Incident Investigation in Health and Safety, with intro to the loss causation model

1. Audrey Foo
Incident Investigation
Notes: Presentation given on May 2, 2018 at Ashton College.
If you wish to use or modify this presentation please contact me at @aufumy or aufumy@gmail.com

2. Goal of Incident Investigation:
To figure out why and how to prevent it from happening again

3. What you need to know
before an incident...

4. Pro Investigation Tips
● Be aware of biases (Individual, Team, Others?)
● Your experience and skills (how it affects your perception)
● Avoid jumping to conclusions. Do not reveal that you may be suspicious
● Use appropriate voice tone. Don’t be overly formal or aggressive
● Minimize stress wherever possible
● Be aware of your non-verbal communication (e.g. facial expressions,
gestures)
● Behave professionally (courteous, open, honest, candid,
non-threatening)

5. Critical Factors in the Investigative Process
Legal Requirements
● Reporting
requirements
● Medical aid or lost
time
Severity
● Serious incidents vs
minor incidents
● Time consuming
● Legal obligation
Timing
● Memory loss
● Site changes
● Removal of evidence
● Retelling of details

6. When an Investigation is Required by Law
1. Serious injury or death
2. Structural failure or collapse
3. Hazardous substance
4. Fire or explosion
5. Near misses
6. Injury with potential for causing
serious injury
Watch a WorkSafeBC video
on the process for filling out
the Employer Incident
Investigation Report (EIIR)

7. Investigation Kit
● Investigation checklist and form
● High visibility tape
● Pencils, pens
● Measuring tape, ruler
● Clipboard, notepaper, graph paper
● Camera/video camera/cell phone with memory
● Plastic bags & envelopes
● Flashlight
● Safety equipment

8. Initial Response...

9. Steps in the Initial Response
Take Control
Ensure First Aid
Control Secondary Accidents
Identify Sources of Evidence
Preserve Evidence
Determine Loss Potential
Notify Managers

10. Example of Incident and Initial Response
Incident Environment Inadequate Response Adequate Response
Watch the initial
incident and write up
a report
Watch what could go
wrong in an initial
response.
Watch how to
properly conduct an
initial response.
Think about: What are the chances you might lose your calm in an accident
situation, and might mirror what Dave did in the Inadequate Response scenario?

11. After the Initial Response...

12. Steps of an Incident Investigation
1. Secure the scene
2. Gather evidence
3. Analyze the information
4. Report the results of the incident investigation
5. Make recommendations
6. Follow up

13. Types of Information Collected
Environmental Factors
● Weather conditions
● Housekeeping
● Temperature (too hot
or cold)
● Noise
● Adequate light
● Toxic or hazardous
gases, dusts, fumes
Situational Factors
● Machine,
equipment, tools
● Control and displays
● Site and location
● Protective
equipment and
guards
● Time of day
Human Factors
● Worker actions
● Procedures followed
● Supervisor present
● Employment status
● Experience

14. Interview Steps
1. Interview witnesses on the spot
2. Interview witnesses separately
3. Put the witness at ease
4. Let the individual speak. Do not try to bias the
account
5. Ask necessary questions without forming
conclusions
6. Repeat back what you understood
7. Record information in a timely fashion
8. End the interview on a positive note
Watch how different
interview styles can help
uncover the truth in an
investigation.

15. Reports to Submit to WorksafeBC
1. Preliminary investigation (Within 48 hours)
2. Interim corrective action (ASAP)
3. Full investigation (within 30 days)
4. Full corrective action
Download the WorksafeBC incident
investigation form and review the
sections required at different stages.

16. Review Corrective Actions
Direct causes
● Temporary corrective actions
● What can I do right now?
Indirect causes
● Permanent corrective actions
● How effective, long-lasting, cost analysis?
● Long-term solutions
Watch the discussion between Dave and
Jim, and determine the temporary and
permanent actions they developed.

17. Overview of Conducting an Incident Investigation
1. Preparation
2. Visiting the Scene
3. Conducting Interviews
4. Examining Physical Evidence
5. Analyzing the Evidence
6. Preparing a Report
Watch this video for a
good overview of the
steps in conducting an
incident investigation

18. Loss Causation Model
In the final stage of the investigation to
analyze the root causes, fill out a paper
with the following columns:
1. Loss
2. Incident
3. Immediate Causes
4. Basic Causes
5. Lack of Control
Note: Depending on your role in the organization, you may be
responsible for only identifying immediate and/or basic causes

19. Summary
● Accidents will happen, no matter how well run our shop is.
● Be prepared, otherwise the way that you handle the initial incident, may
cause similar or worse incidents to occur.
● Understand your obligation to WorkSafeBC. Review the Incident
Investigation Report form.
● Keep your calm, delegate, preserve the scene, write up the report.
● Practice your interviewing techniques.
● Apply the loss causation model to the investigation.

20. References
● Kelloway, Kevin, Francis, Lori, and Gatien, Bernadette, Management of Occupational Health and Safety, 7th edition,
Nelson Education, 2017.
● https://www.youtube.com/watch?v=zPu2CePrHhc
● https://www.youtube.com/watch?v=h-s5DYaodhM
● https://www.youtube.com/watch?v=zew22wCuPJY
● https://www.youtube.com/watch?v=hQilV-mOnC4
● https://www.youtube.com/watch?v=QXYe67-sXAI
● https://www.umanitoba.ca/admin/vp_admin/risk_management/ehso/media/AIguideWSH.pdf
● https://www.worksafebc.com/-/media/WorkSafeBC/Resources/health-safety/forms/52e40guide-pdf-en.pdf
● https://www.worksafebc.com/en/health-safety/create-manage/incident-investigations/reporting-incidents-worksafebc
● https://www.umanitoba.ca/admin/vp_admin/risk_management/ehso/media/AIguideWSH.pdf
● https://www.bcit.ca/files/safetyandsecurity/pdf/incident_investigation_procedure_report_form.pdf
● https://www.worksafebc.com/en/resources/health-safety/forms/incident-investigation-report-form-52e40?lang=en
● images from https://giphy.com/gifs/the-great-mouse-detective-fUXKC3XVDHFFS , https://imgur.com/gallery/e0qlFN7,
http://moziru.com/explore/Falling%20clipart%20animated%20gif/#go_post_2880_falling-clipart-animated-gif-3.gif,
https://safetyimages365.com/media/catalog/product/cache/8/image/9df78eab33525d08d6e5fb8d27136e95/s/p/spebi04
5w.jpg, http://www.theaterproject.com/2018-summer-camps/,
http://www.theaterproject.com/2018-summer-camps/https://aemstatic-ww1.azureedge.net/content/dam/etc/medialib/
new-lib/hydroreview/print-articles/volume-30/issue-3/56274.res/_jcr_content/renditions/pennwell.web.300.348.jpg.
https://safetyimages365.com/media/catalog/product/cache/8/image/9df78eab33525d08d6e5fb8d27136e95/h/a/harsi41
5w.jpg

21. THANK YOU!