LCM 6. Incident Investigation - Compressed

Loss Control Management
INCIDENT INVESTIGATION
Synerquest Management Consultancy Services
“YOUR PARTNER IN YOUR QUEST FOR BUSINESS EXCELLENCE”
OBJECTIVES & PRINCIPLES
14001
Objectives
•  Properly conduct incident investigation

•  Identify the underlying factors of
accidents and faulty management
controls, using root cause analysis.
•  Raise the level of competency of all
employees involved in incident
investigation
“YOUR PARTNER IN YOUR QUEST FOR BUSINESS EXCELLENCE” 14001
REFERENCE
Philippine Occupational
Safety & Health Standards
• REFERENCES
14001
Rule 1050 Incident Investigation
Rule 1050 - Notification and Keeping of Records

of Work-related accidents/illnesses
Forms : Employer’s Work Accident/Illness Report

Annual WAI Exposure Data Report
Accidents Frequency & Severity Rates
• REFERENCES
14001
1053.01: Notification - All work accidents or

occupational illnesses, resulting in
disabling conditions or dangerous
occurrences shall be reported by the
employer to the Regional Labor Office
v If a major work accident results in death or permanent
total disability, employer shall initially notify the Regional
Labor Office within 24 hours.
1054: Keeping of Records - The employer
shall maintain and keep an accident or illness
record which shall be open at all times for
inspection by authorized personnel.
• REFERENCES
14001
© Provides the safety officer means for

an objective evaluation of the program
©  Helps identify high injury rates
©  Provides information on accident

causes which contributes to high injury
rates.
• REFERENCES
14001
OSH RULE REPORT/FORM WHERE TO

WHEN TO REPORT
REPORT
Rule 1050 Work Accident Illness On or before the 20th 2 copies, to

Notification and Report (WAIR) - day of the month be submitted
Keeping of DOLE/BWC/IP-6) following the date of to concerned
Accidents and/ WAIR occurrence of the RO copy
or Occupational accident furnished the
Illnesses Bureau
Annual Exposure - Onor before Jan. 20
Data Report (AEDR) - of the following year
(DOLE/BWC/IP-6b)
Fatal/major accident Within 24 hours

ACCIDENT CAUSATION
The Actual Accident

Investigation
• ACCIDENT INVESTIGATION
14001
Why Investigate Incidents/Accidents???
•  Prevent recurrence
•  Comply with policies and regulatory
requirements
•  Improve Supervisor’s Management
Approach
•  Maintain employee awareness - HSE
14001
Prevention is the reason for

conducting an Incident Investigation
Unless the unsafe acts/conditions are:
•  Identified,
•  Eliminated or
•  Controlled,
… similar mishaps will occur.

14001
All incidents must be

investigated:
•  LTI
•  Non-LTI
•  Near Misses
•  Property damage
•  Environmental damage
14001
__________ is an accident that:

•  Did not happen
•  Could happen
… it is still investigated
ACTUAL INVESTIGATION
14001
Managing the Accident Scene
Two Priorities:
•  Care & Treatment of the Injured
•  Elimination or control of Remaining
Hazards
14001
Controlling Remaining Hazards
If a hazardous environment or toxic

materials exist:
•  Notify necessary personnel
•  Provide PPE to potentially exposed
•  Refer to MSDS for other matters
14001
Isolating the Site
•  To protect people from further

injury
•  To preserve evidence and
valuable clues
14001
Conducting Investigation
Investigate immediately,
because:
•  Operations are disrupted
•  Memories fade
•  Employees are at risk
14001
Who Should Investigate???
•  The size and make-up of the investigation

team is usually dictated by the incident's
seriousness or complexity.
•  The health and safety representative or
committee members, with the help of the
employees involved, usually investigate
minor injury or property damage.
Who Should Investigate???
•  Safety officer
•  Occupational Health Physician
•  Nurse
•  Industrial Hygienist
•  Management – Manager or Supervisor
•  Union/Worker’s Representative
•  Others (HR, maintenance, etc.)
14001
Conducting Investigation
1.  Gather information

2.  Analyze the facts
3.  Make recommendations
14001
Gathering Information
Preliminary Facts
•  NOI, POI, DOI, TOI
•  personnel involved
•  property damage
•  environmental harm
14001
Questions Needing Answers
•  Who was involved?

