moving Parts Struck or Injured by Object Held by
Others Struck or Injured by Lifted Object Unknown
22) Nature of Injury

Abrasion Allergic Reaction Amputation
Asphyxiation Bruise/Contusion Burn/First Degree
Burn / Second Degree Burn / Third Degree Concussion
Criminal Act – Bullet, Knife Wounds Cumulative Trauma Disorder Cut, Laceration, Puncture
Dermatitis/Skin Rash Dislocation Electrical Shock
Foreign Body/Sliver Foreign Body in Eye/Irritation Fracture (Single)
Fracture, Compound Fracture, Multiple Hearing Loss
Heat Exhaustion / Hypothermia Hernia Inflammation
Loss of Consciousness Multiple Injuries Equally Serious Paralysis
Poisoning – Chemical Poisoning – Radiation Exposure Respiratory Distress
Sprain/Strain Unknown Vision Loss
23) Body Part Affected (Check all that apply)

Ankle Arm Buttocks/Tailbone Chest/Rib Circulatory System Clavicle,
Scapula
Ear(s) Elbow(s) Eye(s) Face Foot Groin
Hand/Finger Head Hip Knee Leg Lower Back rea
Mouth Multiple Head Neck Nervous System Nose Pelvis
Respiratory System Scalp Shoulder Skin Systemic Reaction Toe(s)
Unknown Upper Back Middle Back Wrist Other_________________
Complete for Spill/Release Incidents Only

24) Spill or Release
Substance (attach MSDS): ________________________ Estimated Quantity: _________________
Did the spill/release move off the property where work was performed?: _______________________ Spill/Release
From: _________________ Spill/Release To: _________________________________
Was regulatory Agency Notified? Yes No
Complete for Environmental/Permit Issue Incidents Only

25) Environmental/Permit Issue
Describe Environmental or Permit Issue:
______________________________________________________________
Permit Type: _______________________ Permitted Level or Criteria (e.g., discharge limit):
____________________
Permit Name and Number (e.g., NPDES): _________________ Substance and Estimated Quantity:
_______________
Duration of Permit Exceedance: ______________________ Was regulatory Agency Notified? Yes No
Severity of the Incident (Complete for all incident types)

26) UTC Policy 33 Report Type:
Not a UTC Reportable Incident per Corp Policy 33 Guidelines
UTC Reportable Serious Near Miss
27) Cardinal Rule Violation/MOR: Yes No
Cardinal Rule/Minimum Operating Requirement:(Required with a ‘yes’ on question 27)

Business Unit Cardinal Rule Confined Spaces Control of Hazardous Energy
Electrical Safety Emergency Plan Fall Protection
Fork Lift Industrial Hygiene Machine Guarding
Not a Cardinal Rule or MOR
28) Severity Information Status: Preliminary Final
Investigation Information (Complete for all incident types)
29) On Site Investigation Performed: Yes No
30) Investigated By: ___________________________________________________________
31) Date of Investigation: _______________________
32) Was JHA Gold Assessment Conducted: Yes No
33) Applicable JHA Gold Protocol:
Compressed Gas Confined Space Dipping and Coating Operations Electrical Safety/Arc
Flash
Electrical Safety /General Elevated Work Energy Conservation Environment – Air
Environment – Industrial Environment – Waste Environment – Water Environment – Other
Ergonomics Industrial Ergonomics Office Explosive Hazards HAZOP (FHRA)
Hand Portable Power Tools Hazardous Energy Industrial Hygiene Life Safety
Machine Guarding Material Handling Personal Protective Equipment Powered Industrial
Truck Powered Platforms Walking/Working Surface Welding/Cutting/Blazing
34) Hazard:
Broken Tools/Machinery Chemical Exposure Confined Space Electrical Energy Hazard
Equip. Failure/Malfunction Equipment not certified Fire Hazard Hazardous Air Temp
Improper Tool Improper use of tool Inadequate Overhead Protection Insufficient Lighting
Investigation Incomplete Material not designed Mechanical Energy Hazard Other
Other Health Hazards Rotating Moving Equip Safety Equipment Malfunction Trip/Slip/Fall Hazard
Unguarded Equipment Unhealthy Breathing Unprotected Sharp Edge Unsafe Act of Third Party
Unsafe Driving Condition Unsafe Material Handling Unsafe Material Storage Unsafe Noise Level
Unsafe Scaffolding Wet Area
35) Type of Investigation Analysis Completed:

Tap Root 5-Why’s Fish Bone
Other:__________________
Location of Incident (Complete for all incident types)

36) Where Did Incident Occur
(Location):__________________________________________________________
37) Employee Working in Their Usual Department: Yes No
38) Incident Location – Name:__________________________________________________________
Incident Causes/Corrective Actions (Complete for all incident types)

