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– Government of Alberta Occupational Health and Safety Program –
 

Incident Management

Incident Investigation

INTRODUCTION

Incident investigations are an important part of an effective occupational health and safety program. Incident investigations help determine what happened, how it happened and what needs to be done to prevent the incident from recurring without assigning blame or fault.

Prompt investigation lessens the chance that information or equipment will become lost or otherwise unavailable (e.g., vehicles towed away in a vehicular incident), that witnesses will compare events or perceptions related to the incident, or that memories will have faded.

All incident investigations involve a six-step process. The type of incident and its result dictate the extent of the investigation, the degree to which it is investigated and the parties to be involved in the investigation. Serious incidents and fatalities are to be investigated in collaboration with external third-party investigators.

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STANDARD

  • All incidents must be investigated and the relevant required reports completed.

  • Incident investigations must begin as soon as it is safe to do so, but no more than 24 hours after the incident.

  • Supervisors conduct investigations for all incidents except for serious incidents, fatality and radiation incidents.

  • An investigation team, assigned by the manager, conducts investigations for serious incidents, fatality and radiation incidents.

  • An investigation team must consist of:

    • a leader and

    • other employees with knowledge and skills specifically relating to the activities involved in the incident

  • All incident investigations involve six steps.

  1.

Initial Response

The scene must remain undisturbed except to perform the following:

  • administer first aid

  • protect property from further loss (e.g., if property is on fire)

  • report the incident according to Incident Reporting

  2.

Investigate the Incident

Witness statements must be taken as written records or voice recordings.

  • Written witness statements must be legibly documented using the Witness Statement form.

  • Voice recorded statements must be:

    • transcribed and compared to the recorded statement for accuracy

    • retained along with the transcribed statement and investigation report

  • When a voice recording is used, the witness must be informed that the statement is being recorded.

  3.

Identify the Causes

Identify all incident causes.

 
  4.

Implement Corrective Measures

Implement corrective measures to address all incident causes in accordance with Hazard Assessment, Elimination and Control.

 
  5.

Report the Findings

Write the report using the report forms stipulated in Incident Reporting.

 
  6.

Evaluate Effectiveness

Evaluate the effectiveness of corrective measures introduced as result of the incident investigation.

  • Hazard Assessment and Control Reports at the workplace must be reviewed and revised, as a result of completed incident investigations when:

    • new hazards were identified

    • new controls were implemented

    • controls for hazards already identified were modified

Training

  • Investigation leads and supervisors must have completed the Government of Alberta Incident Investigation training course.

Manager Responsibilities

  • See that all incidents are fully investigated.

  • Cooperate with all parties investigating the incident.

  • Assign supervisors and potential investigation leads to complete the Government of Alberta Incident Investigation training course.

  • Appoint an investigation lead to investigate serious incidents or fatalities.

  • In consultation with the appointed investigation lead, assign members of the team to investigate serious incidents, fatalities and radiation incidents.

  • Review and/or complete the required reports as stipulated in Incident Reporting.

  • Signs the required reports stipulated in Incident Reporting. The signature acknowledges understanding the content of the report including the incident cause(s) and approval of the corrective/preventative action(s) reported.

  • Review incident details and causes and assign corrective measures to be implemented. This action must be completed by the senior manager in the event of a serious incident, fatality or radiation incident.

  • Verify that corrective measures have been implemented and evaluate their effectivess. Determine if the corrective measures:

    • are appropriate to eliminate or control the identified hazard

    • have not created additional hazards

  • Assign a hazard assessment lead to review and revise the Hazard Assessment and Control Report where new hazards are identified, new controls are implemented or controls for hazards are modified as a result of an incident investigation.

  • Retain all original completed forms and investigation reports in the department for three years.

Supervisor Responsibilities

  • Complete the Government of Alberta Incident Investigation training.

  • Respond immediately to control access to the incident scene.

  • Cooperate with all parties investigating the incident.

  • Participate in the investigation team, if assigned.

  • Conduct an incident investigation and complete applicable documentation stipulated in Incident Reporting.

  • Assist in the implementation of corrective measures.

Employee Responsibilities

  • Cooperate with all parties investigating the incident.

  • Participate in the investigation team, if assigned by management.

  • Assist in the implementation of corrective measures if assigned.

Investigation Lead Responsibilities

  • Upon designation as a potential investigation lead, complete the Government of Alberta Incident Investigation training course.

  • Recommend to the manager employees to be assigned to participate in an incident investigation team.

  • Coordinate incident investigations with the supervisor and manager at the workplace where the incident occurred.

  • Assign responsibilities to members of the investigation team.

  • Complete the incident investigation report.

  • Review investigation reports with and recommend corrective measures to the manager.

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GUIDELINES

1.

