Chapter 8: Accident

Investigation System

Module 9 OHSAS 18001:1999

 Learning
Objectives
Incident Investigation Process provides a
comprehensive approach to understanding
factors surrounding and contributing to
Upon receipt of the initial incident notification, the IIT
incidents and for preventing future
will identify the Team Leader for this incident, carry out
recurrence.Emphasis must be placed on fact the investigation, analyze root causes, formulate a
finding and not faultfinding corrective action plan, and monitor implementation of all
corrective actions

An Incident Investigation Team must be identified,

trained,and equipped to carry out the investigation,
analyze root causes,formulate a corrective action plan,
and monitor implementation of all corrective actions
related to all work-related incidents

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Definition
Incident: :An
Incident Anunplanned
unplannedevent
eventororchain
chainofofevents,
events,which
whichhas hasororcould
couldhave
havecaused
causedinjury
injuryoror
illnesstotopeople
illness peopleand/or
and/ordamage(loss)
damage(loss)totoassets,
assets,thetheenvironment
environmente.g.near
e.g.nearmiss,
miss,
accident,fire
accident,fire
Accident: :An
Accident Anevent
eventwhich
whichresulted
resultedinjuries
injuriesororillness
illnesstotopeople
peopleand/or
and/ordamage(loss)
damage(loss)toto
assetsand
assets andthe
theenvironments
environments
NearMiss
Near Miss: :An
Anevent
eventwhich
whichdiddidnot
notresult
resultinininjuries
injuriesororillness
illnesstotopeople
peopleand/or
and/ordamage
damage
(loss)totoassets
(loss) assetsand
andthe
theenvironment
environment

MODULE 9 OHSAS 18001:1999

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Objectives of Accident Investigation
1.1.For
Forwelfare
welfareobligation
obligationand
andresponsibilities
responsibilities
2.2.To
Toprevent
preventcontinuous
continuouslosses
lossesand
andclaims
claims/ /recurrence
recurrence
3.3.To
Tocomply
complytotothe
theOccupational
Occupationalsafety
safety&&Health
HealthAct
Actand
andRegulation
Regulation

Toachieve
To achievethe
theobjective,
objective,the
theinvestigations
investigationsneed
needtotodetermine
determinethe
thecausal
causalfactor
factororor
probablecause
probable causethat
thatled
ledtotothe
theinitiating
initiatingevents.
events. All
Allsystem
systemfactors
factors(human
(humanoperators,
operators,
operatingenvironment,
operating environment,equipment
equipmentdesign,
design,equipment
equipmentoperations,
operations,maintenance,
maintenance,etc)
etc)
needtotobe
need belook
lookatatalso
also

MODULE 9 OHSAS 18001:1999

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OHSAS 18001 Requirement
4.52 Accidents,
4.52 Accidents,incidents,
incidents,nonconformance
nonconformanceand
andcorrective
correctiveand
andpreventive
preventive
action
action

Establish and maintain procedure for responsibility and authority to :

• Handle and investigate accident, incident, non-conformance

• Take action and mitigate consequence
• Initiate and complete corrective and preventive action
• Confirm the effectiveness of actions taken
Key Goal
- The organization has implemented the EHS-MS procedure for actions taken as a result of accidents, incidents, and
non-conformances to the EHS-MS through all areas of the organization .
- Results indicate that the corrective/preventive action taken has been effective in most reported instances, root cause of the
issue has been identified, and there is rarely a reoccurrence of a previous accident/incident.
- There are numerous examples of effective corrective/preventive actions taken as a result, or current trends indicate
that accident/incident trends are non-existent.

