Incident Investigation

AMEC Earth & Environmental

Monthly Safety Training Program
March 2009
 Expectations
• This incident investigation presentation provides guidance and
awareness.

• Generally, Safety Professionals, Management, Supervisors

(includes Project Managers), Unit SHE Coordinators, designated
Safety committee members and safety representatives will perform
investigations.

• Employees need to understand the process of incident investigation,

in event that they are involved in an incident or asked to participate
in an investigation.

• This training may also help to prevent incidents through the analysis
of factors, leading to incidents, and their control, elimination or
avoidance.
 Introduction
An incident investigation is an after the fact
reaction to an unfortunate event. By determining
the Root Cause and contributing factors, steps
can be implemented through use of policy,
procedures, and training to avoid future
occurrences.

The goal of the investigation is prevention

and learning, not to place blame!
 Incident or Accident?
• An incident is any unexpected event that may
or may not have caused personal injury or
damage
• An accident is an unexpected or unplanned
event that results in injury to persons, property
damage or loss
• A near miss or dangerous occurrence are
terms for an event that could have caused injury
to persons, property damage or loss.
 Is it an accident or incident?
The term incident is sometimes used to describe
either an accident or a near miss. It is argued
that accident implies that the event was related
to fate or chance. When the root cause is
determined, it is usually found that many events
were predictable and could have been
prevented if the right actions were taken –
making the event not one of chance or fate, thus
the term incident often preferred.
 Causation
Remember these three basic facts:

1. Accidents are caused.

1. Accidents can be prevented if the causes are

eliminated.

1. Unless the causes are eliminated, the same

accidents will happen again.

Usually there are four or five root causes or factors

that contribute to an accident. Often there are even
more - your task is to identify as many as possible.
 Accidents
• There is some correlation
between the numbers of no
injury, light injury, serious injury
and fatality events of similar
causation.
• By investigating all ‘Incidents’
we learn how to prevent more
serious accidents
• Remember: Rare or exotic
incident that may have
catastrophic consequences,
are not be identified by use of
this model alone.
 Investigation Objectives:
ACCIDENT & INCIDENT INVESTIGATION OBJECTIVES
The objectives of effective accident and incident investigations are to:

✓ identify the root and basic causes and determine how these resulted
in injury, property damage or loss.
✓ identify means to prevent similar accidents or incidents from
occurring.
✓ utilize the investigation findings to develop and/or revise policies and
procedures and determine if training is necessary to prevent
reoccurrence.
✓ ensure compliance with legislation as defined by OSHA, EPA,
WCB/WSIB, Departments of Labour or Environment, etc.
✓ provide awareness for all workplace parties.
✓ determine financial implications and process compensation claims.
 Domino Accident Causation
Model
Underlying Immediate Incident Loss
Causal Causal Direct
factors factors cause

Personal Sub Struck Injury

Lack Factors Standard by Damage
of Control - Acts Fell Off Loss

Management Sub
Job Caught
Systems Standard
Factors In
Conditions
 Lack of control - Management Systems

• Inadequate safety program.

• Inadequate program standards.

• Inadequate procedures.

• Inadequate compliance with the standards.

• Inadequate resources and commitment to above.

These failures permit the Underlying (Basic System) Causes to

exist
 Underlying (Basic System) Causal
Factors : Personal
• Inadequate psychological capability.
• Inadequate physical capability.
• Physical stress or illness.
• Improper motivation.
• Lack of knowledge.
• Lack of skill.

These are Preconditions for Immediate Causes

 Underlying (Basic System) Causal
Factors : Job
• Poor leadership or supervision.
• Poor purchasing.
• Poor engineering.
• Poor maintenance.
• Inadequate tools or equipment.
• Poor working standards and systems.
• Negative peer pressure.
• Abuse or misuse.
• Not taking the time to talk (safety meeting, JSA development etc.)

Preconditions for Immediate Causes Continued

 Immediate Causes - Unsafe Acts

• Operating equipment without authority.

• Operating at improper speed.
• Making safety devices inoperable.
• Using defective equipment.
• Using equipment improperly.
• Failure to follow procedures.
• Failure to intervene.
• Failure to recognize change.

Unsafe Acts may be Passive or Active!!

See Human factors

 Human Factors in Accident
Causation
Most Accidents have a human factor.
The skilled Accident Investigator looks beyond human
errors & mistakes.

✓Rule-breaking: Deliberate or Habitual.

✓Lack of knowledge/training.
✓New task, inexperience = action causing accident.
✓Errors following rules - typically misinterpretation.
✓Lapses, errors & mistakes.
✓Unavoidable rule-breaking.
Immediate Causes - Unsafe Conditions

• Inadequate barriers or guards.

• Defective tools or equipment.
• Poor housekeeping.
• Hazardous environment e.g. noise, gas, fume, high temp, low
temp.
• Inadequate warning systems.
• Inadequate ventilation.
• Inadequate PPE.
Underlying (Basic System) Causal factors are the fundamental
reason why Accidents happen. They are an inevitable outcome of
lack of management control!

