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?
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
Meanings & Paradigms
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 Investigations – Key Concepts
Meanings & Paradigms
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
Incident Investigations – Key Concepts
Causation Theories
Domino – Heinrich, Bird & Loftus
Human Error – HSE, Rassmussen
Swiss Cheese Model – Reason
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
Loss Control Domino Models
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
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!
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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…
Incident Investigations – Key Concepts
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;
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
Who to Interview?
Injured Person Witnesses of the incident Witnesses Pre-Accident Witnesses Post-Accident Supervisors Managers Maintenance, Housekeeping,
Engineering, Purchasing……...
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
Open Questions
Closed QuestionsLINK
Process is repeated for every section
LINK
Process is repeated for every section
Open Questions
Closed Questions
Interviewing Techniques Questions & Perceptions
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
Plan & PrepareAccountClosureEvaluate
Engage & ExplainPPEEAACCEE
Interviewing Techniques Formal Statement Taking
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
Examples of Analytical MethodsRoot Causes Analysis
Fishbone 5 Whys Decision / Event Trees Management Oversight Risk Tree
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
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?
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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?
Incident Investigations – Key Concepts
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?
Incident Investigations – Key Concepts
Immediate Causes
Root Root CausesCauses
Incident
Irrelevant
RCA findings from UK Govt Study of construction fatal accidents (2009)
Competence Planning
Equipment
Supervision
Leadership
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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:
Incident Investigations – Key Concepts
Evidence gathering 4Ps
Parts
Positions Paper
People
Incident Investigations – Key Concepts
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?
Incident Investigations – Key Concepts
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?
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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).
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
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.).
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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)
Incident Investigations – Key Concepts
Program
PhysicalChanges
Areas for Corrective and Preventative Actions
EnvironmentChanges
ProcedureChanges
Personnel
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts
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:
Incident Investigations – Key Concepts
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)
Incident Investigations – Key Concepts
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.
Incident Investigations – Key Concepts
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
Incident Investigations – Key Concepts