MODULE 9 OHSAS 18001:1999

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Legal Requirements
[OccupationalSafety
[Occupational Safetyand
andHealth
Health(Notification
(Notificationof
ofAccident,
Accident,Dangerous
Dangerous
Occurrence,Occupational
Occurrence, OccupationalPoisoning
Poisoningand
andOccupational
OccupationalDisease)
Disease)
Regulations]NADOPOD
Regulations] NADOPOD

“Fatal injury” means injury leading to immediate death or death within one year of the accident
“Lost-time” means lost days counted from and including the day following the day of the accident measure in calendar days
“Dangerous occurrence” means an occurrence arising out of or in connection with work and is of a class specified in 3 rd Schedule
“Occupational poisoning and occupational disease” means a poisoning or a disease arising out of or in connection with work and is of a class specified
in Appendix 10-C; and
“Serious bodily injury” means any injury listed in Table 10-3
Immediately report any of the following accidents or incidents to the nearest Department of Occupational Safety and Health office by the quickest
means available and also follow-up the verbal notification with a written report within 7 days of the incident for the defined case
If an employee is determined to be suffering from any of the diseases listed in Table 10-4 or Appendix 10-C and such disease was contracted from
within the facility, medical practitioner will send notification to DOSH and facility
If an accident or dangerous occurrence causes the death or serious bodily injury of an employee or serious damage and danger to plant or other
property, ensure that any plant, substance, article or thing related to the incident is not removed, interfered with or disturbed except to:
- Save the life of, prevent injury to, or relieve the suffering of any person;
–Maintain the access of the general public to an essential service or utility; or
-Prevent further damage to or serious loss of property or environment
Keep the records for at least 5 years

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 Legal Requirements
Serious Bodily Injury

1. Emasculation

2. Permanent loss of the sight of either eye

3. Permanent loss of the hearing of either ear

4. Loss of any member or joint

5. Destruction or permanent impairment of the powers of any member or joint

6. Permanent disfiguration of the head or face

7. Fracture or dislocation of bone

8. Loss of consciousness from lack of oxygen

9. Loss of consciousness or acute illness from absorption, inhalation or ingestion of any substance, which
requires treatment by a registered medical practitioner

10. Any case of acute ill health where there is a reason to believe that this resulted from occupational exposure
to isolated pathogen or infected material

11. Any other work related injury or burns which results in the person injured being admitted immediately into
hospital for more than 24 hours

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Key Value of Accident Investigation System

1. A pre-planned, immediate and appropriate set of emergency response actions should be taken in
the event of an accident or incident in order to eliminate or control the hazards responsible for the
event

2. The department head where the accident occurred should immediately launch a preliminary
investigation to determine the immediate cause and corrective action plans. The individual then
needs to communicate a preliminary alert to all who need to know

3. Appropriate documentation needs to be completed for all accidents and incidents

4. A formal investigation should be initiated for all accidents/ incidents classified as serious or which
have the potential for serious consequences. The immediate cause, causal factors, root cause and
corrective action to prevent recurrence need to be reported

5. The department head and safety committee need to monitor corrective action activities until
complete

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Incident Investigation Process: How It Works

Incident Investigation Steps:

Initial Reporting IIT Actions Management Actions

Incident Investigation Report

Reviewed and Approved

Reviewed and Approved

Corrective Action Plan
Corrective Action Plan
Interviews Conducted
IIT and EHS notified
Mgr/Sup notified

Incident Analysis
Data Collected

Formulated

IIT – Incident Investigation Team A team of company individuals trained, equipped and authorized to investigate work-related incidents for
appropriate determination of root causes and to identify appropriate corrective actions for each root cause.

MODULE 9 OHSAS 18001:1999

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Any incident of a more serious nature
Major and high potential injury and illness investigation reports are
communicated throughout the corporation.

Initial Reporting
Notified to Plant Manager immediately
a) Death.
b) Serious injury, e.g. loss of limb, eyesight, hearing or
consciousness.
IIT and EHS notified
Mgr/Sup notified

c) Hospitalization of multiple persons or one or more day s.

d) Fire or explosion.
e) Chemical spills that require or result in contact with any external
agencies.
f) Property damage in excess of some amount
g) Contact by a representative of the public press.

