SAFETY AND HEALTH INCIDENT
INVESTIGATION AND CORRECTIVE ACTION
“THOSE THAT DO NOT LEARN FROM THEIR
MISTAKES, ARE BOUND TO REPEAT THEM”
TOPIC 4
COURSE OBJECTIVES
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To describe the Sections provision in OSHA 1994
To describe the importance of incident investigation
To describe principles of investigation
To describe the steps in incident investigation
1. INVESTIGATION PROVISION IN OSHA
1994
• PART XI - ENFORCEMENT AND INVESTIGATION
• 12 SECTIONS : 39 – 48 (10 SET OF POWERS):
• SECTION 39 – 42: POWER OF ENTRY TO A PREMISE / A SITE /
LOCATION
• SECTION 45 – 45: POWER TO INVESTIGATE AND ASK WITNESS
• SECTIOIN 47: COMMON OFFENCES DURING INVESTIGATION
• SECTION 48: ISSUANCE OF NOTICES
• IMPROVEMENT NOTICE
• PROHIBITION NOTICE
PART XI - ENFORCEMENT AND
INVESTIGATION OSHA 1994
• Section 39. Powers of entry, inspection, examination, seizure, etc.
• Section 40. Entry into premises with search warrant and power of
seizure.
• Section 41. Entry into premises without search warrant and power
of seizure.
• Section 42. Power of forceful entry and service on occupier of signed
copy of list of things seized from premises.
• Section 43. Further provisions in relation to inspection.
• Section 44. Power of investigation.
• Section 45. Power to examine witnesses.
• Section 46. Employer, etc., to assist officer.
• Section 47. Offences in relation to inspection.
• Section 48. Improvement notice and prohibition notice.
10 POWERS FOR DOSH OFFICERS
• Powers of entry, inspection, examination, seizure, etc.
• To enter premises with search warrant and power of seizure.
• To enter premises without search warrant and power of
seizure.
• Forceful entry
• Taking samples.
• Power to investigate.
• Power to examine witnesses.
• Employer or employee to assist officer.
• Offences in relation to inspection.
• To issue Improvement notice and prohibition notice.
SECTION 39. POWERS OF ENTRY,
INSPECTION, EXAMINATION, SEIZURE,
ETC.
• (1) The "officer", means the DOSH officer
• To produce his certificate of authorisation
• enter,
• inspect and
• examine any place of work
• But not a place used solely for residential purposes. However, he
may enter the residential place only with the consent of the
owner!
Section 39. POWERS DURING ENTRY
• (2). Exercise the power to:
• make examination and investigation of any plant, substance,
article or other things
• direct that the place of work or any part be left undisturbed,
for the purpose of any examination or investigation
• take such measurements and photographs and recordings for
the purpose of examination or investigation
• take samples, articles or substance found in the place and the
atmosphere of the place of work;
• require any person employed in which the diseases FMA1967
which has occurred to be examined by a medical officer or a
registered medical practitioner.
Section 39. POWERS DURING ENTRY
• (3) Where a plant or substance is likely to cause a danger to safety and
health, he may –
• (a) dismantled or test
• (b) take possession and detain it for following purposes:
• (i) to examine
• (ii) to ensure it is not tampered
• (iii) to ensure it is available as evidence
• (4) Where an officer is a medical officer he may• (a) carry out such medical examination
• (b) exercise other powers
• (5) seek assistance of the police if reasonable cause to apprehend any
obstruction in the execution of his duty.
• (6) an officer may bring with him• (a) any other authorised person
• (b) any equipment
Section 40. ENTRY INTO PREMISES
WITH SEARCH WARRANT AND POWER
OF SEIZURE.
• A Magistrate shall issue a warrant to an officer named or referred
• to enter the place of work or residential place
• when there is a case with information and is reasonable for
suspecting an offence commit is committed
• at any reasonable time by day or night
SECTION 41. ENTRY INTO PREMISES
WITHOUT SEARCH WARRANT AND
POWER OF SEIZURE.
• Where an officer is satisfied upon information received and
• has reasonable grounds for believing that,
• by reason of delay in obtaining a search warrant and evidence are
likely to be removed or destroyed,
• he may enter the place of work or residential place without a
warrant and seize or seal the evidence.
SECTION 42. POWER OF FORCEFUL
ENTRY AND SERVICE ON OCCUPIER OF
SIGNED COPY OF LIST OF THINGS
SEIZED FROM PREMISES.
• (1) An officer may if it is necessary;
• break open any outer or inner door of a place of work or residential
place and enter
• forcibly enter the place and every part
• remove by force any obstruction to entry, search, seizure and
removal
• detain every person found in the place until the place has been
searched.