Initial Response

  • Identify and control hazards that could cause further damage or injury to responders.

  • Control access to the incident scene by cordoning it off and restricting access to only the investigating body having jurisdiction over the incident.

  • Make a note of what was done to render the incident scene safe.

 
2.

Investigate the Incident

  • Identify and make a list of all witnesses.

  • Determine who was involved and who can provide advice on technical issues.

  • Prepare a list of witnesses to interview.

  • Collect the facts.

  • Consider all possible causes. Make notes of ideas as they occur, but do not draw conclusions until all information is gathered.

  • Gather physical information. Physical information is subject to rapid change and should be recorded first.

    • Take photographs before anything is moved (the general area and specific items).

    • Take written notes about the location of items at the incident scene.

    • Label and catalogue each photograph.

    • Identify equipment involved in the incident.

  • Identify any new equipment, products or work procedures introduced before the incident.

  • Compare what happened with accepted standards or procedures to identify gaps.

  • If relevant, take note of the lighting, visibility, time of day and weather conditions.

  • Gather product information, including the names and material safety data sheets of any substances involved.

  • Take note of any broken equipment, debris or material samples.

    • These items may be removed and used for further analysis once the initial scene is documented.

    • Look at the pattern of debris and the location of each piece.

  • Record the following information:

    • the exact location of the incident

    • the position of injured employees and others present

    • all equipment being used

    • the presence or absence of appropriate guards

  • Obtain witness statements as soon as possible after the incident.

  • Allow witnesses to write down the version of events. The investigator will read this statement and may have questions.

    • If the investigator asks questions, they should be recorded on the Witness Statement form along with the witness responses.

    • When a written record is used, move the witness to a quiet room to write out his or her statement.

    • The statement must be reasonably legible. If the witness cannot write a legible statement, one of the investigators should write out the statement for the witness using the witness’s own words.

    • Prepare a list of questions to ask, referring to the Witness Statement form.

    • Ask questions after the witness is finished giving his or her statement if more detail or clarification is required.

 
3.

Identify the Causes

An incident rarely has a single cause.

  • A number of factors generally contribute to the incident.

  • Evaluate the role of each factor involved.

Determining the causes of incidents will allow investigators to determine corrective measures which will prevent the incident from reoccurring.

Direct Causes

  • Direct causes usually occur immediately before the incident.

  • Direct causes are defined as hazardous acts or hazardous conditions.

  • Examples of hazardous acts:

    • improper lifting (e.g., manual lifting without using lifting/handling equipment)

    • failure to wear personal protective equipment

    • improper use of equipment

    • changes in equipment design not permitted by the manufacturer’s specifications or approved in specifications certified by a professional engineer

    • failure to follow procedure

    • use of defective equipment

  • Examples of hazardous conditions:

Contributing Factors

  • Contributing factors of an incident can relate to people, equipment used, or other issues.

  • Examples of people factors:

    • physical capability

    • mental stress

    • behaviours

    • knowledge and skill

    • leadership and supervision

    • fatigue (e.g., prolonged work hours and or days of work)

  • Examples of equipment and material factors:

    • engineering (e.g., the manner in which something was designed or manufactured guards on emergency shut offs)

    • purchasing (e.g., was the equipment used appropriate for the task involved in the incident?)

    • maintenance (e.g., was the equipment maintained according to manufacturer specifications?)

  • Examples of other factors:

    • personal protective equipment

    • weather conditions

    • workplace conditions

    • visibility

    • noise

    • temperature extremes

    • safe work practices

    • training

 
4.

Implement Corrective Measures

  • The primary purpose of incident investigation is to prevent future similar occurrences. Implementing the recommended corrective measures aims to make it difficult, if not impossible, for the incident to happen again.

  • Review the completed Hazard Assessment and Control Report with the following questions in mind:

 
5.

Report the Findings

  • Determine how the causes contributed to the incident.

  • Write the report using the report forms stipulated in Incident Reporting.

  • Communicate the results of the investigation and the corrective measures being implemented.

 
6.

Evaluate Effectiveness

  • The manager may choose to involve additional services, such as the incident investigation lead, in this process.

  • When the corrective measures implemented are determined to be ineffective, the manager should review the process to determine alternative controls that will be effective.

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About this Standard

Authority:   Public Service Act
Occupational Health and Safety Act, Regulation and Code
Application:   Departments, agencies and employees under the Public Service Act
Effective Date:   01 September 2010
Contact:   Workplace Health

Last Review / Update: 2011-11-14

Directive: Occupational Health & Safety


Introduction
OH&S Management
Hazard Management
OH&S Training
Inspections
Emergency Preparedness
Incident Management
OH&S Program Evaluation
Glossary of Terms & AbbreviationsPDF icon
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