Near miss

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# Causation Models (cont.) ## Interviewing (cont.) Data can be found in documents such as technical data sheets, health and safety committee minutes, inspection reports, company policies, maintenance reports, past incident reports, safe-work procedures, and training reports. Any relevant information should be studied to see what might have happened, and what changes might be recommended to prevent recurrence of similar incidents. ## What should I know when making the analysis and recommendations? At this stage of the investigation most of the facts about what happened and how it happened should be known. This data gathering has taken considerable effort to accomplish but it represents only the first half of the objective. Now comes the key question - why did it happen? Keep an open mind to all possibilities and look for all pertinent facts. There may still be gaps in your understanding of the sequence of events that resulted in the incident. You may need to re-interview some witnesses or look for other data to fill these gaps in your knowledge. When your analysis is complete, write down a step-by-step account of what happened (the team's conclusions) working back from the moment of the incident, listing all possible causes at each step. This is not extra work: it is a draft for part of the final report. Each conclusion should be checked to see if: - it is supported by evidence - the evidence is direct (physical or documentary) or based on eyewitness accounts, or - the evidence is based on assumption. This list serves as a final check on discrepancies that should be explained. ## Why should recommendations be made? The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar incidents. Recommendations should: - be specific - be constructive - identify root causes - identify contributing factors Resist the temptation to make only general recommendations to save time and effort. …

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# Inspections/Investigations (cont.) ## Performing Inspections Employees should conduct ongoing inspections throughout their workday. Frequency of inspections can vary but should be conducted daily to ensure any equipment is in good working order. An inspection should look at all workplace elements: . The people: Who is involved in the inspection? • The equipment: What equipment is being used? • The materials: What material is being used? • The environment: Does the environment present a hazard? • - The processes: What are the safe job procedures? Are they being followed? Attention should be focused on the areas or processes that are likely to develop into an unsafe act or condition. Results of inspections should be shared with employees, and any corrective actions should be tended to as soon as possible. Corrective actions should be designated to a person and should be given a date of when the corrective action should be done by. ## Investigations Investigations are performed after an incident or a near miss has occurred. Investigations are done to identify the underlying causes that had occurred to allow the incident or near miss to happen. Near misses are investigated because they serve as a signal for potential workplace incidents. When performing an investigation, it is important to investigate as soon as reasonably possible. ## Serious Incidents If the incident being investigated involves a serious injury or fatality, then outside agencies will have to be contacted. These agencies include: • WCB Nova Scotia: Employers must report the injury to WCB within 5 business days. Financial penalties may be applied if reports are late. Visit wcb.ns.ca for more information. • Department of Labour, Skills and Immigration (1-[redacted phone]). In the event that the incident results in any of the following, the employer must contact the Department of Labour, Skills and Immigration in no more than 24 hours after the incident: - Fire or Flood. - Unconsc…

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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

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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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# Causation Models (cont.) ## Why should recommendations be made? (cont.) For example, you have determined that a blind corner contributed to an incident. Rather than just recommending "eliminate blind corners" it would be better to suggest: - install mirrors at the northwest corner of building X (specific to this incident) - install mirrors at blind corners where required throughout the worksite (general) Never make recommendations about disciplining a person or persons who may have been at fault. This action would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future investigations. In the unlikely event that you have not been able to determine the causes of an incident with complete certainty, you probably still have uncovered weaknesses within the process, or management system. It is appropriate that recommendations be made to correct these deficiencies. ## The Written Report The prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of the incident that you have so include all relevant details, including photographs and diagrams. Identify clearly where evidence is based on certain facts, witness accounts, or on the team's assumptions. If doubt exists about any particular part of the event, say so. The reasons for your conclusions should be stated and followed by your recommendations. Do not include extra material that is not required for a full understanding of the incident and its causes such as photographs that are not relevant and parts of the investigation that led you nowhere. The measure of a good report is quality, not quantity. Always communicate your findings and recommendations with workers, supervisors and management. Present your information 'in context' so everyone understands how the incident occurred and the actions needed to put in place to prevent it f…

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## § 5189.1. Process Safety Management for Petroleum Refineries. (cont.) (7) The team shall prepare a written investigation report within ninety (90) calendar days of the incident. If the team demonstrates in writing that additional time is needed due to the complexity of the investigation, the team shall prepare a status report within ninety (90) calendar days of the incident and every thirty (30) calendar days thereafter until the investigation is complete. The team shall prepare a final investigation report within five (5) months of the incident. (8) Investigation reports shall include: (A) The date and time of the incident; (B) The date and time the investigation began; (C) A detailed description of the incident; (D) The factors that caused or contributed to the incident, including direct causes, indirect causes and root causes, determined through the Root Cause Analysis; (E) A list of any DMR(s), PHA(s), SPA(s), and HCA(s) that were reviewed as part of the investigation; (F) Documentation of relevant findings from the review of DMR(s), PHA(s), SPA(s) and HCA(s); (G) The Incident Investigation Team's recommendations; and, (H) Interim measures implemented by the employer. (9) The employer shall implement all recommendations in accordance with subsection (x). (10) The employer shall complete an HCA in a timely manner for all recommendations that result from the investigation of a major incident. The employer shall append the HCA report to the investigation report. (11) Investigation reports shall be provided to and upon request, reviewed with employees whose job tasks are affected by the incident. Investigation reports shall also be made available to all operating, maintenance and other personnel, including employees of contractors where applicable, whose work assignments are within the facility where the incident occurred or whose job tasks are relevant to the incident findings. Investigation reports shall be provided on request to emplo…