NIOSH SHO 15-Incident Investigation and Corrective Action

Incident
Investigation And
Corrective Action
Safety and Health Officer
Certificate Course
1
Learning Objectives
• To describe the importance of incident
investigation
• To list 4 types of incident
• To describe principles of investigation
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Learning Objectives
• To explain 8 steps in incident investigation
• To explain ways to plan and implement

corrective and preventive action
Scope
• Overview of an Incident Investigation
• Principles of Incident Investigation
• Pre-Planning and Strategy of an

Investigation
• Corrective Action
What is an Incident?
• Incident is:
– An unexpected
– Unplanned event in a sequence of events
– That occurs through a combination of causes
– Which result in:
• Physical harm (injury, ill-health or disease) to an
individual
• Damage to property
• A near miss, a loss
• Any combination of these effects
What is a “Near miss”?
• A “Near miss” is:

– An event which did not result in injury or
damage to property but had the
potential to do so
– Shares the same root causes as an
accident. It is only because of chance
that no harm or damage occurred
– Needs similar attention as an accident
Four Basic Types of Incidents
• Minor accidents:
• Paper cut occurs on finger, box of
materials dropped on toe
• Serious accidents (cause injury or

damage to equipment or property):
• Falling off a ladder, hazardous chemical
spill, forklift dropping a load
Four Basic Types of Incidents
• Long Term
•Hearing loss, cancer resulting from
exposure to chemicals
• Near misses
Accident Causation Model
An accident is the result of a sequence of an
immediate cause and an underlying cause
1. Results of the accident - harm or damage

2. Incident – the accident
3. Immediate causes – symptoms of lack of
control
4. Basic (underlying) causes – the real problems
The Three Basic Causes of
Accidents
•Poor Management Safety Policy & Decisions
•Personal Factors
•Environmental Factors
Basic Causes
 Unsafe Act Indirect causes Unsafe
Condition 
 Unplanned Incidence ACCIDENT

Personal Injury,
Property Damage
Direct Causes

Contributing Factors To
Accidents –
Immediate Causes (Symptoms)
The unsafe acts and unsafe conditions
can be categorised as follows:
1. Human behaviour
2. Design of equipment and plant
3. Systems & procedures including use of
materials
4. Environmental surroundings
Root Causes of Incident -
Management (The Real
Problem)
• Personal Factors • Supervisory Performance
– Lack of knowledge or skill, – Inadequate instructions, failure
improper motivation, physical of SOPs, rules not, enforced,
or mental conditions hazards not corrected,
devices not provided
• Job Factors • Management Policy &

– Physical environment, sub- Decisions
standard equipment, – Measurable standards, work in
abnormal usage, wear & tear, progress measure , work-v-
inadequate standards, design standards, evaluation ,
& maintenance, purchasing corrective action
standards
What is an Incident Investigation
• A management tool by which:
– Work-related injuries, ill health, diseases and
incidents are systematically studied so that their
root causes and contributing factors can be
identified
– The organisation’s Occupational Safety and

Health management system can be continually
improved
Why Investigate an Incident
• To prevent repetition of the same work-
related injuries, ill health, diseases and
incidents
• Compliance to Legal Requirement
Why Investigate an Incident
• Accurate record (for insurance, legal
prosecution, public enquiries)
• Organisation’s own policy and business

reasons
Who Should Investigate?
Depends on Severity of the
Incident
• Internal Investigation team
– Individuals involved
– Supervisor, Safety officer
– Upper management
– External consultants
– Members of the Safety and Health Committee
Who Should Investigate?
Depends on Severity of the
Incident
• External agency involvement

– DOSH and / or DOE, Police, etc.
What & When to Investigate
• All serious and long-term incidents &
near misses
• As soon as possible to prevent:

