Module 5: Analysis and Fact-Finding

Research Assignment 1

OHS 115 – Incident Investigation & Response

University of Fredericton

Matthew Thiessen-Edwards
Oct 13th, 2021
 Incident Investigation Recommendations

During an incident investigation, there are three distinct phases that have been outlined in
the CSA Z1005 Standard1, initiation, investigation, and finally the analysis and findings. With all
relevant data having been gathered and evaluated, causes both direct and indirect determined,
recommendations and corrective actions can begin.

SMART and Ready?

Preparedness is a very important part for an investigation throughout every step, as it

impacts not only the resources required, but the difficulty of the investigation. With a well-
prepared incident investigation plan ready and in place, the time and resources required for an
investigation lessen significantly, leaving more resources available for corrective actions and
continual improvement, and ultimately prevention. So how can we tell If we are prepared for an
investigation? By asking some SMART questions!
 Is there a transparent defined list of roles and responsibilities? Communication route for
escalation?
 Do we have the required expertise and knowledge? Are there enough resources available
for outside assistance if needed?
 Have relevant processes and
procedures been documented and
communicated? Are they in line
with safety?
 Are there readily available forms
and documents? Is the team
familiar?
 Are there any relevant legal
obligations documented? Is the
company aware of them?
 Is there regular audits of processes
and procedures? When was the last
time?
 Has all relevant data been gathered?
Has it been stored properly?
 Have there been any new changes or
additions to the data? Has it been
added to report?
 Key Recommendation Elements

When making recommendations for corrective actions during an incident investigation,

there are a few key elements that must be kept in mind. These elements are important to the
recommendation process to keep things clear and concise for those who are not familiar with the
investigation process. In order to achieve this, we must consider the following questions.
 What are the immediate actions? Medium-term? Long-term?
 What is the time frame for these actions?
 What method of communication should be used?
 What materials and resources are required? Are they realistic and reasonable?
 Are there measurable metrics that can be monitored to track improvement?
 What are the necessary steps to implement actions?
 How can continual improvement be achieved?
 Have all costs been determined? Indirect and direct?

The impact these recommendations can have on a report are very important when
presenting the information to high-level stakeholders. As such, we must ensure that all of the
information and recommendations are accurate, easy to understand, and well justified in terms of
cost compared to results. At the end of the day, most high-level stakeholders within an
organization are concerned about costs, especially in terms of immediate action and upfront
costs. To overcome this obstacle, its always best to include all indirect costs as well as direct so
the whole picture can be seen, especially when corrective action isn’t taken.

Conclusion

Incidents and accidents happen all the time, and each one requires an investigation to some
degree. When we are investigating an incident, its not only about gathering information and filing it away
in a cabinet somewhere, but we also must make recommendations and take corrective actions to prevent
further incidents for occurring. Safety is, and should always be, the number on priority always as no
matter what, human life is more valuable than any amount of money. With that in mind, we should
always be trying to strive for continual improvement, and to do so we can follow the PDCA model.

As a cyclical cycle, the PDCA model can be used during an incident investigation during the
recommendation phase to promote continual improvement. After analysing the data of an incident, we
begin Planning our recommendations for immediate action to prevent further incidents. Once we have a
plan of action, we can Do it and begin Checking the results by monitoring activity visually and/or with
metrics. With metrics and other data in mind, we can begin to Act upon improving our recommendations
for short-term actions, thus restarting the cycle back to planning for short-term improvement. By
following the model, we can continually improve processes and procedures to ensure a safer workplace.
Sources

1. CSA Z1005:21 National Standard of Canada, August 2021 - https://view.csagroup.org/RBnCMB

2. UBC CAIRS Quick tips - https://wiki.ubc.ca/images/0/0f/UBC_CAIRS_Quick_Tips.pdf
3. University of Manitoba – A Guide to Investigating Workplace Incidents -
https://umanitoba.ca/admin/vp_admin/risk_management/ehso/media/AIguideWSH.pdf
4. https://lifars.com/2020/09/what-is-incident-response-readiness-assessment/