Accident Investigation – Key Concepts Content Meanings & Paradigms Accident causation theories...

Accident Investigation – Key Concepts

Content Meanings & Paradigms Accident causation

theories What is an

investigation and why do it?

Interviewing witnesses Analytical Methods Case study

Dr Stephen PeckittHead of H&S CEMEABovis Lend Lease

Meanings & ParadigmsWhat does the word accident mean?

A worker drops his hammer whilst working on a roof. The hammer falls off the roof (under gravity (E)) and hits (IB):

1) a person on the head (V) and cracks their skull2) a car (P) denting the roof 3) the path next to the person

Accident as a simple equation –

E + IB + V = Injury (+/-P) E + IB +/- P = Near Miss E = Energy - electricity, gravity, heat, mechanical, virus, wind,

etc. IB = Inadequate Barrier – physical guard to protect against

energy emission or provide personal protection, distance, time,.. V = Victim P = Property

Incident Investigations – Key Concepts

Are these accidents?


Meanings & Paradigms

Definitions of Accidents:

specific, unidentifiable, unexpected, unusual and unintended external action which occurs in a particular time and place, with no apparent and deliberate cause but with marked effects (Wikipedia, 2010).

unplanned loss events which result in physical harm to people or property or the environment (Ridley, 1990)

unplanned damage incidents.

Meanings & ParadigmsCausation

What causes accidents? bad luck, carelessness, risk taking, failure of

management processes, natural products of the very complex world we live in, etc.

Four general accident causation paradigms: Fatalist – acts of god, destiny or bad luck, Individualistic – carelessness, risk taking and rule

breaking Modernist – accidents are inevitable and unimportant by-

products of industrial age, and Postmodernist – accidents are failures to manage risk.



Blame Accident victims often blame themselves; while managers are

quick to blame the victim or immediate supervisor, and are reluctant to place any blame on themselves for accidents.

It is a form of denial, a self-protective mechanism and a way of simplifying a complex phenomena. It is a deep rooted human psychological characteristic known as fundamental attribution error.

We need to keep the blame bias out of investigations in order to get at the facts and identify the root causes of incidents

Only apportion blame where it is clearly proven to be due, eg for sabotage and violations.



Incident v Accident

Risk management experts generally avoid use of the term 'accident' to describe events that cause injury and loss to highlight the predictable and preventable nature of most damage incidents.

The term incident is preferred as it implies a generally negative probabilistic outcome which may have been avoided or prevented had circumstances leading up to the accident been recognized, and acted upon, prior to its occurrence.

Such incidents are viewed from the perspective of epidemiology, (i.e they are predictable and preventable). Preferred words are more descriptive of the event itself or severity of the damage, rather than of its unintended nature (e.g. drowning, fall, first aid, lost time, major, fatal, catastrophic, major and minor damage, etc.)

Source: Wikipedia


Causation Theories

Domino – Heinrich, Bird & Loftus

Human Error – HSE, Rassmussen

Swiss Cheese Model – Reason


Heinrich’s Domino TheoryUnsafe Acts and Unsafe Conditions Paradigm

Herbert Heinrich is credited with the first accident causation theory. He analysed 12,000 accident insurance claims and over 50,000 injury reports in the 1930s, and identified unsafe acts by workers as the primary cause of 88% of accidents.

Heinrich developed a domino theory of accident causation where a single sequence of events results in an accident:

the first domino is concerned with the accident victim’s personal traits;

the second – victims actions; the third - unsafe acts and conditions; the fourth - the accident; the fifth - the injury.


Loss Control Domino Models


HUMAN ERROR – To Err is humanWe all make mistekas

Human

failure

Violations

Errors

Skill based

Mistakes

Slips

Rule-based

Knowledgebased

Routine

Exceptional

Situational

& Lapses

HSE 1999


Prof. James Reason Rather than being the main instigators of an

accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions.

Their part is usually that of adding the final garnish to the lethal brew using ingredients that have already been long in the cooking.

Reason (1990) p173.


Errors made at business planning stage

Errors made during task planning

Active Errors at the workface – lapse, mistake, short cuts

Reason’s Swiss Cheese Model

INCIDENTSLatent Pathogens Active failures

Layers of Defence

strategy

systems

targets

vision

Layers of

Defence

competence

process controls

risk assessment

supervision

Layers of Defence

machine guards

maintenance

training


Key concepts from causation theories

Incident causation is a complex dynamic process, not a simple linear process.

Everyone makes mistakes so activities and equipment need to be designed to take account of human error.

The negative impact of incidents and injuries is wider than the victim – includes their family, worker morale, production, profitability, and both personal and corporate reputation (BP, Toyota!).

Employers and those who control activities have a duty of care towards workers and others who may be impacted by their activities, so must ensure they effectively manage the risks involved in their undertaking to prevent incidents occurring.


An investigation is a systematic and thorough attempt to learn the facts about something complex or hidden; an inquiry to ascertain facts based on the detailed and careful examination of evidence.