• (2) The officer seizing any articles, things, books, documents, plants,
substances, installation shall:
• prepare a list of the things seized
• deliver a copy of the list signed by him to the occupier,
• post a list of the things seized on the premises.
SECTION 43. FURTHER PROVISIONS IN
RELATION TO INSPECTION.
• (1) Upon entering an officer shall notify the employer and the
SHCo of the entry.
• (2) Upon concluding an inspection, an officer shall give to the
employer and the SHCo information with respect to his
observations and any action proposes.
• (3) When samples taken or remove from a place of work for
the purposes of analysis, he notifies the employer and the
SHCo and where possible• divide the sample taken into as many parts as are necessary and
marked, sealed or and fastened
• deliver one part each to the employer or the SHCo if required
• retain one part for future comparison; and
• if an analysis of the sample is to be made, submit another part to
an analyst for analysis.
SECTION 45. POWER TO EXAMINE
WITNESSES.
• (1) May examine orally any person with the facts and circumstances
of the case.
• (2) The person is legally bound to answer all questions only if
• the officer fails or refuses on demand to produce to him the
certificate of authorisation
• there is a tendency to expose him to a criminal charge or penalty
• (3) A person making a statement is legally bound to state the truth
• (4) An officer must inform the person of the subsections (2) and (3)
above.
• (5) A statement made is reduced into writing and signed by him or
affixed with his thumb print, given an opportunity to make any
correction he may wish.
• (6) An officer may use the assistance of an interpreter.
SECTION 46. EMPLOYER, ETC., TO
ASSIST OFFICER.
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Assistance to the officer is by;
The owner or occupier
The employer at, any place of work
The agent or
Employee of the owner,
SECTION 47. OFFENCES IN RELATION
TO INSPECTION.
• A person who –
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refuses access or to assist
obstructs, induces or attempts to induce the officer
fails to produce any document required
conceals the location or person or any plant or substance from
the officer;
• prevents or attempts other person from assisting the officer;
• (hinders, impedes or opposes the officer
SECTION 48. IMPROVEMENT NOTICE
AND PROHIBITION NOTICE.
• If an officer is of the opinion that a place of work, plant,
substance or process is ;
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likely to be a danger, or
likely to cause bodily injury
a serious risk to the health of any person,
likely to cause damage to any property,
• The officer shall serve an improvement notice requiring the
person to
• take measures to remove the danger
• rectify any defect
• within such period after which it is not be used or operated when
the period expires.
SECTION 48. IMPROVEMENT NOTICE
AND PROHIBITION NOTICE.
• If an officer is of the opinion that the defect in subsection (1)
is;
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• likely to cause immediate danger to life or property,
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• The officer shall serve a prohibition notice prohibiting
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• of the use or operation of the place of work, plant, substance or
process until danger posed is removed
• the defect made good and satisfy the officer.
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WHAT IS ACCIDENT / INCIDENT
INVESTIGATION
• A management tool by which work-related injuries, ill health,
diseases and incidents are systematically studied so that
• their root causes and contributing factors can be identified
• the OSH Management System can be continually improved
• corrective actions as good OSH program and management
system be implementated
4 MAIN AIMS OF AN INVESTIGATION
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An incident investigation shall, as far as possible,
• determine the cause or causes of the incident,
• identify any unsafe conditions, unsafe acts or procedures which
contributed in any manner to the incident and
• recommend corrective action to prevent similar incidents.
• to prevent a recurrence of the same accident.
THE AIM IS NOT TO:
• Exonerate (to declare free from being blame) individuals or
management.
• Satisfy insurance requirements.
• Defend a position for legal argument.
• Or, to assign blame.
INVESTIGATION CONCEPTS
• Why do we investigate accidents?
• Prevent future incidents
• To identify and correct/eliminate unsafe conditions, acts or
procedures
• Reduce costs and down time
• Regulatory requirements
• Process WCB claims
2. FIVE BASIC PRINCIPLES OF
EFFECTIVE ACCIDENT INVESTIGATION
• Accidents are generally rooted in management system flaws
or failures
• All accidents (or at least their outcomes) are preventable
• Investigations must be aimed at identifying root causes
• Proper investigative techniques & tools
• Proper investigative training
WHO SHOULD DO THE INVESTIGATION
• Expert in accident causation: Investigations shall be carried
out by persons knowledgeable about the type of work
involved
• Experienced in investigative techniques and full
knowledgeable of
• work processes
• procedures
• persons and industrial relations environment
• Unbiased/impartial
• Safety Committee member or other investigating bodies
WHOSE ROLES & RESPONSIBILITIES?