Pressure
vessel ruptures
below swp

Why?
Corroded
vessel

Why? Corrosive
Corrosion
Conditions, not
undetected corrosion proof ROOT
WHY? Why? CAUSES

Lack of Inadequate design/

Maintenance/ specification
Inspection prog
 REMEMBER…
Accident Investigations
are not just a good
idea…they are required
by law!
 Quiz
What is the purpose of an Accident
Investigation?

• To determine Root Cause or causes

• To prevent reoccurrence
• Learning
 Notification
In an EMERGENCY provide first aid to the injured then the
supervisor immediately calls:
• 9-1-1 to summon medical aid if necessary.
• WorkCare’s 24/7 hotline: (800) 455-6155.
• One of the following Incident Team Members:
• Regional SHE Manager or SHE Director
• Local/Unit SHE Coordinator
• Human Resources
• Project Manager, Unit Manager/Group Leader.
• Member of Safety Committee, if applicable.
• Media Crisis, if necessary.
 AMEC First Alerts
• An internal Notification process.
• Responsibility of an Incident Team
Member to complete and submit the First
Alert form to senior management.

Criteria for First Alert Notification:

1. Accident occurs which results in serious
injury or death;
2. A reportable dangerous occurrence occurs;
3. An incident occurs which could lead to
enforcement action;
4. An enforcement notice is issued;
5. An incident occurs which results in injury to
a member of the public/visitor;
6. An incident occurs that is classified as high
potential severity;
7. An incident that results in environmental
damage.
 Notification continued…
• In the case of immediately reportable incidents such as
those requiring an AMEC First Alert, the notification of
external agencies may be required to be performed by
AMEC SHE Department, Management, or designee.
• Local regulations vary for agency reporting obligations –
review your local requirements or contact the SHE
Department.
• Management also needs to be notified immediately so
they can contact the family of the injured worker.
 Accident Investigations
The Investigation Process
Stage 3
Research, Analysis
Corrective Actions
Stage 2
and Communication
Active Investigation
Stage 1
Preparation
Review documentation
Incident Preserving &
Procedures Tests/simulations/
Documenting Scene.
calculations.
Training M obilizing Team
Toolkits Collecting,preserving
Analyze findings
& controlling evidence
identify direct and
First Alert Reporting.
underlying causes.
Interviewing witnesses.
Communicate lessons
learned and prevent
re-occurrence

Continuous Critical Review of Process

 Active Investigation

The Team will gather their

information from:

Documentary Interviews
Observation
Evidence
 Investigation Kit
BE PREPARED!
Have a kit ready that includes:

• Appropriate forms or checklists and applicable regulations.

• Floor plans, diagrams, or maps of the workplace.
• Camera (with film or digital capacity)* and voice recorder.
• Flashlight, batteries.
• Emergency phone numbers and other useful contacts.
• Tape measure.
• Required PPE for investigators.
• Pencils, papers, pens and clipboard.
• Barricade tape, paint.

*It is of crucial importance to ensure that digital images have not been modified.
Do not change file names, and store securely.
 QUIZ
List 3 other items that you would include in an
Accident Investigation kit:
• Checklists.
• An extra disposable camera.
• Measuring wheel.
 First on the scene - Investigator
First on Scene
• Summon emergency response / First Aid Hazard
Assessment - Check the area for any hazards (no fire,
no wire, no gas, no glass, no confined space, don gloves
and get CPR mask)
• Secure the scene and address risk of any further injury.
• Keep the accident scene as undisturbed as possible.

Supervisors and Investigators actions continue. . .

• Cooperate with Emergency Response Providers / Police
/ Labour
• Document the accident scene by photographs, drawings
and measurements.
• Identify and interview all witnesses separately and
individually.
• Record all information accurately.
 The Physical Investigation
Start by:
1. Identify witnesses to interview.
2. Record the accident scene and evidence:
a) Photograph several angles of the scene and close-up
details of equipment/material or property damage.
b) Prepare drawings of the scene to clarify written reports
and prompt witnesses during interviews. Note the
locations (and viewing angles) of all witnesses,
equipment, and materials.
c) include measurements of objects and locations of
witnesses.
 Collecting Information

Information from:

• Written instructions - JSA

• Safe Operating Procedures
• Risk assessments
• Permits-to-work
• Inspection results
• Specifications
• Health & Safety Plan
• Method statements

Documentary Evidence
 Gather Documentary Evidence
Examine training records
• Was appropriate training provided?
When was training provided?

Examine equipment maintenance records

• Is regular service provided?

Has it been inspected?
Is there a recurring type of failure?

Examine accident records

• Have there been similar incidents or
injuries involving other employees?
 The Interview

Interview anyone present at the scene and consider others who may not
have been present, but who have special knowledge of the job, task, or
equipment involved in the accident (e.g. project manager or site
maintenance personnel).