There are four main reasons for investigating accidents: Identify causes – immediate and underlying; Assess weaknesses - legal compliance and risk

management; Define remedial actions - corrective & preventative; Share lessons learnt – prevent similar incidents occurring by

encouraging learning, change and improved risk management.

The focus and depth of the investigation will vary depending on the role and expertise of those undertaking the investigation.

The ultimate goal is to prevent similar events occurring again!


Why Investigate Incidents?

What Incidents should be Investigated?

Fatal Incidents Major Injury Incidents Legally Reportable Incidents - > 3 day Lost Time Injury Incidents First Aid Injury Incidents Near Misses – no injury


Injury statistics are commonly the sole

focus of safety initiatives

To prevent incidents we

need to focus on making the right

decisions

What you permit to happen here… bad

practice, poor decisions, unsafe acts & conditions

The Injury Pyramid – where to focus our efforts?

Become reality here in the form of damage to people,

property and the environment…


Who should be involved?Dictated by severity of incident, speed of investigation, technical complexity, processes, etc.

Investigation Team – number of people, skills, experience, availability, consultants, police, lawyers;

Timing - ASAP to examine and record scene, collect witness details and statements, consider wider implications, reporting timescales;

Reporting – to who, by when, what format, regular updates, legal privilege;

Management – who, roles and responsibilities Review – factually correct, technical issues, lessons

learnt; Implementation of remedial measures – by who and

when, tracking and verification;


Investigations - Common Errors

Stating the apparent, immediate cause rather than the root cause.

Slip on oil spot on floor. Cause is related to outcome rather than the incident itself.

Chemical leak spray in face - “employee not using face shield”

Stopping investigation too soon not going far enough. Facility equipment failure “Be more careful”

Blaming the victim Operator was attempting to pick up parts that were on floor

while not leaving their stool

It is easy and quick to identify the immediate causes but to get to underlying causes to really understand how an incident occurs and how to prevent a repeat – we need to get deeper into the chain of events which ended in the injury.



Importance of Analytical Approach to Investigations

Avoid investigators’ personal assumptions

Logical approach to gathering evidence

Co-ordinate investigation activities

Identify Root Causes

Verify findings

Clearly communicate findings

Implement actions taken to prevent future incidents

Evidence Gathering

• Gather the known facts about the incident to understand the nature, scale, technical complexity, etc.

• Allocate appropriate resources to conduct investigation.• Collect physical evidence at the scene.• Identify witnesses and the organisations involved.• Conduct interviews to establish:

• Who, What, Where, When, Why & How• Keep probing for more information with open questions.• Clarify understanding of the key issues with interviewees

• Don’t jump to conclusions and recommendations too quickly• Go back and collect more evidence and statements if

needed


Evidence Gathering Physical Evidence

take pictures, copies of documents, measurements, drawings, etc.

take possession of items for detailed examination or evidence for legal case

obtain expert analysis of equipment

Interviewing People Informal - information gathering Formal - statement taking

Chain of evidence Give receipts for all physical evidence obtained All statements should be signed Keep secure where they cannot be tampered with


Evidence Gathering – Investigator's Tools

Personal Protective Equipment Digital Camera Logbook Statement forms Evidence bags & tags Tape measure Spare batteries, pens, SD card, etc Video recorder


Who to Interview?

Injured Person Witnesses of the incident Witnesses Pre-Accident Witnesses Post-Accident Supervisors Managers Maintenance, Housekeeping,

Engineering, Purchasing……...


An interview is a structured conversation with a purpose – to establish facts.

Developing a rapport with the witness is crucial to effective interviewing

RRespect EEmpathy SSupportive PPositive Open Non-Judgemental Straight forward Equal

Interviewing Techniques


Interviewing Techniques Put person at ease - Assure “no blame” Listen carefully Repeat the story back and check

understanding Be polite and thank the witness

Questions should be: Clear - short and simple using easily

understood language, one point at a time Logical - follow lines of enquiry, ask only

relevant questions Polite but firm tone – establish status


Interview Techniques – Key Information

Personal details; Confirm employer, profession and role; What they were doing at the time of

the incident; What relevant information they

remember: Use open questions about what they

saw happen?, where they were?, who was involved?, what they did, etc.

Probe issues of concern for clarity or to check validity and compare with other evidence;

Use closed questions to confirm specific details

Witness signature and date Avoid using

Leading & Hypothetical questions Statements

Specific Open Questionsto focus on specific areas of the account

Use 5 Whysprobe every key issue

LINK

Process is repeated for every section

At home Journey to work

Day at work

Journeyhome

Closed Questionsclear-up issues or close out line of enquiry

General Open Questionleads to an account of several smaller sections

Interview Techniques FUNNELLING


Open Questions

Closed QuestionsLINK


LINK


Open Questions

Closed Questions

Interviewing Techniques Questions & Perceptions


Memory is selective and stored in isolated fragments which fade and become influenced by attitudes and beliefs. Cognitive interview techniques can help increase memory recall by 10%.

