The six-step process for conducting an incident investigation includes: 1) Preserving and documenting the scene immediately by taking photos, securing evidence, and interviewing witnesses while memories are fresh. 2) Collecting facts through interviews to understand what happened without blame. 3) Analyzing the collected information to determine the sequence of events. 4) Identifying the underlying causes that contributed to the incident. 5) Developing recommendations to address the root causes and prevent future incidents. 6) Writing a report of the investigation findings, causes, and corrective actions.

1. Background
Classes: OSHA 10/30 Hour, Incident Investigation,
Confined Space, Excavation Safety, Cranes Signaling,
Rigging Safety, Fall Protection, Scaffold Competent Person,
Silica Competent Person, CHST Prep, Lockout, Machine
Guarding, OSHA Recordkeeping, and Safety Management
Services: Mock OSHA Inspections, Site Safety Audits,
Expert Witness,
Since 1987, he has trained over 50,000 people including
OSHA compliance officers and Fortune 500 Clients in
numerous areas of Safety and Health.
1
40 years working with top companies to
achieve world class safety in their sector.
815-354-6853 johnanewquist@gmail.com

2. Introductionto
AccidentInvestigation
Preserve &
Document Scene
Collect Facts
Through Interviews
Develop Sequence
Determine Causes
Develop
Recommendations
Write Report
Draft 11 12
2020
Introduction to Incident Investigation

3. Course Overview
Part One
• Accident/Incident investigation definitions
• Characteristics of an effective program
Part Two: The six-step process
• Step 1: Preserving and documenting the scene
• Step 2: Collecting the facts through interviews
• Step 3: Developing sequence
• Step 4: Determining causes
Part Three
• Step 5: Developing effective recommendations
• Tools and techniques to measure costs/benefits
• Step 6: Writing the report
Introduction to Incident Investigation

4. Introduction to Accident Investigation
Introduction to Accident Investigation
Part 1 – The Basics
•Accident/Incident investigations determine
how and why failures occur.
Introduction to Incident Investigation

5. Dec 2018
Southern Cook
County
Dump Truck
backed over the
worker’s legs
Introduction to Incident Investigation

6. Exercise Investigation
You were just notified of the injury.
Get out a piece a paper
Write down 8 things that need to be
done, checked, or investigated.
Introduction to Incident Investigation

7. Goals of Incident Investigation
Determine the Incident
Sequence without
Placing Blame
Recommend Corrective
Actions
Update Overall Safety
Program
Introduction to Incident Investigation

8. The Basics
Accident or Incident?
In the past, the term "accident" was often used
when referring to an unplanned, unwanted
event.
To many, "accident" suggests an event that was
random, and could not have been prevented.
Since nearly all worksite fatalities, injuries, and
illnesses are preventable, OSHA suggests using
the term "incident" investigation.
Source: https://www.osha.gov/dcsp/products/topics/incidentinvestigation/index.htmlIntroduction to Incident Investigation

9. Incident?
Incident: An unplanned,
undesired event that hinders
completion of a task and may
cause injury, illness, or
property damage or some
combination of all three in
varying degrees from minor to
catastrophic.
Unplanned and undesired do
not mean unable to prevent.
Introduction to Incident Investigation

10. What Is An Accident?
Accident: Definition is often similar to
incident, but supports the mindset that it
could not have been prevented
Accident usually means
harm or damage to the
victim.
This can be an issue if you
feel there was no work
related injury
Introduction to Incident Investigation
“A catastrophic failure of a 15,000 gallon
polymer reactor vessel was initiated by a
runaway chemical reaction” in the
company’s Kraton-D polymer unit. “The
reactor failure and resulting fire,”

11. The Basics
What are the goals in incident investigations?
What is the difference between accident and incident?
Does your organization conduct accident investigations for the
same reason as OSHA?
Introduction to Incident Investigation

12. November 2013
EPA Case
68.81(d)(4) Incident reports
did not include factors that
contributed to the incident.
In the 161 incident reports
selected by EPA for review 133
had no or inadequate
information under the factors
contributed to the incident.
$326,000 to settle nine
violations of the Risk
Management Program
Introduction to Incident Investigation