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Management / Managers
Safety Director / Executive
Safety and Health Committee
Supervisors
Task Force
INFORMING DOSH OFFICE (NADOOPOD
2004)
• Every employer shall inform DOSH Office immediately of the
occurrence of any accident which:
• resulted in serious injury to or the death of a worker, or
• involved a major structural failure or collapse of a building,
bridge, tower, crane, hoist, temporary construction support
system, or excavation, or
• involved the major release of a hazardous substance, or
• was an incident required by regulation to be reported.
WHAT TO INVESTIGATE?
• Serious and Major accidents
• usually investigated automatically.
• Minor and Near-Miss
• indicators that point to a condition or practice that, if allowed to
continue, could cause injury or equipment damage.
• Investigations of serious accidents often reveal earlier
incidents of a similar nature that have been dismissed as
insignificant.
WHAT TO DETERMINE DURING
ACCIDENT INVESTIGATION?
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Who - was involved/injured? Witnesses
Where- did accident happen? exactly
When - did accident occur? Time, date, activities,
What - were immediate & basic causes
Why - was unsafe act/condition permitted
How - can similar accidents be prevented
ACCIDENT TIME PHASES
• Look at accident in three time phases.
Events leading up to accident.
The accident.
Immediately afterwards.
3. INVESTIGATION PLANNING &
STRATEGY : SIX STEPS
• STEP 1: Collect Information: Search and gather for establish
facts: On-Site and Off-Site
• STEP 2: Analyze/Determine All Causes: Immediate and Root
causes
• STEP 3: Assess Future Accident Potential
• STEP 4: Develop Corrective Action
• STEP 5: Report data ,review findings and make
recommendations
• STEP 6: Implement/Take Corrective Actions and Monitor
INVESTIGATION STEPS
• STEP 1: Collect Information: On-Site and Off-Site
• On-site:
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Securing the scene
Investigating at the scene
Recording key information
Equipment is needed...
• Off-site:
• Interview key people
• Assess past accident history
• Review pertinent records
STEP 1
SECURING THE SCENE
STEP 1
• Identify of the individual/person who is in charge and assigns
responsibilities
• Determine the authority to conduct investigation;
• Securing the accident site for the duration of the investigation,
after rescue and damage control are complete
• Gather photographic support or capability
• Follow procedures to ensure observation and recording of
fragile, perishable or transient evidence (instrument readings,
control panel settings, weather & other environmental
conditions, chemical spills, stains, skid marks)
MAKING SCENE OBSERVATION
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STEP 1
Visit all accident scenes/locations
Take/collect samples
Visual records: for evidence proving
Preserve accident items: labelled / barracade
Identify people involved: worker /supervisor /manager /
visitors/vendors
• Interview witnesses: within /outside the scene
• Review information: counter check between observations
/locations
RECORDING KEY INFORMATION
STEP 1
• What was the exact/nature of injury or damage ?
• What was the damaging source of energy?
• What event before and immediately preceded the damaging
event ?
• What happened in between ?
• What else was going on at the time of the accident ?
• Was anyone else involved ?
• Interview witnesses
STEP 1
EQUIPEMENTS & INVESTIGATION KITS
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• specimen containers
camera, film, flash
• magnifying glass
tape measure
• compass
clipboard, pad of paper
• danger tags
pens, pencils
• yellow crayon
A.I. forms
• orange flouro spray paint
Checklist
• Torch/flash light
cassette recorder & spare tapes • with batteries
Highly vissible barrier tape for scene
preservation
• Highly
vissible orange vest
first aid kit
• hearing & eye protection
identification tags for parts
• plastic containers for
samples
gloves (industrial & medical)
• roll of paper towelling
safety helmet
INTERVIEWING KEY PEOPLE /
WITNESS
STEP 1
• Availability of witnesses: The employer must:
• make every reasonable effort to have available for interview
by the person conducting the investigation, or by an officer of
the SHCo: all witnesses to the incident and any other persons
whose presence might be required for a proper investigation
of the incident.
• Record the names, addresses and telephone numbers of
witnesses and other persons with information
WHO TO INTERVIEW?
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Injured worker
supervisor
eye witnesses
workers on another shift
new or transferred workers to area
anyone with information!
STEP 1
MANNER OF CONDUCTING
INTERVIEWS
STEP 1
• Put the person a ease
• they may not see the bigger picture and feel personally
responsible.
• Reassure each person of the investigation’s main purpose.
• Ask person/witness to relate their account of the accident (in
their own words).
• Listen but do not interrupt.