Free recall – ask the witness to recall everything they can remember – don’t question

Mental reconstruction – describe the scene by describing everything they felt and saw

Reorder recall – question issues in different order Different perspective – ask how other witnesses

may have perceived the incident Focus on specifics - conversations, reactions,

noises, numbers, smells, etc.


Interviewing TechniquesCognitive Interviewing

Interview Tips Actively listen - concentrate, comprehend and sustain

Encouraging cues – open posture, eye contact, nod head, open hand gestures, “uh huh”

Pauses and silence - encourage responses

Echoing – repeating witness phrases to prompt further elaboration;

Summarise regularly - to keep focus, revisit issues if necessary and agree statements

Avoid misleading the witness – do not use leading questions, and opinion

Observe Body Language – deception indicated by, shuffling feet and crossing legs, touching face and licking lips, drumming and gripping, blushing and perspiring.


Plan & PrepareAccountClosureEvaluate

Engage & ExplainPPEEAACCEE

Interviewing Techniques Formal Statement Taking


PP - - Plan & Plan & PreparePrepare

Venue – Your place or theirs?Timing – Too soon, too late?Witness Support – accompanied?Agenda – what do you need?Prepare key questionsPhysical evidence verification

INTERVIEWING Techniques

Introductions - reason for interview,their role, subsequent actionsExplain format of interviewAny questions before starting?

E - Engage & E - Engage & Explain Explain


A - A - AccountAccount

Their account of what they witnessedIntroduce evidenceEnsure key questions answeredGo back to issues which need clarifying

INTERVIEWING WITNESSES

Check understanding of key issuesGo through statement to agree content Witness to sign any changes and at end of statementGive them a copyAsk if they have any questions?Clarify what happens nextThank them for their cooperation

C - C - ClosureClosure

What have you learned?How does this fit with other evidence?Anything missing – to follow up?How did you perform?Next actions

E - EvaluationE - Evaluation


Interview Techniques - Summary

Conduct the interview as soon after the incident as possible.

Create a relaxed atmosphere, avoid blame, get all sides and request ideas for prevention.

Keep the interview private to avoid group biases. Focus on establishing facts, avoid irrelevancies,

assumptions, and smoke screens. Ask open-ended non-leading questions to explore lines of

enquiry. Listen, test understanding and validate key evidence with

closed questions. Repeat the story back, probe into all aspects of the non-

conformance or accident, get all sides of the story.


Examples of Analytical MethodsRoot Causes Analysis

Fishbone 5 Whys Decision / Event Trees Management Oversight Risk Tree


Problem Roots

People

Environment

Methods

Equipment

Fishbone Diagram

Tool for systematic review of cause and effects. Assists in categorizing many potential causes of problems

in orderly way. Start with categories – people, methods, environment,

equipment, etc. Review causes within each category.


Example Flow/Decision Tree

YES NO

POSSIBLE CORRECTIVE ACTIONS

REVIEW PROCEDURES FOR DID ANY DEFECTS IN EQUIPMENT, WAS THE LOCATION/POSITION OF

INSPECTING, REPORTING, MAIN- YES TOOLS, OR MATERIAL CONTRIBUTE EQUIPMENT, MATERIAL, EMPLOYEE NOPOSSIBLE CORRECTIVE ACTIONS TAINING, REPAIRING, REPLACING, TO HAZARDOUS CONDITIONS? A CONTRIBUTING FACTOR?

REVIEW J OB PROCEDURE FOR OR RECALLING DEFECTIVE EQUIP-

HAZARD AVOIDANCE. REVIEW MENT, TOOLS, OR MATERIALS. NO YESSUPERVISORY RESPONSIBILITY &

SUPERVISOR-EMPLOYEE POSSIBLE CORRECTIVE ACTIONS

COMMUNICATIONS YES WAS THE HAZARDOUS WAS THE HAZARDOUS CONDITION DID THE LOCATION/POSITION OF PERFORM J OB SAFETY ANALYSIS. WAS THE J OB PROCEDURE USED (CONTINUED PAGE 2) (CONTINUED FROM PAGE 1)

CONDITION REPORTED? YES RECOGNIZED? EQUIPMENT, MATERIAL, EMPLOYEE YES REVIEW J OB PROCEDURE. CHANGE A CONTRIBUTING FACTOR? NOPOSSIBLE CORRECTIVE ACTIONS NO CAUSE HAZARDOUS CONDITION? LOCATION/POSITION OF EQUIPMENT POSSIBLE CORRECTIVE ACTIONS

TRAIN EMPLOYEE IN REPORTING OR EMPLOYEE. PROVIDE GUARD REVIEW J OB PROCEDURE FOR

PROCEDURES. STRESS INDIVIDUAL POSSIBLE CORRECTIVE ACTIONS NO NO RAILS, BARRIERS, SIGNS, ETC. HAZARD AVOIDANCE. REVIEW YESACCEPTANCE OF RESPONSIBILITY . PERFORM J OB SAFETY ANALYSIS. SUPERVISORY RESPONSIBILITY &