39) Direct Accident/Incident Cause(s):
A)_______________________ B)___________________________C)___________________________
40) Corrective Actions:
Immediate Corrective Action:________________________________________________________________
Long Term Preventive Action:________________________________________________________________
Severity/Incident Type Person Involved in Incident

1. Check the box that best characterizes the type of 3.Last and first name of employee who was injured or otherwise involved in
accident/incident. incident
2. This data is used to categorize the injury or illness 4.Optional field for employee’s clock number or employee number
for safety performance reporting. For U.S. locations, For Injuries and Illnesses Only
this information is also used to categorize the injury 5.Age of employee at time of the incident.
or illness for safety performance reporting. For U.S. 6.Total years of service with the company. If the company was acquired by
locations, this information is also used to generate UTC, then include the years of service prior to the acquisition.
the OSHA 300 log. If the incident you are entering 7.Work schedule of employee when incident occurred.
is a UTC Serious Injury, select the most appropriate • First Shift – start in the morning, finish in the afternoon.
option (i.e. lost time, restricted duty, etc.). • Second Shift – start in the afternoon, finish in the evening.
• Fatality – A work-related employee death • Third Shift – start in the evening, finish in the early morning.
• Lost Time – The employee does not have any • Long Day Shift – Greater than 10 hour shift during mostly daylight hours.
work capacity on at least one day following the • Long Night Shift – Greater than 10 hour shift during mostly
work-related injury or illness (regardless of whether evening/darkness hours.
the employee was scheduled to work that day or not). 8.Check one of the following:
• Restricted Duty – Also called “Suitable Duty” in •Contractor (Directly Supervised): Contract employee under the direct
some parts of the world – The employee has partial supervision of a UTC employee.
work capacity following the work-related injury or •Contractor (Not Supervised): Any contract employee who is not directly
illness, AND this is not a Lost Time Case. supervised by a UTC employee. Example: contract employee that is directly
• Medical Treatment Only – The employee received supervised by an employee of his/her company.
medical treatment for the injury/illness, AND this is •Direct/Hourly: Direct labor employee; works directly on a product or
not a Lost Time Case or Restricted Duty Case. directly provides a service to a UTC customer.
• First Aid Only – The employee received no more •Indirect/Salary: Indirect labor employee; works in a supporting function to
than first aid for the injury/illness. the direct labor employee population (human resources, finance, all
management, etc.).
9. Describes the employment status of the employee (i.e., Permanent full
time, Permanent Part Time, Temporary Full Time or Temporarily Part
Time).
10. Unique identifier assigned to the employee such as an employee number.
11. Full name of supervisor of employee who was involved in the incident.
Timing of Incident Information About What Happened
12. Actual Date that the incident occurred regardless 16. Very brief description of the incident that can be displayed on summary
of when it was reported. reports.
13. Actual time that the incident occurred regardless 17. Describe the sequence of events before and during the incident and any
of when it was reported. other important details relating to the event.
14. This field contains the date that the incident was 18. The activity that was being performed by the employee at the time of the
first reported by the employee to supervisor/ incident.
management. 19. Length of job/equipment experience.
15. Name of employee completing report 20. Yes or No. Standard Operating Procedures could include, but are not
limited to Manufacturing Procedures, Job Safety Analysis, Test Lab
Instructions, etc.
Information for Injury/Illness Only Information for Spill/Release Incident Only
21. Source 24. Indicate the name of the product or material spilled or released; attach
22. Nature Material Safety Data Sheet. Estimate number of gallons or pounds released.
23. Indicate body part involved in incident Also describe the type of environment (ground, concrete, water, air) the
material was spilled on or released to. Indicate the name of all government
agencies that were notified. The EH&S Department normally determines
which agencies need to be notified.
Information Environmental/Permit Issues Only Severity/Incident Type
25. Permit Issue 26 Indicate an incident qualifies as a “UTC Reportable Incident” if it meets
any of the following criteria of UTC Corporate Policy 33 – Fatality and
Serious Injury/Incident Investigation & Reporting which includes;
• Any fatality involving a UTC Employee, occurring in or relating to the
workplace, regardless of the time lapse between the incident and death;
• Any fatality involving a contractor employee working directly for UTC at
a UTC facility or job site, regardless of the time lapse between the incident
and death;
• Any Serious injury to a UTC employee defined as: Any life-threatening
injury/Any injury resulting in paralysis/Any fracture to the skull, jaw or
back, any compound fracture; fracture to long bones in multiple limbs; or
multiple fracture to long bones in the same limb;
• Any injury that results in the loss of a body part or function such as
amputation or loss of vision; Loss of consciousness/Any puncture wound