MODULE 9 OHSAS 18001:1999

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Incident Investigation Process:
Initial Reporting
Initial Reporting

1. Supervisor contacted
Employee reports incident to the supervisor with
direct responsibility for the affected individual or work area

2. IIT activated and EHS notified

The responsible supervisor submits the initial
notification form to the IIT and EHS

3. Data Gathering
Affected employee and witnesses are interviewed
Facts and data are collected

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Incident Investigation Process:
Initial Reporting
Initial Incident Notification and Form is designed to:

Quickly Initiate Process

Collect Critical Early Information

Highlight Information Required

Guide Routing of Notification

Incident Investigation Team Organization


After notification team members convene immediately

Members review Initial Notification Form

Assign data-gathering tasks

Arrange for access to areas for Investigations

Arrange for participation of employee(s), supervisor(s)
and others

Determines when the Team will convene

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Incident Investigation Process:
IIT Actions
Gathering Data

Physical Data

Sketches

Photos

Interviews- Affected Employee,
Witnesses & Others

Records

Equipment Data

Schematics

Process Flowcharts

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Incident Investigation Process:
Physical Evidence
Gathering Physical Data

Physical evidence should be recorded first as it can rapidly

change or be obliterated. Check items such as:


Positions of employees Damage to equipment

Equipment being used Housekeeping of area

Materials being used Weather conditions

Safety devices in use Lighting levels

Position of appropriate guards Noise levels

Position of controls of machinery Permits

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Incident Investigation Process:
Physical Evidence
Physical Data Basics


Photos : Take photographs before anything is
moved. Later study may reveal conditions or
observations missed previously

Sketches : Draw the incident scene based on
measurements taken which may help in subsequent
analysis and will clarify any written reports

Broken equipment, debris, and samples of
materials : Remove for further analysis by experts

Written notes : Should be prepared regarding the
scene even if photographs are taken

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Incident Investigation Process:
Physical Evidence
Gathering Physical Data

Records Review- An overlooked source of information is company

documents such as:
 Training records: Should be checked when a person hasn't used
the right procedure or equipment.
 Maintenance logs and records: Should be checked for all
equipment related incidents.
 Schedules: Should be checked if people are trying to operate and
service equipment at the same time or if there is evidence of
congestion, interference, fatigue or stress.
 Job procedures and practices: Should be checked to ensure
there are current standards for the jobs being done.
 Permits: Collect and copy all permits.

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Incident Investigation Process:
The Interview
Gathering Data: Interviewing

Put the person being interviewed at ease

No-Fault Approach- enlist the person to participate in determining
cause and solutions

Two-Step Process

“What” - Behavioral Sequence of Events

“Why” - What factors influenced decision making

Who to interview?

Affected employee, witness
other knowledgeable employees

Who should conduct Interview?

Trained II Team member, who is
not a supervisor of the employee

Interview Location?

When? Resistance?
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Incident Investigation Process:
The Interview
DO DON’T
 Intimidate the witness

Put the person at ease
 Interrupt

Emphasize the reason for the
 Ask leading questions
investigation (determining what
 Show emotions
happened and why)
 Agree or disagree

Listen intently
 Make lengthy notes while

Confirm what you have heard
the witness is talking
(discovery agreements)

Try to sense any underlying
feelings of the witness

Make short notes during the
interview

Be slow witted, patient and friendly

Stop the interview if legal issues arise

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Incident Investigation Process:
The Interview
Putting the Person at Ease
Opening Questions
These questions are helpful in breaking the ice, getting started,
or if the conversation stalls.

We have read the initial report, but would you tell us in what
happened?

That’s very helpful, now could you back up from the incident to say
when you left the ______ and describe your action from there?

What happened after that?

How often does that happen?

What do you do when that occurs? What do you think other
coworkers do?

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Incident Investigation Process:
The Interview
Putting the Employee/Witness at Ease
Below are some general questions that should be asked each time:

 Where were you at the time of the incident?

 What were you doing at the time?
 What did you see, hear?
 What were the environmental conditions (weather, light,
noise, etc.) at
the time?
 What was (were) the injured worker(s) doing at the time?
 In your opinion, what caused the incident?
 How might similar incidents be prevented in the future?
Ask open-ended questions. Questions that cannot be answered by
"yes" or "no".