IMPROVE EMPLOYEE ABILITY TO SUPERVISOR-EMPLOYEE POSSIBLE CORRECTIVE ACTIONS

RECOGNIZE EXISTING OR WAS THE HAZARDOUS WAS THE HAZARDOUS YES COMMUNICATIONS WAS THERE A WRITTEN OR DID J OB PROCEDURES ANTICIPATE PERFORM J OB SAFETY WAS LACK OF PPE OR EMERGENCY

POTENTIAL HAZARDS. CONDITION RECOGNIZED? YES CONDITION REPORTED? KNOWN PROCEDURE (RULE) YES THE FACTORS THAT CONTRIBUTED NO ANALYSIS AND CHANGE EQUIPMENT A CONTRIBUTING NOMENT, TOOLS, OR MATERIALS. NO POSSIBLE CORRECTIVE ACTIONS FOR THIS J OB? TO THE ACCIDENT? J OB PROCEDURE. FACTOR IN THE INJ URY?

TRAIN EMPLOYEE IN REPORTING

POSSIBLE CORRECTIVE ACTIONS NO PROCEDURES. STRESS INDIVIDUAL NO YES YESDEVELOP & ADOPT PROCEDURES WAS THERE EQUIPMENT INSPEC- ACCEPTANCE OF RESPONSIBILITY .

TO DETECT HAZARDOUS NO TION PROCEDURES TO DETECT POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS

CONDITIONS. CONDUCT TEST. THE HAZARDOUS CONDITION? WAS EMPLOYEE SUPPOSED TO BE REVIEW J OB PROCEDURES & DID EMPLOYEE KNOW IMPROVE J OB INSTRUCTION. WAS APPROPRIATE PPE SPECIFIED WAS APPROPRIATE PPE PROVIDE APPROPRIATE PPE. WAS MANAGEMENT SYSTEM

IN THE VICINITY OF THE NO INSTRUCTIONS. PROVIDE GUARD THE J OB PROCEDURE? NO TRAIN EMPLOYEES IN CORRECT FOR THE TASK OR J OB? YES AVAILABLE? NO REVIEW PURCHASING AND A CONTRIBUTING FACTOR?

YES EQUIPMENT/MATERIAL? RAILS, BARRIERS, SIGNS, ETC. J OB PROCEDURE. DISTRIBUTION PROCEDURES.

POSSIBLE CORRECTIVE ACTIONS YES YES NO YES YESREVIEW PROCEDURES. CHANGE DID THE EXISTING EQUIPMENT

FREQUENCY OR COMPREHENSIVE- NO INSPECTION PROCEDURES DETECT POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS

NESS. IMPROVE EMPLOYEE ABILITY THE HAZARDOUS CONDITION? WAS THE HAZARDOUS CONDITION CHANGE LIGHTING OR LAYOUT TO DID EMPLOYEE DEVIATE DETERMINE WHY. ENCOURAGE ALL DID EMPLOYEE KNOW THAT REVIEW J OB PROCEDURES. WAS THERE A FAILURE BY SUPER- IMPROVE SUPERVISOR CAPABILITY

TO DETECT DEFECT & HAZARDOUS CREATED BY LOCATION/POSITION NO INCREASE VISIBILITY OF EQUIPMENT FROM THE KNOWN J OB YES EMPLOYEES TO REPORT PROBLEMS WEARING SPECIFIED PPE WAS NO IMPROVE J OB INSTRUCTION. VISION TO DETECT, ANTICIPATE, YES IN HAZARD RECOGNITION AND

CONDITIONS. YES OF EQUIPMENT/MATERIAL VISIBLE? PROVIDE GUARDRAILS BARRIERS, PROCEDURE? WITH ESTABLISHED PROCEDURE. REQUIRED? OR REPORT A HAZARD CONDITION? REPORTING PROCEDURES.

SIGNS, ETC. COUNSEL OR DISCIPLINE EMPLOYEE.

POSSIBLE CORRECTIVE ACTIONS YES PROVIDE CLOSER SUPERVISION. YES NOSPECIFY CORRECT EQUIPMENT, WAS THE CORRECT

TOOLS, & MATERIALS IN J OB NO EQUIPMENT, TOOLS, OR MATERIALS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS

PROCEDURES. USED? WAS THERE SUFFICIENT REVIEW WORK SPACE WAS THE EMPLOYEE MENTALLY REVIEW EMPLOYEE REQUIREMENTS DID EMPLOYEE KNOW HOW TO USE IMPROVE J OB INSTRUCTION. WAS THERE A FAILURE BY SUPER- REVIEW J OB SAFETY ANALYSIS &

WORK SPACE? NO REQUIREMENTS AND MODIFY AND PHYSICALLY CAPABLE OF NO FOR THE J OB. IMPROVE EMPLOYEE AND MAINTAIN THE PPE? YES VISION TO DETECT/CORRECT DEV- YES J OB PROCEDURES. INCREASE

YES AS REQUIRED. PERFORMING THE J OB? SELECTION. REMOVE OR TRANSFER IATION FROM J OB PROCEDURE? SUPERVISOR MONITORING.