that penetrates the skull, spine or body cavity;/or Any 3rd degree burn larger
than 2% of Body Surface Area or 2nd degree burn larger than 15% of BSA.
• Any Serious Near Miss incident. A reportable serious near miss is any
incident involving a UTC employee that as determined by the business unit
senior EH&S officer, reasonably could have resulted in loss of life or serious
injury. These incidents may occur as a result of employee error, equipment
malfunction, an unsafe condition, and/or events caused by a third party or
other external factors. Also included is any incident involving three or more
employees who require medical treatment in a hospital, clinic, or hospital
admission and individually do not otherwise meet the requirements of the
above “reportable incident” definition.
• UTC Reportable Potential Serious Injury Any incident which results in
an injury to the UTC employee & does not meet the requirements of a UTC
Reportable Serious Injury (e.g. Medical Treatment, First Aid) that, as
determined by the business unit senior EH&S officer, reasonably could have
resulted in loss of life or serious injury.
Severity/Incident Type Continued Investigation Information
26Select “YES” for this item if the incident resulted 28Indicate whether the incident investigation was performed at the location
from an action that was a violation of a UTC where the incident occurred (YES) or not (NO)
Cardinal Rule or a UTC Minimum Operation 29Full name of person who lead the investigation of the incident.
Requirements. A “YES” answer will force a single 30Date of the incident investigation began.
selection from the list of the Cardinal Rule/Minimum 31Determine if a JHA Gold assessment has been conducted on the process
Operation Requirements. that was associated with the incident.
27The purpose of this field is to identify whether the 32If a JHA Gold assessment has been conducted, please select the JHA Gold
information in this section is final or preliminary. protocol that was most closely associated with the issue that resulted in the
Select Final if the employee has returned to work incident. If a JHA Gold assessment was not conducted, select the JHA Gold
and the correct number of lost and restricted duty protocol that would have been most likely associate with the issue that
days has been entered. resulted in the incident.
Select Preliminary if the information is estimated or 33Hazard
likely to change as more information is available 34Type of
about the employee.
Location of Incident Incident Causes/Corrective Actions
35 The name of the location where the incident 38Conduct a root cause analysis of the incident and list all direct cause(s);
occurred. If the incident occurred at a job site, enter List direct causes of the incident. Stay away from fixing a symptom. This
the name of the job site such as “XYZ Office question should not be answered until a root cause analysis or 5 whys have
Building” been completed.
36 Usual department 39Immediate corrective actions are short-term, stopgap type solutions; not
37 Business Unit? necessarily the root cause. These may be fixing a symptom until a root cause
can be implemented. Long-term preventive action is action to ensure that
the incident will not occur again. These usually take longer to implement
and can take more than one person to implement. This usually results from a
root cause analysis.
Attachment 2
UT Aerospace Systems
OSHA Recordkeeping Rationale Form
004A OSHA Rationale Form
Name: Date of potential case:

Is the person an employee? Choose an item.
Did the employee experience an injury or illness? Choose an item.
Description of injury/illness:
Determined or diagnosed by:
Is a work event or exposure a discernable cause of the case or of significant aggravation to a pre-
existing condition (PEC)? Choose an item.
If yes or maybe, describe work event or exposure:
If no, explain why not:
Does an OSHA exception apply? Choose an item.

Is the injury or illness a new case? Choose an item.
Was medical treatment beyond first aid given or recommended by a licensed health care professional
(LHCP)?Choose an item.
If yes, what was it?
Were there restrictions of work? Choose an item.
If yes or maybe, describe them:
If restricted, was the employee able to perform routine job functions and work a full shift or
workday? Choose an item.
If restricted, was it preventive and related to minor musculoskeletal discomfort with the
employee cleared by a LHCP to perform routine job functions? Choose an item.
Were there days away from work? Choose an item.
Does the injury or illness meet the general recording criteria or the specific cases recording criteria?
Choose an item.
Case recorded on OSHA log as number:
* Case not recorded on OSHA log because (check all that apply):
the injured or ill person is not an employee
the employee did not experience an injury or illness
the case is not work-related since (check all that apply)
no work event or exposure is a discernable cause of the case or of significant aggravation
to a pre-existing condition
an OSHA exception to work relatedness applies
the case is not new – enter case number if already recorded on an OSHA log:
the case does not meet the general or specific cases recording criteria
Comments:
Recordkeeper: Date
Attachment 3
Cardinal Rule Violation Reporting Flowchart
Actors
Cardinal Rule Violations
Managers,
Identify CR violations through
Supervisors, Cell Leaders,
Observations, Risk Assessments (JHA
Site Employees,
Gold), Inspections, Audits, Program
EH&S Personnel,
Evaluations & AR/Risk Reviews
External Auditors
Enter data into on-line reporting

EH&S Personnel system, Incident Module as a result of
CR violations (no injury) near miss and
CR violation (with injury)
Incident/Accident Perform TapRooT investigation in

