investigation report

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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.) ## 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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# How to conduct an accident investigation 1. Establish an investigation team: Include employees who have been trained to conduct an effective investigation. A typical team might include: • - An employee from the work area where the accident occurred • A supervisor from a work area not involved in the accident • A maintenance supervisor or an employee who understands equipment or processes associated with the accident • The safety supervisor • A safety committee representative 2. Gather information: Record the facts about the accident. Interview witnesses and others involved. 3. Analyze the facts: Identify the accident's causes and contributing factors. Determine how the accident could have been prevented. 4. Report the findings: Prepare a written report that describes who was involved, where the accident occurred, when it happened, and what caused it. Recommend, specifically, how to prevent the accident from happening again. 5. Act on the recommendations: Have management review the report and determine what will be done to prevent the accident. 6. Follow up: Ensures that appropriate corrective action was taken to prevent the accident.