EMPLOYEES WHO ARE MENTALLY CORRECT DEVIATIONS.

POSSIBLE CORRECTIVE ACTIONS YES YES OR PHYSICALLY INCAPABLE OF J OB. NOPROVIDE CORRECT EQUIPMENT, WAS THE CORRECT

MATERIALS, & TOOLS. REVIEW PUR- NO EQUIPMENT, TOOLS, OR MATERIALS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS

CHASING SPECIFICATIONS & READILY AVAILABLE? WERE ENVIRONMENTAL CONDI- MONITOR OR PERIODICALLY CHECK WERE ANY TASK IN THE J OB CHANGE J OB DESIGN AND WAS THE PPE USED PROPERLY DETERMINE WHY AND TAKE WAS THERE A SUPERVISOR/EMPL- ESTABLISH A PROCEDURE THAT

PROCEDURES. ANTICIPATE TIONS A CONTRIBUTING FACTOR YES ENVIRONMENTAL CONDITIONS AS PROCEDURE TO DIFFICULT TO YES PROCEDURES. WHEN THE INJ URY OCCURRED? NO APPROPRIATE ACTION. IMPLEMENT OYEE REVIEW OF HAZARDS & J OB YES REQUIRES A REVIEW OF HAZARDS

FUTURE REQUIREMENTS. YES (LIGHTING, NOISE, TEMP, AIR, ETC)? REQUIRED. CHECK RESULTS PERFORM (MENTAL OR PHYSICAL)? PROCEDURES TO MONITOR AND PROCEDURE FOR TASK & J OB PROCEDURES FOR TASK

AGAINST ACCEPTABLE LEVELS. ENFORCE USE OF PPE. INFREQUENTLY? PERFORMED INFREQUENTLY.

POSSIBLE CORRECTIVE ACTIONS INITIATE ACTION IF NEEDED. NO YESREVIEW PROCEDURES FOR STOR- DID EMPLOYEE KNOW WHERE TO NOAGE, ACCESS, DELIVERY, OR DIS- NO OBTAIN EQUIPMENT, TOOLS, OR POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS

TRIBUTION. REVIEW J OB PROCED- MATERIALS REQUIRED FOR J OB? IS THE J OB STRUCTURED TO EN- CHANGE J OB DESIGN AND WAS THE PPE ADEQUATE? REVIEW PPE REQUIREMENTS. POSSIBLE CORRECTIVE ACTIONS

URES FOR OBTAINING EQUIPMENT, COURAGE OR REQUIRE DEVIATION YES PROCEDURES. NO CHECK STANDARDS, SPECIFICA- WAS SUPERVISOR RESPONSIBILITY DEFINE AND COMMUNICATE

TOOLS, & MATERIALS. YES FROM J OB PROCEDURES? TIONS, AND CERTIFICATION & ACCOUNTABILITY ADEQUATELY NO SUPERVISOR RESPONSIBILITY &

OF THE PPE. DEFINED AND UNDERSTOOD? ACCOUNTABILITY. TEST FOR

POSSIBLE CORRECTIVE ACTIONS YES UNDERSTANDABILITY AND

PROVIDE CORRECT EQUIPMENT, WAS SUBSTITUTE EQUIPMENT, CONTINUED YES ACCEPTANCE.

TOOLS, & MATERIALS. WARN YES TOOLS, OR MATERIALS USED IN POSSIBLE CORRECTIVE ACTIONS ON PAGE 1

AGAINST USE OF SUBSTITUTES PLACE OF THE CORRECT ONE? INSTALL EMERGENCY WAS EMERGENCY EQUIPMENT WAS EMERGENCY EQUIPMENT POSSIBLE CORRECTIVE ACTIONS

IN J OB PROCEDURES AND IN EQUIPMENT AT APPROPRIATE NO READILY AVAILABLE? (CONTINUED FROM PAGE 2) YES SPECIFIED FOR THIS J OB (eg EMER- NO WAS SUPERVISOR ADEQUATELY TRAIN SUPERVISORS IN

J OB INSTRUCTION. NO LOCATIONS. GENCY SHOWER, EYEWASH)? TRAINED TO FULFILL RESPONSIBILITY NO ACCIDENT PREVENTION

IN ACCIDENT PREVENTION? FUNDAMENTALS.