Key Considerations
• Recollection declines by 50-80% in the first 24 hours after an incident.
• Influence of third party discussions.
• Consider trauma and shock effects, counseling needs etc.

Advise witnesses who may be interviewed by HSE/Police/Labour under

caution to seek assistance from AMEC prior to the interview.

Remember: It is desirable to interview witnesses ASAP after the event but

in practice circumstances may prohibit this.
 The Interview Process
When an accident occurs it is important to remember
that witnesses have experienced a traumatic event and
empathy should be expressed. A stressed or defensive
witness can hinder the process.

Remember we are all working towards the same

goal of preventing reoccurrences!
 Interview Tips…
• Investigators should conduct separate interviews with
each person.
• Put the interviewee at ease, remind them that the
purpose of the investigation is prevention, not to place
blame.
• Introduce the investigation team, and if using a tape
recorder ask permission.
• Ask the witness to explain what happened in their own
words.
• Ask for further detail if unsure of their explanation.
• Follow-up with open-ended questions that require more
than a ‘yes’ or ‘no’ answer.
 Tips Continued…
• Listen carefully and avoid interruptions.
• Avoid asking ‘leading questions’.
• Go over your notes with the witness and ask
them to verify their accuracy by signing.
• Encourage them to contact you with any
information they may remember, and inform
them you may need to speak with them again.
• Thank them for their help and cooperation.
 Determining Causal Factors
While it is crucial to establish the immediate
causes of the accident, these are generally the
symptoms of higher level or management
systems failures.
Management system failures have the largest
potential to cause accidents and it is incumbent
on the investigator/team to ensure that the
investigation is not ended until the Root Causes
are identified.
 Causal Analysis
You will now be presented with a tool that may be used to
analyze the causes (acts, conditions, personal and job factors)
of incidents/accidents.
When applied correctly it will comprehensively identify the
incident/accident causes. (Note: legible on 11x17 paper)
A-Z of Accident Causes
For each immediate cause (act or condition) identify any and
all applicable root causes (personal or job factors), or specify
other. Every Root Cause is colour coded to associate with a
System Cause. This is where corrective actions may be
warranted.
 Investigation Traps

Put your emotions aside!

- Don’t let your feelings interfere - stick to the facts!

Do not pre-judge.
- Find out the what really happened.
- Do not let your beliefs cloud the facts.

Never assume anything.

Do not make any judgments.

 The Investigation Report
An accident investigation must determine certain facts
and the report must include them.
• WHO was involved or injured? Were there witnesses? (Names, job titles.)
• WHERE did the accident happen? (Name of department, machine, location,
etc.)
• WHEN did the accident occur? (Date, exact time of day, shift.)
• WHAT happened? (A brief description of the accident.)
• WHAT were the immediate causes? (Conditions, procedures, equipment,
acts, sequence of events that preceded the accident.)
• WHY was the unsafe act or condition permitted? (Lack of training,
supervision, rule enforcement, maintenance.)
• HOW can a similar accident be prevented? (Must be specific and provide
recommendations for specific action.)

Once the recommendations are made, the employer has an

obligation to initiate corrective action, report the action to the
health and safety committee and communicate to employees.
Remove CONFIDENTIAL personal/medical information
 Recommendations
• Corrective actions should always consider
the hierarchy of hazard controls from the
most effective through to the least effective:

• Engineering Controls
• Administrative Controls
Less
• Retraining and PPE Effective
 Potential Actions
• It is worth reiterating that the goal of the investigation is
not to place blame, but a potential outcome may result in
disciplinary action, an agency order, occupational or
criminal charges to an individual or corporation.
• The infraction of policies, safety rules, procedures, acts
and regulations may be subject to disciplinary action,
based on a weight of evidence.
• At AMEC, where necessary, disciplinary action would
involve collaboration between the SHE Department,
Human Resources, and Management.
 Accident Investigation Summary
The provision of first aid or medical attention is always the first
priority!

Secure and Manage Accident Scene

• Secure the scene immediately. Usually this is the responsibility of the

first person on the scene. The employer or supervisor notified is
responsible to preserve evidence and ensure that there is no further
risk of injury or damage.
• Critical injury or fatality scenes must not be disturbed without
permission from an Agency Inspector (or other regulatory authority).
• No one may disturb, alter, or remove anything at/or connected to the
scene or occurrence.
• Exceptions may apply where lives are endangered, or where the
interruption of essential services or further damage to
equipment/property is possible. Security support should be
considered.
 Cost of Accidents

• Please review the safety video at the following link. This

12 min. video demonstrates clearly the distinction
between incident types and outcomes.
• Link to Safety Video
• Reference: Harsco Corporation is a diversified,
worldwide industrial services company.
 Evaluation
• An online Quiz has been developed
• Safety professionals, Management, Supervisors, Project
Managers, SHE Coordinators, designated Safety
committee members and safety representatives are
required to complete the Quiz.
• All employees are welcome to complete the online Quiz.