13. Opportunity
Investigating a
worksite incident— a
fatality, injury, illness,
or close call—
provides employers
and workers the
opportunity to identify
hazards in their
operations and
shortcomings in their
safety and health
programs. Introduction to Incident Investigation
Storage of flammable inside
vehicle

14. October 2014
Delivery Driver
strikes
pedestrian in
center turn lane
Introduction to Incident Investigation

15. 2017
Drug testing
forklift operator in
gas line hit.
Remove or not?
Tell to drive?
Tested hot yet
doing more work
Introduction to Incident Investigation

16. Focus
Incident investigations that focus on
identifying and correcting root causes, not
on finding fault or blame, also improve
workplace morale and increase
productivity, by demonstrating an
employer’s commitment to a safe and
healthful workplace.
Introduction to Incident Investigation

17. Root Cause?
Event Date: 01/27/2009
On January 27, 2009, Gerald
Holland was walking across an
aircraft hanger to exit the
building for lunch.
Ice and sleet had been
blowing through gaps in the
hanger doors, creating
slippery conditions on the
adjacent floor.
Gerald slipped and fell,
striking his head on the
concrete floor. He was
hospitalized for severe head
trauma and later died.
Introduction to Incident Investigation

18. Team
Incident investigations are
often conducted by a
supervisor, but to be most
effective, these
investigations should include
managers and employees
working together, since each
bring different knowledge,
understanding and
perspectives to the
investigation.
Introduction to Incident Investigation

19. Neutrality
It is advisable to have the supervisor
responsible for only the incident
report and not the incident analysis
The immediate supervisor of the
injured may be part of the reason
why the incident happened.
The supervisor may, therefore, be
unwilling to identify deficiencies in
training, supervision, discipline, etc.,
for which he or she is responsible.
Introduction to Incident Investigation

20. Attitudes?
He replied "you come in here and point out what's out if compliance and
generally unsafe.
You leave and then management tells us we need to get er' done.
They won't approve any extra equipment for us to get er' done.
They know we have to do things that may not be exactly safe or by policy.
They sit and watch us and know what's going on and then praise us for getting
the job done.
You have got to understand what's really going on here...
They asked us to do the job, they watch us do the job, they praise us for
getting the job done, they give us annual increases for doing the job.
They don't spend money on new equipment or safety items.
Why would we think what we're doing is wrong?
After all, they pay us and the safety department doesn’t.”
Worker to Jerry Peters
Introduction to Incident Investigation

21. Back to Root Cause
May 2014
$87,000 Shoulder
strain
Employee used
inappropriate
procedures
Introduction to Incident Investigation

22. Conducting
In conducting an incident
investigation, the team must look
beyond the immediate causes of an
incident.
It is far too easy, and often
misleading, to conclude that
carelessness or failure to follow a
procedure alone was the cause of an
incident.
Introduction to Incident Investigation

23. 2014
Introduction to Incident Investigation
Temporary worker loses
leg below knee in screw
auger.
What are 8
documents/records that
would be reviewed

24. Problem
Those investigations necessarily
start at the bottom, with the
immediate event that caused the
injury.
And, starting at the bottom, the
biggest problem we face is
whether the investigation focuses
on “what went wrong?” or on
“who screwed up?”
If it’s the latter, it’s much harder to
get to root causes, and not just
because witnesses clam up.
The whole investigation gets
skewed. – MW
Introduction to Incident Investigation

25. July 2015
A Santa Fe jury awarded a $165.5
million verdict Friday in connection
with a triple-fatal crash west of Las
Cruces.
Fedex driver had been taking
medication for sleeping problems
related to late-night driving and was
driving about 65 mph when she
slammed into the rear of the young
mother’s truck.
“FedEx Ground had no safety
program, no safety manual for danger
zone driving nor fatigue,”
Midnight and 6 a.m. — otherwise
known in the trucking industry as
the “danger zone,” when accidents
are seven times more likely to
occur
Introduction to Incident Investigation

26. Root Causes
To do so fails to discover the
underlying or root causes of the
incident, and therefore fails to
identify the systemic changes
and measures needed to prevent
future incidents.
When a shortcoming is
identified, it is important to ask
why it existed and why it was not
previously addressed
Introduction to Incident Investigation