– Scene interference
– Deterioration of evidence
– Losing people’s recollection of the
incidence
Principles of Incident
Investigation
Principles of Investigation
• Carried out according to

procedure:
– For all incidents
– By competent persons with
participation of workers.
• Should:
– Be systematic and documented
– Be treated as urgent (to prevent productivity loss
and deterioration of evidence)
– Be objective (fact finding only)
– Find the underlying (root) cause(s)
– Identify failures in OSH management system
– Implement corrective action
• The results should:

– Be communicated to the Safety and Health
Committee who should make appropriate
recommendations
– Include external investigation reports such as
DOSH and SOCSO
– Be communicated to appropriate persons for
corrective action
– Included in management review (OHSAS 18001)
Be Prepared –
Before the Incident
• Identify who has the authority to investigate
and carry out mitigation action and
corrective action to completion
• Have a system for notification and

recording of all incidents and injuries
Be Prepared –
Before the Incident
• Designated trained and competent
investigator
– Only be responsible for investigating
How Much to Prepare
Dependent on:
– The number and type of workplaces
– The equipment required to conduct the
investigation
– Ability for investigator to reach an
investigation site as soon as possible
– Geographical location
– Reliable transportation requirements
Notification Procedure
• Notification:
– To management after an incident
– Initiated by the person involved
– Should be to his immediate superior
– To visitors and contractors
– Recorded
• Automatic system to notify investigator
• Include members of Safety and Health
Committee (if any)
Investigation Procedure
1. For recording evidence
2. For observation and recording of fragile,

perishable or transient evidence
e.g. Instrument readings, control panel
settings, weather & other environmental
conditions, chemical spills, stains, skid
marks
Investigation Kit Preparation
• Camera & • Clipboard, Pre-
Video Camera printed Forms
• Cassette Tape • PPE
Recorder • Containers for
• Flash and Batteries Taking and Storing
• Mobile Telephone / Samples
Walkie-Talkie • Barrier Tape
Responsibilities
• Employee
– Record in incident book (supervisor
checks)
• Supervisor / Manager
– Initiate risk control response: first-aid,
fence area, etc. other preventive action
– Inform SHO
Responsibilities
SHO
• Organise camera, tape and report form
• Check line management report
• Investigate if incident is serious and require to notify
authorities such as DOSH, DOE, Police, etc.
• Complete incident record form
• Summary report to Safety and Health Committee
Responsibilities
Investigator
• Visit and survey incident scene
• Eliminate the hazards:
– Control of chemicals
– De-energise
– De-pressurise
– Light it up
– Shore it up
– Ventilate
On-Site Investigation Strategy
Steps in Incident Investigation
1. Gather information
2. Search for and establish facts
3. Isolate essential contributing factors
4. Determine the causes & root cause
Steps in Incident Investigation
5. Determine corrective actions
6. Report, review the findings
7. Analyze incidents
8. Implement corrective actions
Gathering Information
• Time is of the essence
• Take samples, photos, measurements and

sketch diagrams,
– Preserve and protect data, Information and evidence
– Collect in order of fragility
• People, Positions, Parts and Papers; (4Ps)
• Record injury types & groups
• Identify people involved

– Excellent source of first hand
knowledge
• Interview injured, witnesses,

supervisors and others
• Get preliminary statements as soon as
possible from all witnesses
• May present pitfalls in the form of:

– Bias, perspective, exaggeration, hidden
agenda
Gathering Information -
People (Witnesses)
• One-to-one in private
• Put them at ease

– Make it clear the objective of the investigation is
to avoid recurrence, not to apportion blame
• Do not interrogate but Question!

