what incident should I focus on as a learning exampel

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# INCIDENT INVESTIGATION INCIDENT INVESTIGATION Summary Report Address: me: Phone: ## Date Posted: 05/29/2024 Incident investigation is determining the root causes of incidents, on-the-job injuries, property damage, and close calls to prevent them from occurring again. An incident investigation should lead you to the real cause of why something happened, and armed with that knowledge, you can take affirmative steps to prevent future incidents from occurring. In addition to the root cause, several causal factors may contribute to the incident. These will be evidenced in the answers to the "why" questions. Several factors may have contributed to the root cause, and correctly identifying them will help you develop a plan to mitigate the hazard in the future. ## WHAT IS AN INCIDENT? An event resulting in personal injury, property damage, equipment damage, impact to environmental resources, loss of production or product, or an event that has the potential to cause significant injury, damage, loss, or effect to environmental resources. ## WHY SHOULD INCIDENTS BE INVESTIGATED? Prevention is the purpose of an investigation. An incident investigation should: • Determine what happened. - Determine the cause or causes of the incident. . Identify any unsafe conditions, acts, or procedures. • Help management to identify practical corrective actions. - Determines whether due diligence was observed. • - Show the commitment of management that an adequate investigation system is in place. An incident investigation should not strive to determine fault or blame but to identify the primary causes of incidents so that controls can be implemented to prevent further occurrences. ## INCIDENT INVESTIGATION STEPS Preserve and Document the Incident Scene: Before anything occurs, one must ensure that the incident scene secure and does not present further potential for environmental damage or harm to those around. Gather Information: As little time as possible should be lost…

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# FactSheet OSHA SEPA # The Importance of Root Cause Analysis During Incident Investigation The Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA) urge employers (owners and operators) to conduct a root cause analysis following an incident or near miss at a facility.' A root cause is a fundamental, underlying, system-related reason why an incident occurred that identifies one or more correctable system failures.² By conducting a root cause analysis and addressing root causes, an employer may be able to substantially or completely prevent the same or a similar incident from recurring. ## OSHA Process Safety Management and EPA Risk Management Program Requirements Employers covered by OSHA's Process Safety Management (PSM) standard are required to investigate incidents that resulted in, or could reasonably have resulted in, catastrophic releases of highly hazardous chemicals.³ Similarly, owners or operators of facilities regulated under EPA's Risk Management Program (RMP) regulations must conduct incident investigations.4 During an incident investigation, an employer must determine which factors contributed to the incident, and both OSHA and the EPA encourage employers to go beyond the minimum investigation required and conduct a root cause analysis. A root cause analysis allows an employer to discover the underlying or systemic, rather than the generalized or immediate, causes of an incident. Correcting only an immediate cause may eliminate a symptom of a problem, but not the problem itself. ## How to Conduct a Root Cause Analysis A successful root cause analysis identifies all root causes there are often more than one. Consider the following example: A worker slips on a puddle of oil on the plant floor and falls. A traditional investigation may find the cause to be "oil spilled on the floor" with the remedy limited to cleaning up the spill and instructing the worker to be more careful.5 A root cause analysis wou…

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Issue 01 Volume 14, July 2015 # HAZALERT Traffic Incident Management Responders Struck and Killed by Oncoming Traffic Case studies and prevention tips for employers and employees alike ## Recommendations to Prevent Highway Struck-By Incidents: • Always ensure that proper advance warning equipment has been displayed prior to working on the roadside - Whenever possible, work away from the flow of traffic • Reduce reliance on emergency lights and place more emphasis on traffic controls - Always wear American Na- tional Standards Institute (ANSI) approved safety re- flective gear such as vests and hardhats when working on the roadside • Know that the adjacent lane or roadway may need to be closed in order to provide safe incident management - Employees should receive regular traffic incident management safety training "My son died an honorable death. He was out there trying to make a living to take care of his children". - mother of a victim A tragedy that traffic incident management (TIM) responders know all too well: a worker loses a life after being struck by approaching traffic on the roadside, while assisting someone in need. Below is a review of two cases where TIM responders were struck and killed on Kentucky roadsides in 2014. Recommendations are offered to help prevent these types of tragic incidents from reoccurring. Case #1: Just before midnight, a self -employed tow truck driver was about to end his day, when he de- cided to take one last call. A car was stalled on a roadside and needed assistance. The victim parked his tow truck in front of the stalled vehi- cle in the right-hand-side emergency lane. As he operated the driver's- side winch controls, an approaching vehicle traveling in the same direc- tion struck the stalled vehicle, then crashed into the tow truck, causing crushing injuries to the victim. It was determined that the driver of the approaching vehicle was under the influence of alcohol at the time of the incident. The driver d…

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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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WORK SAFE KENTUCKY Free safety resources provided by KEMI HOME SAFETY RESOURCES SAFETY TRAINING SAFETY BLOG ABOUT KEMI CONTACT US O # The Importance of Incident Investigations ## Print a Sign-In Sheet | Spanish Version Coming Soon The Occupational Safety and Health Administration (OSHA) strongly encourages employers to investigate all incidents in which a worker was hurt (i.e., accidents) as well as "near misses," in which a worker might have been hurt if the circumstances had been slightly different. Investigating a workplace incident provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety programs. OSHA defines an accident as an unplanned, unexpected, and not purposefully caused event that occurs suddenly and causes injury or loss, decreased value in resources, and increased liabilities. ## Why Do You Investigate a Workplace Incident? - To find the "root cause" of an accident so you can prevent similar accidents from occurring in the future. • To fulfill any legal requirements. • To determine compliance with OSHA standards. • To determine the cost of an incident/accident: • Direct costs may include medical expenses and indemnity payments. • Indirect costs may include increased absenteeism, scheduling delays, added administrative time, repairing property damage, and training a replacement worker. • To help your workers' compensation insurance company process the claim. Make sure you do not place employee blame for the accident or make statements such as "employee did not follow safety procedures" or "the worker was careless." The investigation should not hamper workplace morale and decrease productivity. It is important to look at all contributing factors to determine the cause and, if a shortcoming is identified, to ask why it existed or was not previously addressed. KEMI does not assume liability for the content of information contained herein. Safety and health remain your responsib…

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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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# 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…