27. OSHA Required?
1910.119(m)
The employer shall investigate each incident which resulted in, or
could reasonably have resulted in a catastrophic release of highly
hazardous chemical in the workplace.
An incident investigation shall be initiated as promptly as possible,
but not later than 48 hours following the incident.
An incident investigation team shall be established and consist of at
least one person knowledgeable in the process involved, including a
contract employee if the incident involved work of the contractor,
and other persons with appropriate knowledge and experience to
thoroughly investigate and analyze the incident.
Introduction to Incident Investigation

28. 1910.119(m)
A report shall be prepared at the conclusion of the investigation which
includes at a minimum:
Date of incident;
Date investigation began;
A description of the incident;
The factors that contributed to the incident; and,
Any recommendations resulting from the investigation.
The employer shall establish a system to promptly address and
resolve the incident report findings and recommendations.
Resolutions and corrective actions shall be documented.
Introduction to Incident Investigation

29. 1910.119(m)
 The employer shall establish a system to promptly address and
resolve the incident report findings and recommendations.
 Resolutions and corrective actions shall be documented.
 The report shall be reviewed with all affected personnel whose job
tasks are relevant to the incident findings including contract
employees where applicable.
Introduction to Incident Investigation

30. Why Conduct “Investigation”
Save lives
Prevent future injuries/illnesses
Save money
And?
Introduction to Incident Investigation

31. What do accidents cost your company?
Direct -
Insured Costs
“Just the tip of the iceberg”
Indirect - Uninsured, Hidden Costs - Out of Pocket
Examples:
1. Lost time by fellow employees and supervisor.
2. Investigation of accident.
3. Schedule delays.
4. Legal fees.
5. Training costs for new/replacement workers.
6. Damage to tools and equipment.
7. Lower morale.
8. Increased absenteeism.
9. Poorer customer relations.
10. Others?
Unseen costs
can sink the
ship!
Introduction to Incident Investigation

32. Sales Impact of Selected Injuries
Injury/
Illness
Average
Direct Cost
Indirect
Cost
Total Cost Sales
Needed
(5% profit)
Sprain $4,245 $6,792 $11,037 $220,740
Laceration $1,101 $4,955 $6,056 $121,120
Foreign
Body
$317 $1,427 $1,744 $34,880
Introduction to Incident Investigation

33. Safety Pays
Total costs
Average $37,000
Amputation $138,881
Foreign Body in eye
$40,494
Fracture $112,261
Puncture $53,575
Strain $69,213
33

34. Heinrich
300-29-1 ratio
between near-miss
incidents, minor
injuries, and major
injuries
88 percent of all near
misses and workplace
injuries resulted from
unsafe acts. (old
thinking)
Introduction to Incident Investigation

35. Frank Bird
Analyzed 1,753,498
"accidents" reported by 297
companies.
These companies employed a
total of 1,750,000 employees
who worked more than three-
billion hours during the
exposure period analyzed.
Introduction to Incident Investigation

36. BLS Pyramid
1 death
390 DART
650 Injuries
Introduction to Incident Investigation

37. 2014
The only thing Heinrich's Pyramid
gets right (I think) is that
dangerous work practices and
deficient safety controls rarely
cause a fatality every time, so the
death that occurs is often the
result of an activity that has been
repeated, over and over.
But the notion that that same
activity will generate a bunch of
minor injuries and a smaller
group of more serious injuries is
simply wrong
- Michael Wood
Introduction to Incident Investigation

38. What Is An Near Miss?
Unplanned and
unwanted event which
disrupts the work
process OR has the
potential of resulting in
injury, harm, or damage
to persons or property.
Introduction to Incident Investigation

39. Near Miss
The only difference
between most near-miss
experiences and an injury
is timing or a few inches.
Searching for root
causes of near-miss
experiences and
following up with
corrective action will
certainly lead to lower
injury rates.
Introduction to Incident Investigation

40. Near Miss Problems
People don't like to do it.
It's usually inconvenient to fill
out a "near-miss investigation
form.
It's convenient and sometimes
less stressful to just forget the
near miss ever happened.
Who wants to report a
personal experience that
reflects at-risk behavior,
inattention and carelessness,
and maybe an irresponsible
attitude?
Introduction to Incident Investigation