POSSIBLE CORRECTIVE ACTIONS YES NOALTER EQUIPMENT/TOOL TO MAKE DID DESIGN OF THE EQUIPMENT OR YESMORE COMPATIBLE WITH HUMAN YES TOOLS CREATE OPERATOR STRESS POSSIBLE CORRECTIVE ACTIONS

CAPABILITY & LIMITATIONS. EN- OR ENCOURAGE ERROR? INCORPORATE USE OF WAS EMERGENCY EQUIPMENT POSSIBLE CORRECTIVE ACTIONS POSSIBLE CORRECTIVE ACTIONS

COURAGE EMPLOYEES TO REPORT EMERGENCY EQUIPMENT IN NO PROPERLY USED? PROVIDE EMERGENCY WAS THERE A FAILURE TO INITIATE REVIEW MANAGEMENT SAFETY

POTENTIAL HAZARD CONDITIONS. NO J OB PROCEDURES. EQUIPMENT AS REQUIRED? CORRECTIVE ACTION FOR A KNOWN YES POLICY AND LEVEL OF RISK ACC-

HAZARDOUS CONDITION? EPTANCE. REVIEW PROCEDURE &

POSSIBLE CORRECTIVE ACTIONS YES RESPONSIBILITY TO CARRY OUT

REVIEW CRITERIA IN STANDARDS, DID THE GENERAL DESIGN OR CORRECTIVE ACTIONS.

SPECIFICATIONS, & REGULATIONS. YES QUALITY OF THE EQUIPMENT OR POSSIBLE CORRECTIVE ACTIONS

ESTABLISH NEW CRITERIA AS TOOLS CAUSE HAZARD CONDITION. ESTABLISH INSPECTION/MON- DID EMERGENCY EQUIPMENT

REQUIRED. ITORING SYSTEM FOR EMERGENCY NO FUNCTION PROPERLY?

POTENTIAL HAZARD CONDITIONS. EQUIPMENT. PROVIDE FOR

IMMEDIATE REPAIR OF DEFECTS.

WAS THE HAZARDOUS

CONDITION(S) OF EQUIPMENT

A CONTRIBUTION FACTOR?


Event analysis trees Management

Oversight and Risk Tree -

logical, structured, generic fault tree based on equation E+V+IB = Incident

Aims to identify and prevent - management errors, control risks and optimise performance


A ‘5 Why’ analysis is a simple method which adds discipline to the incident investigation based on asking “why” something occurred and answering with “because” then repeating this up to five times

It ensures that the key relevant contributory factors are fully considered and analysed.

It focuses on gaining a deep understanding of why an incident occurred by analysing critical factors

It facilitates the identification of the root causes of an incident It facilitates the creation of remedial action plans which focus on

preventing the root causes occurring again.

“5 Whys” Cause & Effect Analysis

Why?

Why?

Why?

Why?

Why?


Cause & Effect Analysis – “5 Whys”

• The 5 Why’s analysis leads to a comprehensive picture of the potential contributing factors of an incident and ultimately their root causes

Why?

Why?

Why?

Why?

Why?


Immediate Causes

Root Root CausesCauses

Incident

Irrelevant

RCA findings from UK Govt Study of construction fatal accidents (2009)

Competence Planning

Equipment

Supervision

Leadership


Incident Incident

Analyse and Identify underlying causes and root cause of each critical factor

Validate findings, lessons learnt, and corrective and preventative measures

Phase 1

Phase 3

Phase 4

Phase 2Analyse and identify the immediate

critical factors

Gather the key informationWho, What, Where, When, Why

Complete investigation report

Close out investigation report by

validating implementation of improved

risk control measures.

Phase 5

Conduct Root Cause Analysis for fatal and major accidents, major environmental or property damage and high potential near miss incidents

Emergency Response: Emergency Response: Rescue, Treat, Make Safe, Preserve, Record

LESSONS LEARNT LESSONS LEARNT CORPORATE MEMORY

All injury incidents and near misses should be investigated to determine 5 Ws


RCA RCA INVESTIGATIONINVESTIGATIONPROCESS PROCESS

Phase 6

Rescue and Treat Injured Persons

Make Safe

Preserve Scene – secure evidence

Record - witness details, etc.

Emergency Response: Emergency Response:


Evidence gathering 4Ps

Parts

Positions Paper

People


Who What

Where When

WhyPhase 1When gathering evidence

it is useful to remember the 4Ps.

• Ensure that all relevant people have been identified and interviewed

• Review the equipment and parts of machinery which may have been involved

• Consider the positions of people and equipment at the time of the incident

• Examine and collect copies of relevant documents

Evidence gathering - Phase 1

People

Who was injured, suffered ill health or was otherwise involvedWhat injury, ill health or damage was caused?Who witnessed the incident?Who was in charge of supervising the work?What other people and organisations were involved?

PartsWere any of the following involved - Plant / Equipment / Machinery / Tools / Equipment / Materials / PPE.How was it being used and was it in good working order? What activity was being carried out and was there anything unusual in the work environment? Were the shape / nature of the materials, etc., relevant to the accident / incident?Was difficulty / unfamiliarity in using the plant, etc. a contributory factor?Was safety equipment adequate?