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Incident Investigation Process:
The Interview
What is resistance?
An attempt to stop, interrupt the interview process or to get the
interview off track. Examples:

Angry outbursts or tears

Avoid answering a question

Get off track

Tell unrelated stories

Yes/no answers

Question your knowledge or authority
How will you know?

Monitor your reactions to the resistance

Look for patterns

Good faith dealing
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Incident Investigation Process:
The Interview
Goal of the Interview is to be able to document a Behavioral
Sequence of Events

What is it?
Like a movie script

Why do it?
Gets facts, not blame

How to do it?
Focus on “WHAT” instead of “why”

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Incident Investigation Process: ITT Actions
Incident Investigation Team Re-Groups
 Evaluate data
 Interviews
 Photos
 Forms, Records, permits,
 etc.
 Is data complete?
 Would a third party understand what happened?

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Sample Incidents Questions Re: Tasks

WHAT SHOULD BE LOOKED AT AS THE CAUSE OF AN

INCIDENT?
These sample questions provided do not make up a complete
checklist, but are examples only. These questions should be used
as a checklist to determine if a fairly thorough interview was
conducted. Because we are asking open-ended questions during
the interview, these questions should not be asked directly to the
individual being interviewed.

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Sample Incidents Questions Re: Tasks

Task
Here the actual work procedure being used at the time of the incident is
explored. Members of the incident investigation team will look for answers
to questions such as:
Was a safe work procedure used?
Had conditions changed to make the normal procedure unsafe?
Were the appropriate tools and materials available?
Were they used?
Were safety devices working properly?
Was lockout used when necessary?
For most of these questions, an important follow-up question
is "If not, why not?“

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Sample Incidents Questions Re: Material
Material
To seek out possible causes resulting from the equipment and materials used,
investigators might ask:
Was there equipment failure?
What caused it to fail?
Was the machinery poorly designed?
Were hazardous substances involved?
Were they clearly identified?
Was a less hazardous alternative substance possible and available?
Was the raw material substandard in some way?
Should personal protective equipment (PPE) have been used?
Was the PPE used?
Again, each time the answer reveals an unsafe condition,
the investigator must ask why this situation was allowed to exist.

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Sample Incidents Questions
Re: Environment
Environment
The physical environment, and especially sudden changes to that environment,
are factors that need to be identified. The situation at the time of the incident is
what is important, not what the "usual" conditions were. For example, incident
investigators may want to know:

What were the weather conditions?

Was poor housekeeping a problem?
Was it too hot or too cold?
Was noise a problem?
Was there adequate light?
Were toxic or hazardous gases, dusts, or fumes present?

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Sample Incidents Questions Re: Personnel

Personnel
The physical and mental condition of those individuals directly involved in the event
must be explored. The purpose for investigating the incident is not to establish
blame against someone, but the inquiry will not be complete unless personal
characteristics are considered. Some factors will remain essentially constant while
others may vary from day to day:

Were workers experienced in the work being done?

Had they been adequately trained?
Can they physically do the work?
What was the status of their health?
Were they tired?
Were they under stress (work or personal)?

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Sample Incidents Questions Re: Mgmt
Management
Management holds the legal responsibility for the safety of the workplace and
therefore the role of supervisors and higher management must always be
considered in an incident investigation. Answers to any of the preceding types of
questions logically lead to further questions such as:
Were safety rules communicated to and understood by all employees?
Were written procedures available?
Were they being enforced?
Was there adequate supervision?
Were workers trained to do the work?
Had hazards been previously identified?
Had procedures been developed to overcome them?
Were unsafe conditions corrected?
Was regular maintenance of equipment carried out?
Were regular safety inspections carried out?

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Root Cause Analysis: S/C/M
Identify Systems/Conditions/Method (S/C/M) Issues
Critical to Incident

Why are they critical?

Contributed to the Incident

May be antecedents to at-risk behaviors

S/C/M examples: inadequate procedures, congested
working conditions, lack of training, poor work flow
design, inadequate machine guarding, etc.

