I need life scenarios of accident investigation cases using 5 why's and fishbone analysis in finding Root Causes and making recommendations to management

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# Causation Models Many models of causation have been proposed, ranging from Heinrich's domino theory to the sophisticated Management Oversight and Risk Tree (MORT). The simple model shown in Figure 1 attempts to illustrate that the causes of any incident can be grouped into five categories - task, material, environment, personnel, and management. When this model is used, possible causes in each category should be investigated. Each category is examined more closely below. Remember that these are sample questions only: no attempt has been made to develop a comprehensive checklist. Figure 1: Incident Categories Material ## Task Here the actual work procedure being used at the time of the incident is explored. Members of the 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?" Material Incident Investigation CCOHS

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# Incident Investigation (cont.) ## What is an incident and why should it be investigated? (cont.) The information that follows is intended to be a general guide for employers, supervisors, health and safety committee members, or members of an incident investigation team. When incidents are investigated, the emphasis should be concentrated on finding the root cause of the incident so you can prevent the event from happening again. The purpose is to find facts that can lead to corrective actions, not to find fault. Always look for deeper causes. Do not simply record the steps of the event. Reasons to investigate a workplace incident include: - most importantly, to find out the cause of incidents and to prevent similar incidents in the future - to fulfill any legal requirements - to determine the cost of an incident - to determine compliance with applicable regulations (e.g., occupational health and safety, criminal, etc.) - to process workers' compensation claims The same principles apply to an inquiry of a minor incident and to the more formal investigation of a serious event. Most importantly, these steps can be used to investigate any situation (e.g., where no incident has occurred yet) as a way to prevent an incident. ## Who should do the investigating? Ideally, an investigation would be conducted by someone or a group of people who are: - experienced in incident causation models, - experienced in investigative techniques, - knowledgeable of any legal or organizational requirements, - knowledgeable in occupational health and safety fundamentals, - knowledgeable in the work processes, procedures, persons, and industrial relations environment for that particular situation, - able to use interview and other person-to-person techniques effectively (such as mediation or conflict resolution), knowledgeable of requirements for documents, records, and data collection; and - able to analyze the data gathered to determine findings and reach recommendat…

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# Incident Investigation (cont.) ## Why look for the root cause? (cont.) - Was a safe work procedure being followed? If not, why not? - 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 that are more open to correction. ## What are the steps involved in investigating an incident? First: - Report the incident occurrence to a designated person within the organization. - Provide first aid and medical care to injured person(s) and prevent further injuries or damage. The incident investigation team would perform the following general steps: - Scene management and scene assessment (secure the scene, make sure it is safe for investigators to do their job). - Witness management (provide support, limit interaction with other witnesses, interview). - Investigate the incident, collect data. - Analyze the data, identify the root causes. - Report the findings and recommendations. The organization would then: - Develop a plan for corrective action. - Implement the plan. - Evaluate the effectiveness of the corrective action. - Make changes for continual improvement. As little time as possible should be lost between the moment of an incident and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses. The tools that members of the investigating team may need (pencil, paper, camera or recording device, tape measure, etc.) should be immediately available so that no time is wasted. What should be looked at as the cause of an incident? Incident Investigation CCOHS

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# Causation Models (cont.) ## Personnel (cont.) - Did the worker follow the safe operating procedures? - Were workers experienced in the work being done? - Had they been adequately educated and trained? - Can they physically do the work? - What was the status of their health? - Were they tired? - Was fatigue or shiftwork an issue? - Were they under stress (work or personal)? - Was there pressure to complete tasks under a deadline, or to by-pass safety procedures? ## Management Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management and the role or presence of management systems must always be considered in an incident investigation. These factors may also be called organizational factors. Failures of management systems are often found to be direct or indirect causes. Ask questions such as: - Were safety rules or safe work procedures communicated to and understood by all employees? - Were written procedures and orientation available? - Were the safe work procedures being enforced? - Was there adequate supervision? - Were workers educated and trained to do the work? - Had hazards and risks been previously identified and assessed? - Had procedures been developed to eliminate the hazards or control the risks? - Were unsafe conditions corrected? - Was regular maintenance of equipment carried out? - Were regular safety inspections carried out? - Had the condition or concern been reported beforehand? - Was action taken? Incident Investigation CCOHS

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# Causation Models (cont.) ## What should be done if the investigation reveals human error? (cont.) Failing to point out human failings that contributed to an incident will not only downgrade the quality of the investigation, it will also allow future incidents to happen from similar causes because they have not been addressed. However never make recommendations about disciplining anyone who may be at fault. Any disciplinary steps should be done within the normal personnel procedures. ## How should follow-up be done? Management is responsible for acting on the recommendations in the investigation report. The health and safety committee or representative, if present, can monitor the progress of these actions. Follow-up actions include: - Respond to the recommendations in the report by explaining what can and cannot be done (and why or why not). - Develop a timetable for corrective actions. - Monitor that the scheduled actions have been completed. - Check the condition of injured worker(s). - Educate and train other workers at risk. - Re-orient worker(s) on their return to work. Fact sheet last revised: 2019-11-26 ## Disclaimer Although every effort is made to ensure the accuracy, currency and completeness of the information, CCOHS does not guarantee, warrant, represent or undertake that the information provided is correct, accurate or current. CCOHS is not liable for any loss, claim, or demand arising directly or indirectly from any use or reliance upon the information. Incident Investigation CCOHS