•  What happened and what were the
contributing factors?
•  When did the accident occur?
•  Where did the accident occur?
•  Finally, and most importantly: how can a
similar accident be prevented from
happening again.
14001
Sources of Information
•  Witnesses
•  Physical evidence at the scene
•  Existing records
14001
Fact collection
•  The Preliminary Investigation Process

•  Importance of the interview (as soon as
possible, on the place of the accident
and with the people concerned)
•  The barriers of communication
14001
Two Main Types of Witnesses
•  Eye witnesses: persons who actually

saw the accident happen;
•  Circumstantial witnesses: those who
did not actually see the accident, but
who can contribute valuable
background information
Witnesses
•  Victim & onlookers

•  Those who heard what happened
•  Saw area prior to incident
•  Others with info about involved
individuals, equipment or
circumstances
14001
Interview Techniques
•  Conduct the interview in private at the workplace;

•  Put the interviewee at ease, don't hurry things;
•  Ask for the interviewee's version of what
happened;
•  Only ask necessary questions;
•  Repeat the interviewee's story as you (the
interviewer) understand it;
•  Close the interview on a positive note and thank
the witness.
14001
Advise: Never judge . . .

14001
Physical Evidence
Provides information about an
accident that witnesses may
overlook or take for granted
14001
Sketches
To record important details at the
accident site for later study
Comfort Room
Electrocution
victim
14001
Include everything that could

be important:
•  Floor plan from overhead view
•  Location of involved man,
machine, tool
•  Size and location of transient
evidences (spills, dust,
footprints, skid marks)
AHU
X
2nd Entrance and Exit Door

(Swing-In Only)
Main Entrance and Exit Door

(Swing-In Only)
Gates Gates
closed closed
Gates
opened
Gates
closed
14001
Use of Photographs
•  General area
•  Detailed shots
•  Show scale on small objects
•  Indicate reference point
•  Better to take too many than too few
14001
Examining: Materials, Machines, Environment
Machines & Equipment

•  Physical condition
•  Position of switches/levers
•  Reading of gauges
•  Safeguards
•  Warning devices
14001
Material
Position and condition can indicate
•  Misuse
•  Abuse
•  Disuse
•  Improper handling
•  Damage
14001
Material - Chemical
If chemicals are involved:
•  correct item used
•  correct concentration
•  expired
•  contaminated
•  MSDS availability
14001
If items have to be removed from

the scene for detailed
examination:
•  Log and Label
•  Secure storage & transport
•  Avoid contamination
•  Guard against tampering and loss
•  Appropriate HSE warnings
14001
Environment (Work)
•  Temperature conditions
•  Illumination
•  Noise
•  Housekeeping
14001
Existing Records
•  Employee records
•  Equipment records
•  Job or Task records
•  Previous Accident Investigation
reports
14001
ROOT CAUSE ANALYSIS

Using Problem Solving
Analysis Tools
14001
Root Cause Analysis Tools
•  Why-Why Analysis
•  Fishbone Diagram
•  Fault Tree Analysis (FTA)
•  Change Analysis
•  Systematic Cause Analysis
Technique (SCAT)
5 Whys Analysis
- Why?
Why?
Why?
Why?
Why?
Ø  Use the 5 Whys to Find the Root Cause

5 Whys Analysis
SLIPPERY and
UNSAFE FLOOR
2
Machine is leaking
3
Oil coupling is leaking
4
Rubber lining inside oil
coupling is worn out
1
5 Stock of rubber
Oil on Floor lining ran out
14001
Fishbone Analysis
Factor 2 Factor 1
Problem
Factor 3 Factor 4
14001
Constructing Fishbone
Appliances Food
& devices Supplies
Too many High quality
High energy
consumption
Requires costly
Simultaneous processing
usage High Household
Electric Bill
Disorganized Unaware of
activities energy
conservation “Aksiong Aksaya”
measures
Homemaking
Procedures Occupants
§  Use an idea-generating technique (e.g., brainstorming) to identify
the factors within each category that may be affecting the problem/
issue and/or effect being studies. The team should ask… “What
are the machine issues affecting/causing…”
FAULT ANALYSIS
14001
Examples: OR Gate
Electric device damaged

by environmental
Car does not start conditions
Car has no Car has an High High

fuel electrical temperature humidity
problem in room in room.
FAULT ANALYSIS
14001
Examples: AND Gate
No oil flow to gear box Fire Starts in the Chem.