– Let each witness speak freely on their version
People (Questioning)
• Strategic questioning - No leading
questions
• Obtain facts not opinions
• Ask What, Where, When, Why, Who and
How
• Get observation on events before, during
and after the incident
People (Questioning)
• Make sure the witness understands questions
• Use sketches and diagrams to help the

witness
Recording Interview
• Take notes without distracting the witness
• Record the exact words used by the witness

to describe each observation
• Use a tape recorder only with consent of the

witness
Recording Interview
• Differentiate what is directly observed and
what is hearsay and note accordingly
• Verify claims afterwards
Closing the Interview
• Identify the designation and qualifications of
each witness (name, address, occupation,
years of experience, etc.)
• Supply each witness with a copy of their

statements
Closing the Interview
• Get signed statements where possible and

necessary
• Thank the interviewee
Position
• Document the incident scene before any
changes are made:
• Victim location
• Position of each witness on a master chart (including
the direction of view)
• Machinery, energy and chemical sources
• Other contributing factors
• Take photos, draw scaled sketches
• Record measurements
Parts
• Around incident scene prior to, during or
after the incident that may have influence
• Materials, pieces of plant, tools, equipment,
buildings
• May require qualified person to examine or
comprehensive testing or sophisticated
equipment
• Reports by “expert witness." will form part of
the investigation evidence
Gathering Evidence –
Paper
• Production schedules or process diagrams
• Check current working procedure
• Check qualifications
• Check training records
• Check corrective actions
• Check equipment maintenance records
• Check incident records
Findings
• Isolate essential contributory factors
“Would the incident have happened if this
particular factor was not present?”
• Determine Causes
Employee actions, environmental conditions,
equipment condition, procedures, training
Findings
• Find Root Causes. Ask:
What caused behaviour? Why equipment

was not fixed? Why condition was not
corrected?
Determine Corrective Action
• Recommendations made for

corrective actions
• Recommendations for corrective

actions to improve OSH
management system
Incident Investigation Report
• Clear, complete description and

accurate information of events leading
up to the accident
• Clear, complete and correct
identification of all causal factors
• Recommendations
• Supporting documentation
• Proper review and sign off
Preventive and Corrective
Action
Corrective and Preventive
Action
• Preventive and corrective action should be
carried out for:
• Incidents
• Management system non-conformances
• Recommendation(s) for preventive and

corrective actions must be communicated
clearly
Corrective and Preventive
Action Planning
• Procedure for handling investigation and
preventive and corrective action
• Identification and authority for personnel
handling investigation and preventive and
corrective action
• Authority for initiating and confirming the
completion of corrective action
Implementing Corrective and
Preventive Action
• Must be based on root causes

• Appropriate to the problem at hand
• Reviewed through risk assessment
process to ensure that the correction will
not introduce a new hazard
• Strict time table for implementation
established
• Follow up conducted
Summary
• Aim of investigation is to find root causes

• Purpose is so that similar incident will not be
repeated
• Prepare organisation, procedure and
equipment in anticipation of incidents
• Corrective and preventive action should be
carried out for incidents and management
system non-conformances

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Incident

• To list 4 types of incident

• To describe principles of investigation

• To explain ways to plan and implement

• Principles of Incident Investigation

• Pre-Planning and Strategy of an

• A “Near miss” is:

• Serious accidents (cause injury or

1. Results of the accident - harm or damage

 Unplanned Incidence ACCIDENT

• Job Factors • Management Policy &

– The organisation’s Occupational Safety and

• Compliance to Legal Requirement

• Organisation’s own policy and business

• External agency involvement

• As soon as possible to prevent:

• Carried out according to

• The results should:

• Have a system for notification and

1. For recording evidence

2. For observation and recording of fragile,

2. Search for and establish facts

3. Isolate essential contributing factors

4. Determine the causes & root cause

6. Report, review the findings

8. Implement corrective actions

• Take samples, photos, measurements and

• Record injury types & groups

• Identify people involved

• Interview injured, witnesses,

• May present pitfalls in the form of:

• Put them at ease

• Do not interrogate but Question!

• Make sure the witness understands questions

• Use sketches and diagrams to help the

• Record the exact words used by the witness

• Use a tape recorder only with consent of the

• Verify claims afterwards

• Supply each witness with a copy of their

• Get signed statements where possible and

• Thank the interviewee

What caused behaviour? Why equipment

• Recommendations made for

• Recommendations for corrective

• Clear, complete description and

• Recommendation(s) for preventive and

• Must be based on root causes

• Aim of investigation is to find root causes

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