Positions

Where and when did the incident occur?Was the immediate environment safe?The position of all parties (injured party(s) / witnesses), any machinery, materials, barriers, signs, protections, tools & equipment are to be consideredWas there anything unusual about the working conditions? Were maintenance, workplace layout or housekeeping relevant factors?

Paper

Paper evidence includes all relevant documentation, e.g. risk assessment and risk register / safety method statements / H&S plans / drawings / instructions / permits / certification (test, examination, training) / licenses / induction & toolbox talk registers. Was the method for completing task detailed in a written plan?Are there records of inspections, training, etc.What are the organisation’s processes and systems?


Evidence gathering - Phase 1

Evidence gathering - Phase 1 Culture

Assess the impact of company culture: - the way things are done around here - interplay of people, systems, technology, and power- eg rule breaking, short cuts,

command and control

Culture


When is Root Causes Analysis required?

After fatal & major injury incidents Other incidents, including near misses where

circumstances could have resulted in a fatal or majory injury – eg falls from height above 2 metres

To be completed with 4 weeks (where possible).


Investigation and RCA summary

Establish Investigation Teams – number, skills, etc.

Collect Evidence - 4 Ps + statement taking Establish the time line and immediate causes of

the incident, Identify the critical factors (ie which if eliminated

would prevent the incident) in the time line Identify the underlying causes of each critical

factor using Why/Because analysis (5 Whys) Label the key cause of each factor using the

underlying factors terminology Identify key Corrective & Preventative actions Identify the Lessons Learnt which need to be

communicated and implemented


RCA Terminology

Immediate causes• Actions – acts directly contributing to the incident

• Conditions – environmental/operational factors directly contributing to the incident

• Critical Factor – an immediate cause which if taken away would have prevented the incident

Underlying causes• Job Factors – how the task was planned and executed

• Organisational Factors – effectiveness of policies and systems

• Personnel Factors – attitudes, competencies, personality,

perceptions

ROOT CAUSES – the factors at the end of the causal chain for each critical factor – the causes which need to be addressed to prevent reoccurrence.


Phase 2 – Analyse the information

1) Sift through all the evidence gathered to establish the facts.

- John had tip of finger amputated by v belt on compressor in paint shop which was not guarded

2) Identify the IMMEDIATE CAUSES:

Conditions: (operating / environmental conditions)

- the air compressor was running.

Actions: (what people did immediately prior to the incident occurring)

- John’s hand slipped off the side of the machine and onto the drive belt

3) Establish a ‘timeline’ of single, irreducible facts that describe the key actions and conditions working backwards from the incident.


Phase 2 – Analyse the information – Timeline and Critical Factors

Establish a time line from immediate causes backwards. Then identify the ‘CRITICAL FACTORS’, i.e. those factors in the ‘timeline’ or sequence of events leading up to the incident, that had they not been present the sequence of events would have been broken and the accident / incident would not have occurred or at least its severity reduced. As a guide the number of critical factors identified for any incident should range from five to ten


Critical Factors

The compressor was running

John was maintaining the compressor

The guard was missing to the “v”belt pulley drive

Actions1 - Work at height (inc

Access)2 – Lifting (Manual or

mechanical)3 – Use of safety devices and

equipment4 – Use of tools, equipment,

plant and machines5 – Use of PPE6 – Method of work7 – Communications8 – Operator error 9 – Violation10 – Horse play11- other (specify)

Conditions1 – Open / Exposed edge (ext., Int.,

platform, etc.)2 – Guards, protective devices or

equipment3 – Housekeeping4 – Tools, equipment, plant5 – Vehicle movements6 – Lifting and Slinging7 – Live systems or equipment

(electrical / mechanical)8 – Exposure to chemicals, noise,

vibration, etc.9 – Environment (heat, cold, ventilation,

weather, etc.)10 – Structural failure11 – Communications - instructions,

signs, barriers and warnings

Immediate Causes


Phase 3 - Identify the Underlying causes for each Critical Factor

For each Critical Factor – identify: Underlying Causes - the factors that resulted in

or allowed the immediate cause of each critical factor to exist

Root Causes - the last factor identified in the causal chain of each critical factor

By Examining each critical factor using the “why and

“because” question and answer technique. Asking “why” and “because” between 3 and 5

times to identify the underlying causes. Choose the most relevant factor from the factors

detailed in the RCA topic headings which best describes the root cause identified.


Critical Factors – 5 Whys Analysis

The compressor was running – why? …… becausewhy? …… because- Being used for spraying operation - Supervisor said do not switch off- Part of finishing an urgent order- Focus on production

John was examining the compressor- Supervisor asked him to look at it because it was not operating

correctly - Not maintained and inspected regularly- Manager not aware of need for regular maintenance- New to role and not experienced- Inadequate training and instructions

The guard was missing to the “v”belt pulley drive- Removed and not replaced over a year ago when belt was

replaced- Person who did it was not trained in safe maintenance operations- No formal machinery maintenance or safety systems in

place

Underlying Causes of Incidents:Job Factors

1) Risk assessment and safe method of work (done, adequate, appropriate, checked, etc.).