Storage Area
No oil flow No oil flow

Flammable Ignition
to port #1 to port #2
Chemical Source
Present Present
Change Analysis
Compares how a job was actually

performed with the way it should
have been performed
Change Analysis
How it was How it should Prevailing

done be done conditions
(Action) (SOP) (Factors)
1.
2.
3.
.
4
SCAT
Systematic Causal Analysis

Technique
ROOT CAUSE ANALYSIS
14001
SCAT
•  DESCRIPTION OF ACCIDENT OR INCIDENT

•  EVALUATION OF LOSS POTENTIAL IF NOT
CONTROLLED
•  Probable Loss Severity (Major, Serious, Minor)
•  Probability of Occurrence (High, Moderate, Rare)
•  Exposure Level (Extensive, Moderate, Low)
•  Type of Contact or Near Contact With Energy or
Substance
•  Immediate/ Direct Causes (IC’s)
•  Basic /Underlying Causes (BC’s)
•  Control Action Needs (CAN)
Use of the
Investigation Result
INVESTIGATION RESULT
14001
Use the Results in Decision Making
Recommending Corrective
Actions
•  Specific
•  Measurable
•  Attainable
•  Realistic
•  Time-bound
Follow-up -
It’s the best way to ensure that
recommendations are carried out
Documenting an Accident
Investigation
Report forms require four

basic types of information
•  General information
•  A Summary
•  An Analysis
•  Recommendations

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Loss Control Management

• Properly conduct incident investigation

Rule 1050 Incident Investigation

Rule 1050 - Notification and Keeping of Records

Forms : Employer’s Work Accident/Illness Report

Rule 1050 Incident Investigation

1053.01: Notification - All work accidents or

Rule 1050 Incident Investigation

© Provides the safety officer means for

© Helps identify high injury rates

© Provides information on accident

Rule 1050 Incident Investigation

OSH RULE REPORT/FORM WHERE TO

Rule 1050 Work Accident Illness On or before the 20th 2 copies, to

Fatal/major accident Within 24 hours

The Actual Accident

Why Investigate Incidents/Accidents???

Why Investigate Incidents/Accidents???

Prevention is the reason for

… similar mishaps will occur.

Why Investigate Incidents/Accidents???

All incidents must be

Why Investigate Incidents/Accidents???

__________ is an accident that:

Managing the Accident Scene

Controlling Remaining Hazards

If a hazardous environment or toxic

Isolating the Site

• To protect people from further

Who Should Investigate???

• The size and make-up of the investigation

Who Should Investigate???

1. Gather information

Questions Needing Answers

• Who was involved?

• The Preliminary Investigation Process

Two Main Types of Witnesses

• Eye witnesses: persons who actually

• Victim & onlookers

• Conduct the interview in private at the workplace;

Advise: Never judge . . .

Include everything that could

2nd Entrance and Exit Door

Main Entrance and Exit Door

Examining: Materials, Machines, Environment

Machines & Equipment

Examining: Materials, Machines, Environment

Examining: Materials, Machines, Environment

Examining: Materials, Machines, Environment

If items have to be removed from

Examining: Materials, Machines, Environment

ROOT CAUSE ANALYSIS

Root Cause Analysis Tools

Ø Use the 5 Whys to Find the Root Cause

Electric device damaged

Car has no Car has an High High

Examples: AND Gate

No oil flow to gear box Fire Starts in the Chem.

No oil flow No oil flow

Compares how a job was actually

How it was How it should Prevailing

Systematic Causal Analysis

• DESCRIPTION OF ACCIDENT OR INCIDENT

•  Properly conduct incident investigation

© Provides the safety officer means for

©  Helps identify high injury rates

©  Provides information on accident

•  To protect people from further

•  The size and make-up of the investigation

1.  Gather information

•  Who was involved?

•  The Preliminary Investigation Process

•  Eye witnesses: persons who actually

•  Victim & onlookers

•  Conduct the interview in private at the workplace;

Ø  Use the 5 Whys to Find the Root Cause

•  DESCRIPTION OF ACCIDENT OR INCIDENT