Investigation Team accordance with HS EH&S instruction
004
Enter Corrective Action Plans (CAP’s)

EH&S Personnel from the Tap Root investigation into
the on-line reporting system
EH&S Personnel Monitor CAP’s to completion
EH&S Personnel Verify effectiveness of CAP’s
Attachment 4
UTAS Incident Review / TapRoot Template
004B TapRoot Template
Attachment 5
Example of site-specific incident protocol checklist
Incident Investigation Process (Recordables and Lost Time)
Incident:
Date of Incident:
Step Timeframe (from date of Action

incident)
1 ASAP Capture incident data using the Incident Investigation Report found in Attachment 1
of Instruction 004.
2 ASAP Complete the OSHA Recordkeeping form – even for sites not covered by OSHA.
(Attachment 2 of Instruction 004)
3 48 Hours Create a new incident record in the EHS Reporting System within 48 hours (as per
Instruction 011 EHS Reporting). NOTE: for serious incidents, Instruction 037 requires
immediate reporting
4 5 days Perform RRCA investigation to determine root causes and corrective actions.
5 5 days (immediately after Populate Root Causes and Corrective Actions into the EHS Reporting System, with
RRCA) owners and dates.
6 7-10 days Populate the PowerPoint template with a summary of the incident and investigation.
These slides will be the talking points for management review.
7 Second week of the Discuss Incident and RRCA at monthly SBU EHS Dashboard Call. **
following month
8 as committed Execute Corrective Actions
9 by committed date Close Corrective Actions in the EHS Reporting System
** Until Dashboard Call is Initiated, use the following instruction:

7 7-10 days Site Leader to schedule a conference call to discuss Incident and RRCA. Conference
call to include business president and relevant members of UTAS EH&S (at a
minimum UTAS Safety and EH&S Region Lead) and any site staff the Site Leader
requires.
Attachment 6
Potential tools for root cause analysis of first aids and near misses
(See RRCA Interactive Tool for more information
http://aceprod7.utc.com/vgn-ext-
templating/v/index.jsp?vgnextoid=654a466142440110VgnVCM1000000881000aRCRD)
FAULT TREE:
004C RRCA Fault Tree
FLOW CHART:
004D RRCA Process Flow
FISHBONE / CAUSE AND EFFECT DIAGRAM:
004E RRCA Fishbone
3-LEGGED 5-WHY:
004F RRCA 5 Why Tool for EH&S
Attachment 7
EH&S Incident Reporting Guidance
004G Incident Reporting Guidance Matrix

004 Incident Investigations PDF

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004 Incident Investigations PDF

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UTAS EH&S INSTRUCTION No.

EH&S Incident Investigations

Analyze Verify Root Implement Review/Update Document Lessons

Classify significance of incident / near miss & report

Form Cross Functional Team

Site Evaluation/Data Collections

Implement Corrective Action

Review/Update All-risk program

Document Lessons Learned

INCIDENT MANAGEMENT TIMELINE:

Revised and added as attachment 1, Incident Investigation Report (

5 10/17/13 Clarified responsibilities of applicable supervisor / manager in

Severity/Incident Type (Select at least one)

Person Involved in Incident (Complete for all incident types)

Person Involved in Incident Cont. (Complete for Injuries/Illnesses Only)

Information About What Happened

Information About What Happened (Continued)

22) Nature of Injury

23) Body Part Affected (Check all that apply)

Complete for Spill/Release Incidents Only

Complete for Environmental/Permit Issue Incidents Only

Severity of the Incident (Complete for all incident types)

Cardinal Rule/Minimum Operating Requirement:(Required with a ‘yes’ on question 27)

35) Type of Investigation Analysis Completed:

Location of Incident (Complete for all incident types)

Incident Causes/Corrective Actions (Complete for all incident types)

Severity/Incident Type Person Involved in Incident

amputation or loss of vision; Loss of consciousness/Any puncture wound

Name: Date of potential case:

If no, explain why not:

Does an OSHA exception apply? Choose an item.

Enter data into on-line reporting

Incident/Accident Perform TapRooT investigation in

Enter Corrective Action Plans (CAP’s)

EH&S Personnel Monitor CAP’s to completion

EH&S Personnel Verify effectiveness of CAP’s

Incident Investigation Process (Recordables and Lost Time)

Step Timeframe (from date of Action

8 as committed Execute Corrective Actions

9 by committed date Close Corrective Actions in the EHS Reporting System

** Until Dashboard Call is Initiated, use the following instruction:

004C RRCA Fault Tree

004D RRCA Process Flow

FISHBONE / CAUSE AND EFFECT DIAGRAM:

004E RRCA Fishbone

004F RRCA 5 Why Tool for EH&S

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