• Do not take notes?
• Do not use a tape recorder?
MANNER OF CONDUCTING
INTERVIEWS (CONTINUED)
• Have person relate account again.
• Take notes.
• Ask questions.
• Go over notes with person to ensure accuracy.
• Ask for suggestions to prevent recurrence.
• Thank person for their help.
STEP 1
STEP 2: DETERMINING CAUSES;
STEP 2
• The root cause is the most fundamental and direct cause of an
accident or incident
• There may be one or more contributory causes, in addition to
the root cause
• Accident Investigation is ineffective unless all causes are
determined and corrected
ACCIDENT CAUSATION:
STEP 2
MUST REMEMBER 3 BASIC FACTS:
• Accidents are caused.
• Unsafe Acts or
• Unsafe Conditions?
• Most accidents have at four or five root causes or factors that
contribute. Often there are more.
• Your task is to identify as many as possible
• Accidents can be prevented by eliminating the causes.
• Unless the causes are eliminated, the same accidents will happen
again.
ACCIDENT CAUSATION
STEP 2
• 3 questions to ask, when considering the contributing factors
of an accident.
• What can management do to prevent the incident from
recurring?
• What can the supervisor do to prevent recurrence?
• What can the worker do?
A. ACCIDENT CAUSES –
IMMEDIATE CAUSE ANALYSIS
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Human behaviour
Design of equipment and plant
Systems & procedures including use of materials
Environmental Surroundings
STEP 2
B. ACCIDENT CAUSES –
ROOT CAUSE ANALYSIS
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Task
Material/Equipment
Environment
Human Factors
Management (cultural factors)
STEP 2
1. Task
STEP 2
• Was a safe work procedure used?
• Had conditions changed to make the normal procedure
unsafe?
• Were the appropriate tools and materials available and used?
• Were safety devices working properly?
2. Materials / Equipment
• Was there an equipment failure?
• What caused it to fail?
• Poor design? …. Poor Maintenance?
• Were hazardous materials involved?
• Were they clearly identified?
• Was a less hazardous material possible/available?
• Should PPE has been used?
STEP 2
3. Environment
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Weather conditions?
Housekeeping?
Temperature?
Lighting?
Noise?
Air contaminants?
STEP 2
4. Human Factors
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Age
Experience
Attitude
Physical condition
Health status
Emotional status
STEP 2
C. Accident Causes - Management /
Organizational ANALYSIS
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Had hazards been previously identified?
Were hazards eliminated or adequately controlled?
Had procedures been developed to address them?
Were work procedures available/followed?
STEP 2
ANALSYSE THE Core Management
Responsibilities:
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Task Structure
Work organization
Workplace design/layout
Equipment availability
Policies/procedures
Training program-new & transferred
Supervision
New employee screening program
Management’s example
STEP 2
WHY INSPECTION FAIL?
• Inspection was done by incompetent person
• Inspection did not identify the hazard which could lead to the
accident
• Inspection must have done using outdated checklist
• The result of the inspection was not communicated to the
management
• Lack of management commitment to take necessary action to
implement the control measures identified in the inspection
• Poor employees health and safety culture toward identified
control measures
• The control measures recommended are not enough to
eliminate the hazard
• Poor health and safety culture within the organization
STEP 3
STEP 3: ASSESS FUTURE POTENTIAL
• Assess Severity:
• Class A Hazard (Major):
• A condition or practice likely to cause permanent disability, loss of life, body part
and/or extensive property loss or damage
• Class B Hazard (Serious):
• A condition or practice likely to cause serious injury or illness
(resulting in temporary disability) or property damage that is
disruptive, but less severe than Class A
• Class C Hazard (Minor):
• A condition or practice likely to cause minor (non-disabling)
injury or illness or non-disruptive property damage
Analyze for Remedies
STEP 3
• Identify factors which if modified would eliminate the unsafe
behavior
• Example - in this instance it may be discovered that:
• worker had not been trained in lockout procedures,
• unsafe behavior not corrected in past as supervisors not
adequately trained to correct
• workload means that if lockout device is not readily available,
then it will not be used
ANALYSE Impact and effect of accidents
STEP 3
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On the Victim
Death
Pain & suffering
Permanent disability
Effects on family & dependents
Loss of earnings
Extra expenditure
Inability to resume occupation
Psychological effects
Feeling of uselessness
Fear of further injury
Social effects
Loss of sports or hobby
ANALYSISE Impact and effect of
accidents
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1. On the Victim
2. On the Supervisor
loss of trained worker
loss of production
extra work
investigations & reports
training new employee
loss of prestige by:
• management
• other workers
• effects on promotion
• worry (could I have prevented it ?)