2) Task planning (complies with RA and SMW, adequate resources, buy in, communication, etc.).

3) Supervision (numbers, communication, competence, control, etc.).

4) Communications (shift hand over, changes, toolbox talks, language, induction, etc.).

5) Provision & maintenance of plant, tools, equipment.6) Management of hazardous materials and

emergency response.7) Maintenance of safe work environment (noise,

layout, interfaces, atmosphere, etc.).8) Compliance (Law, procedures, permits, etc.).


1 – Contractor management (selection, standard setting, liaison, monitoring, supervision)

2 – Programme (time, co-ordination, progress, realism, change)

3 – Design & planning risk management (elimination, assessment, control HSE risks)

4 – Training (provided, adequate, recent)

5 – Leadership (provided, adequate, visible, followed, credible, trusted)

6 – Change Management (communication, consultation evaluation, implementation)

7 – HSE management system (document control, investigation, lessons learnt)

8 – Communication (Corporate, project, business unit)

9 – Responses to emergencies and previous incidents

10 – Allocation and fulfillment of responsibilities (just culture approach)

11 – Allocation of staff & resources (competence, time, cost, equipment)

12 – Community issues (lack of liaison – neighbours / regulators)

13 – Client demands (time, cost, schedule, design, novated contractors, etc.)

14 – External pressures (legal, market, environment)

15 – Corporate values and perceptions

16 – Reward and recognition

Underlying Causes of Incidents:Organisation Factors


Underlying Causes of Incidents:Personnel Factors

1 – Competence (skill, knowledge, experience)2 – Excessive demands (physical, mental, workload)3 – Fatigue (Excessive work hours, personal issues)4 – Error (lapse, slip, mistake)5 – Violation (deliberate rule breaking)6 – Rushing work (programme, catch up, bonus, etc.)7 – Morale (bored, disheartened, personal issues)8 – Perception of risk – (unaware, under estimate,

macho)9 – Perception of priorities (supervision, peers, site

team)10 – Distraction (by colleagues, others, personal

issues)11 – other (specify)


Program

PhysicalChanges

Areas for Corrective and Preventative Actions

EnvironmentChanges

ProcedureChanges

Personnel


Behavioral

Training

New manager

Training on maintenance and risk assessment

New guard fitted

Maintenance and safety systems implemented

Writing up the Investigation

Try to be as concise, factual and precise as possible summarise findings at start and conclusion at the end use neutral language “incident vs. catastrophe” use referenced diagrams and pictures put detailed evidence in appendices, eg statements

Describe the 5Ws State RCA findings Identify corrective and preventative actions Do not draw legal conclusions, e.g., “the negligence of

the two electricians caused the accident” Avoid speculation on facts, motives, causes, and

outcomes, unless absolutely essential for the report. Personal opinion should be kept out of the factual report – should put in a separate section

Consider carefully to who should be sent the report


Investigation Report

Business Unit:

Investigation Completed by:

Date of Incident:

Severity of Incident (from list below): Fatal/ Major Injury/High Potential Incident (minor injury or near hit)/ Ill health

Nature of Incident (from list below):fall,of person(s) lifting equip or plant failure vehicle,

fall of material release violence

collapse exposure, viral

electrical fire / explosion other

Description of Incident

Who:

What:

Where:

When:

Why:


Immediate Causes (see terminology – pick most relevant factors):

Actions:

Conditions:

Underlying Causes (see terminology - pick most relevant factors):

Job factors:

Organisational factors:

Personnel factors:

Corrective Action(s) (ie actions to correct deficiencies - inc responsibilities, resources and timescales)

Preventative Action(s) ( ie actions to prevent situation occurring again - inc responsibilities, resources and timescales)

Lessons Learnt (i.e. what are the key learning points for the business to prevent this type of incident happening again)


Investigation Report pt2

Corrective & Preventative Actions

Identify the corrective/remedial actions necessary to eliminate the root cause of each critical factor following the hierarchy of control: Measures that eliminate the causal factor, e.g. a change of

process, equipment, sequence, materials, etc. Measures that control the causal factor, e.g. the provision of

physical barriers, guarding, protection, etc. Measure which protect people from the risk, e.g. PPE, etc.

Action By Whom, By When Date to be completed by – verification/sign off by who? Capture lessons learnt for the organisation –

communicate, revise process and standards.


INVESTIGATION SUMMARY

When undertaking an incident investigation, think carefully about who to involve and when – then act quickly

Gather the evidence to answer – who, what, where, when why and how

Stick to the facts and follow chains of evidence. Analyse the evidence methodically using “5

Whys” approach to identify root causes Take the time to write the report correctly

excluding personal opinion. Avoid derogatory remarks, legal buzzwords and jargon that can be misinterpreted or difficult to explain.

Ensure corrective and preventative actions are identified and implemented


Date post:	20-Dec-2015
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