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Root Cause Analysis: S/C/M
S/C/M Common Issues to Review

Work Procedures

Appropriate Tools/Equipment

Equipment Malfunction

Environmental Conditions (weather, lighting, etc.)

Proper Training

Work Hours

Corrective Action Responses

Resource Issues

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Root Cause Analysis: S/C/M Method
Root Cause Analysis - a problem analysis process that
begins with undesirable effects and works back to root
causes and core problems.

Uses Six Sigma method

Asks “why” until deepest root cause that company can
affect is found

Breaks chain of cause and effect

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 Root Cause Analysis: Process

 Start with Undesirable Effect (UDE)

 UDE because of negative occurrence; goal of “0” not being met
 Start with “what” happened, then “when”
 Identify Verb - Action word

 For each verb, ask why the issue exists or occurs

 Test with “IF” – “THEN”

 Continue asking why until you get to the lowest cause

in the chain of cause and effect at which we have
some capability to cause the break

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Examples of UDE’s

Employee fell down stairs when foot missed step and hand rail
broke

Hydrochloric acid spilled on floor when bottle fell off counter

Employee lost tip of finger when reaching in to clear jammed

machine

Cart ran over employees foot when it rolled backward

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Example: Root Cause Analysis
THEN Why did employee fall?
UDE: Employee fell down stairs when
foot missed step and hand rail broke
AND
 Once the problem or situation is

She missed Lost her

defined, brainstorm the UDE’s
IF
step balance

 If a problem has several

Handrail broke potential
causes, you must analyze each
Bolts missing

AND  From each UDE, ask “Why” and

continue until root cause is
Installed Bolt came
with only loose over reached.
one bolt time

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Example: Root Cause Analysis
(cont’d)

Installed with only one bolt Bolt came loose over time

AND AND

Contractor – No inspection
shortcut to after completed Not secured Constant
save $ work due to holding/weig
inappropriate ht on
installation handrail
when people
use stairs

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Example: Root Cause Analysis
UDE: Fire Alarm system was activated due to a programming
error, which shut down power to the data center.

Why does this problem happen?

Contractor technician did not program the new device correctly; and he did not test the
system.
Why did the technician incorrectly program the fire alarm?
Because he was following alarm schematics that were outdated.

Why were the alarm schematics outdated?

After prior changes to the system, a previous service technician did not update the
schematics; there was no process in place by company to verify.
Why is there no established verification procedure?
In the past, the organization has not recognized this need. Lack of company
expertise.

UDE: Contractor technician did not test fire alarm system

after programming resulting in activation of the alarm.

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Example: Root Cause Analysis
UDE: Customers complain about waiting too long to get connected to staff
during lunch hours.

Why does this problem happen?

Backup operators take longer to connect callers.

Why does it take operators longer?

Backup operators don’t know the job as well as the regular operator/receptionists do.

Why don’t backup operators know the job as well?

There is no special training, no job aids to make up for the gap in experience and on-
the-job learning for the backups.

Why don’t they have special training or job aids?

In the past, the organization has not recognized this need.

Why hasn’t the organization recognized the need?

The organization has no system to identify training needs.

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Root Cause Analysis: S/C/M & Behavior
Remember an incident may have both At-Risk Behaviors and
S/C/M issues

Before concluding an incident was due to worker carelessness, have the

following been considered?
Was the worker distracted? If yes, why?


Was a safe work procedure being followed? If not, why not?



Does the at risk behavior occur routinely? If so, what



consequences support the behavior?

Were safety devices in order? If not, why not?


Was the worker trained? If not, why not?



An inquiry that answers these and related questions will probably reveal
conditions in addition to behavior that require correction beyond
attempts to prevent "carelessness".