• Stress
STEP 3
ANALYSE Impact and effect of accidents
STEP 3
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1. On the Victim
2. On the Supervisor
3. On the Company
loss of trained worker
loss of production
damage to machinery
damage to equipment
wasted materials
increased insurance premiums
prosecutions
fines
civil actions
legal costs
loss of prestige - customers
ANALYSE Impact and effect of accidents
STEP 3
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1. On the Victim
2. On the Supervisor
3. On the Company
4. On the Nation
loss of section of workforce
loss of production
increased cost of production
effects on imports
effects on exports
effects on balance of trade
the community pays !
Evaluating / Analyzing Information
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STEP 3
Be objective - don’t start with a fixed opinion.
Consider all contributing factors.
Consider what information is direct, circumstantial or hearsay.
Do not draw conclusion on the first basic cause found.
Key questions:
• why did unsafe behavior occur?
• why did unsafe condition exist?
STEP 4: Correcting the causes
STEP 4
• Control(s) must directly address each cause identified
• Consider short term controls if permanent controls are not
readily available
• More than one control may be needed
• Use the “Control Hit List” to make sure that the “best” control
has been found
The Control hit list
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Eliminate the Hazard
Substitute a less hazardous material
Use Engineering Controls
Use Administrative Controls
Personal Protective Equipment (PPE)
Training of Employees
STEP 4
STEP 5: Report data &
recommendations
STEP 5
• Document facts only
• Determine if the corrective action applies to more than one
employee, more than one job function, more than one shift,
etc.
• Prioritize corrective actions based on future accident potential
• Submit both short term and long term solutions, if necessary
Element of a good report
STEP 5
• Accuracy & completeness of information
• Clarity & completeness of the description of the sequence of
events leading up to the accident
• Correct identification of all causal factors
• Clarity & completeness of all causal factors
• Recommendations made for corrective actions to reduce or
eliminate the probability of recurrence of a similar accident
• Recommendations for corrective actions to improve
management system
• Timelines - specific time periods, monitoring and
responsibilities
• Proper review and sign off
Incident investigation reports
STEP 5
• The employer shall ensure that an incident investigation
report is prepared containing:
• a) the place, date and time of the incident
• (b) the names and job titles of persons
injured
• (c) the names of witnesses
• (d) a brief description of the incident
• (e) a statement of the sequence of events which preceded the
incident,
• (f) identification of any unsafe conditions, acts or procedures
which contributed in any manner to the incident,
• (g) recommended corrective actions to prevent similar
incidents,
• (h) the names of the persons who investigated the incident.
Distribution of reports Follow-up action
STEP 5
and report
• Copies of incident investigation reports shall be forwarded
without undue delay to the OH&S Committee and to the
nearest DOSH office.
• Every employer shall initiate corrective action without undue
delay to prevent recurrence of similar incidents
• Prepare a report of the action taken to the Health & Safety
Committee
STEP 6: Take action & monitor
STEP 6
• Ensure that long term solutions don’t get “lost in the shuffle”
• Evaluate the effectiveness of implemented controls:
- Interview Employees
- Job Safety Analysis
- Accident / Incident Experience
Determining Corrective Action
STEP 6
• Review training program-analyze to determine flaws
• Review training for supervisors-look at motivation
• Purchase additional lockout devices and issue one set to each
electrician
• GOAL IS TO PREVENT FUTURE INCIDENTS
• often necessitates making fundamental changes
Investigation Follow Up
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Delegate recommendations for corrective action.
Publicize the investigation results.
Copies of reports through usual routings.
Post action taken as well as any
non-action and reasons.
• Confirm that action has corrected the problem.
STEP 6
Investigation Procedure-Summary
• Visit the scene - secure to minimize risk of further
injury/damage
• Keep scene as undisturbed as possible
• Make accurate record of scene (photos, drawings,
measurements)
• Conduct interviews
• Evaluate evidence, draw conclusions
• Write report with recommendations.
• Follow-up.
Why Accident Investigations fail...
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Lack of time to complete
Lack of motivation to complete
Lack of accountability
Lack of skills & knowledge
Investigation stopped short and didn’t reveal all causes of the
accident
REMEMBER…..
• Focus on causes NOT on to blame
• This allows management and supervisors to consider failures
in the management system (company’s basic operating
procedures and management/supervisors attitudes), as the
real cause of the accident, rather to simply blame the
“defective worker”.
• Murphy’s Law - “If it can go wrong, it will”
• goal is to minimize consequences of mistakes or unsafe acts