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Exercise

A machine operator is involved in an accident by coming into

contact with a dangerous part of a machine, describe
i. The possible immediate causes (4)
ii. The possible root (underlying) causes (4)

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 Answer
Answer 1
The possible immediate causes
- Inadequate or non-existent safety devices
- Poor housekeeping
- Loose clothing
- Machine malfunction
Answer 2
- Operator error
Inadequate training
Inadequate instruction/supervision
Poor maintenance
Inadequate risk assessment
Personal factors – stress, fatigue and the influence of
drugs and alcohol
Poor management systems
Selection of personnel
Selection of correct equipment

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Corrective Action
Develop Corrective Action Plan

What, Who and By When

Must be Concrete and Measurable

Write so the “Who” knows specifically “What” to Do

Plant Manager’s Review and Approval Required

Approves both the Incident Investigation Report and
Corrective Action Plan

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Approval/Continuing Roles
Approvals

Ensure all report data and analysis is complete and
accurate

The IIT Leader will route the Root Cause Report to
the Plant Manager for approval.

Continuing Role

Person responsible for Corrective Action(s) provides
updates on the IIT system.

Information is tracked until closure.

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Sample of Process Flow
Incident Reporting and Investigation Process Flow
Responsible
Supervisor
Individual /

Affected Individual reports to

RS submits incident notification form
Affected

responsible supervisor (RS)

Performs root cause

Does incident
EHS / IIT

analysis using tool of Formulates Notification provided to Monitors closure of

Immediately initiates Conducts interviews classification meet EHS/IIT for corrective corrective actions to
choice or from corrective action
investigation and collects incident “Extreme” or “High” action(s) monitoring closure
NO recommended Six Sigma plan
process facts severity?
toolkit *
YES
Business Unit

NO
Director

Reviews root cause

Validates Severity Approved?
report and action plan
classification before team is
formed YES
Black Belt

Facilitates analysis with EHS/IIT Injections are then

Facilitates risk
utilizing Six Sigma Current Reality determined and tested for
assessment on final
Tree to determine the correct validity using the Future
injections using FMEA
Root Cause(s) Reality Tree
Site/Plant Mgr

NO

Reviews root cause

Approved?
report and action plan

YES
Responsible.
Person (for
Corrective
Action)

Notification provided to responsible Responsible person(s)

person(s) for corrective action(s) complete and document
implementation corrective action closure

NO
OH / Case

Determines
Mgr

Did Injury/
immediate Illness occur? Determines/documents Manages case to Determines/documents
Reviews
reporting classification closure Seagate classification
notification YES
requirements for
form
Government and
Seagate)
EHS

* Cause-Effect Matrix, Fishbone, Mind Map, Affinity Diagram.

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 ROLES AND RESPONSIBILITY
Manager/Department Responsibility
Site Management Appoint individuals to serve on the IIT.
· Provide necessary resources to carry out investigations and corrective actions.
· Review quality and content of incident reports and corrective action plans. Approve or reject as appropriate
Site EHS Department  Train and equip the IIT to perform responsibilities.
 Participate as a member of the IIT.
 Determine and comply with local government and Company reporting requirements. (submission / notification , etc NADOPOD regulations )
 Evaluate, manage, and maintain records related to work -related injury or illness.
· Regularly review the status of all incidents under investigation or open cases of injury or illness to determine appropriate company classification.
· Maintain accident investigation records
Incident Investigation · Attend required training
Team · Perform investigation and analysis according to the SOP and associated training
· Document and submit required reports on a timely basis.
· Communicate required actions to the responsible person.
· Communicate findings to affected individual and responsible supervisor.
· Monitor and verify corrective action closure.
· Ensure all incident data is final and complete.
Managers and · Understand the incident reporting process.
Supervisors · Initiate reporting when an incident occurs.
· Participate in the investigation process. Assist IIT in conducting investigation
· Timely completion of required corrective actions as assigned.
· Follow requirements related to injury/illness management.
Employees · Understand the incident reporting process.
· Report all incidents as soon as they occur.
· Participate in the investigation process.
· Follow requirements related to injury/illness management.

MODULE 9 OHSAS 18001:1999

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Process FMEA Form

MODULE 9 OHSAS 18001:1999

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Construction of a Cause-Effect Diagram

Materials Methods C/N

C C

N N
Problem/
Desired
N N Improvement
N
C
C
C

Machinery Manpower

C = Control Factor
N = Noise Factor
MODULE 9 OHSAS 18001:1999
PDOSH Page 47
Fish Bone Diagram
Man

Machine Methods
Five Key
Sources of + Environment
Variation

Materials Measurement

Use
UseCause
CauseandandEffect
EffectDiagram
DiagramtotoSingle
SingleOut
Out
Variation
VariationSources
Sourceswithin
withinthe
the“5M’s
“5M’s++E”
E”
MODULE 9 OHSAS 18001:1999
PDOSH Page 48
Fishbone Diagram
MAN MACHINE
Production staff
awareness of
treatment limitation Poor communication
Awareness
with production staff
Training Shock load

Competence Inadequate capacity Recommendations of

review over-ridden
Discharge Motivation
Increased treatment Inappropriate process
compliance
plant capacity
failure Resource provision Poor maintenance

Supervision Inaccurate

Communication Infrequent
Between production
and treatment plant
supervisor

MANAGEMENT MAINTENANCE

MODULE 9 OHSAS 18001:1999

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 Fishbone Diagram: Analysis 1:
Missing Scheduled Waste Label
No one was
accountable

The drum was in The adhesive

a caustic specification was
environment incorrect for this type
of drum

The change in
A label was The purchasing agent
The label’s label type was not
missing from a The label “fell bought cheaper labels
adhesive was of cleared by the EHS
scheduled waste off” than those specified
poor quality Manager
drum

The drum has The supplier

been around for provided a bad
years and the batch of labels
label
There was no deteriorated
scheduled waste
training

WHAT? WHY? WHY? WHY? ROOT CAUSE!

MODULE 9 OHSAS 18001:1999
PDOSH Page 50
Fishbone Diagram: Analysis 2

EQUIPMENT PEOPLE

Computer not tracking drum movement Poor leadership

Constant job rotation

Forklift regularly grazes drum
Storage area manager not trained
A label was
Automatic drum handler rips off label Lack of empowerment
missing from the
scheduled waste
Poor label adhesive No one was assigned accountability drum
No written labeling procedure
Label supply ran out
No inspection procedures
Labels inaccessible
Accountability only given to one shift

MATERIALS PROCEDURES

CAUSES EFFECT

MODULE 9 OHSAS 18001:1999

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Systematic Cause Analysis
Technique (SCAT)
- Prediction of most possible immediate and root cause
-Reference during investigation and assist to identify
possible unsafe act and condition

SCAT

MODULE 9 OHSAS 18001:1999

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Test Question
If the incident did not result in any injury or illness, there is no reason to
conduct an incident investigation.

A. True
B. False

Answer :B

MODULE 9 OHSAS 18001:1999

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Test Question
Which of the following is critical to an effective investigation
report:

A. Interviewing the affected individual(s) and witness(es).

B. Reviewing records.
C. Taking photos or sketches
D. All of the above.

Answer :D

MODULE 9 OHSAS 18001:1999

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Test Question
Incident investigation process:

A. Focuses on fact finding rather than fault finding

B. Provides a comprehensive approach to understanding factors
surrounding and contributing to incidents and for preventing
future recurrence
C. Utilizes Six Sigma tools on Extreme and High severity
incidents for more in-depth analysis.
D. Focus is on identifying system problems
E. All of the above.

Answer :E

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Test Question

The best way to obtain the facts regarding an incident is to

ask the affected individual closed ended questions?

A. True
B. False

Answer :B

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Test Question

An at-risk behavior is a behavior that results in an incident.

A. True
B. False

Answer :B

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Test Question

In root cause analysis, the type of issues that are identified can
be grouped as :

A. System , Conditions and Machine

B. Statistic, Communication and Method
C. System, Conditions and Methods
D. Statistic, Communication and Machine

Answer :C

MODULE 9 OHSAS 18001:1999

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Essay Question

(Bird and Loftus) for the following five ‘dominos’; give

examples for each domino.
• lack of management control
• basic causes (personal and job factors)
• immediate causes
• accident
• loss

MODULE 9 OHSAS 18001:1999

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