41. Timing
Do we have to wait until
a serious injury occurs
before correcting
environmental and
behavioral conditions?
Introduction to Incident Investigation

42. Seen This?
What would cause
an employee not
to report?
List five.
Introduction to Incident Investigation

43. Investigation Plan –
Lay the Groundwork
Who to notify
Who contacts police, fire, etc.
Who conducts investigation
Conduct investigator training
Who receives/acts on reports
Timetables for investigation and
follow-up
Introduction to Incident Investigation

44. Who fills out the reports?
“No one wants to
take the time.”
“They still think
safety is the safety
manager's job.”
Introduction to Incident Investigation

45. Effective Program
Written procedures
Responsibility for conducting
investigation
Training plan
Separation from disciplinary
procedures
Written report
Follow-up procedures
Annual review of accident reports
Introduction to Incident Investigation

46. Exercise
Instructions:
Review the following sample accident investigation program. Edit
the program as you think it should be written.
 Does it meet the criteria you said was important?
 What should be added/changed?
Introduction to Incident Investigation

47. Introduction to Accident Investigation
Introduction to Accident Investigation
Part 2 – The Six Step Process
This section covers the process of
accident analysis, using an organized
approach.
Introduction to Incident Investigation

48. Six Step Process
Gather
information
Analyze
the facts
Implement
solutions
1. Preserve and document the
scene
2. Collect the facts through
interviews
5. Recommend improvements
6. Write report
3. Develop event sequence
4. Determine causes
Introduction to Incident Investigation

49. Step 1 – Preserve and Document
the Scene
A. Call 911
B. Supervisory Personnel – Who?
C. Insurance Company
D. Family – Next of Kin
E. OSHA – if meets reporting
Introduction to Incident Investigation

50. Step 1 – Preserve and Document
the Scene
Treat as an Ally - Cooperate
a) Provide Basic Facts
b) Stay Calm
c) Give Short Version of your own observations
d) Watch your words about Fault (Even if you think it was your
fault you may be mistaken!)
e) Take Photos and Memorize/write what you told Anyone at the
Scene
f) Ask how to get police report
Police and EMS
Introduction to Incident Investigation

51. Step 1 – Preserve and Document
the Scene
Why begin immediately?
1. Materials. Things disappear as the
employer is anxious to get back to
work.
2. Memory fails or gets altered.
Introduction to Incident Investigation

52. Immediately
It’s crucial to collect evidence and
interview witnesses as soon as possible
because evidence will disappear and
people will forget.
Introduction to Incident Investigation

53. What are effective methods to
secure or preserve an accident
scene?
Step 1 – Preserve and Document
the Scene
Introduction to Incident Investigation

54. Name ways to document the
scene and collect facts about
what happened
Step 1 – Preserve and Document
the Scene
Introduction to Incident Investigation

55. Step 1 – Preserve and Document
the Scene
Height
8 Ft.
Height
8 Ft.
Height
8 Ft.
Height
8 Ft.
Height
8 Ft.
Example Sketch for a Fatality
Lumber Storage Area, ZYX Sawmill, Ltd.
N
Height
8 Ft.
Height
8 Ft.
Height
8 Ft.
Lumber Piles
Location of deceased (face down)
Direction of travel of deceased
Mr. J. Operator
Accident-Details
Time: 6.45 p.m.
Lighting: Dusk
Deceased: 6’1” Tall
Eye Level of Operator: 7’
Top of Load: 9’4”
Traveling Speed of Load:
Approx. 5 mph
Very Poor Operator
Visibility
22” SpaceIntroduction to Incident Investigation

56. Exercise
Draw the scene
Introduction to Incident Investigation

57. Step 1 – Preserve and Document
the Scene
Preserve documents
The duty to preserve begins when
litigation is reasonably foreseeable
SPOLIATION.
A litigation hold is an instruction
directing custodians of certain
documents and electronically stored
information to preserve relevant
evidence in response to a pending or
reasonably foreseeable litigation.
Make Sure All Sources of Data Are
Preserved
Limit Use of Personal Email Accounts
and Devices Introduction to Incident Investigation

58. Exercise
Group Exercise:
What “documents” will
you be interested in
interviewing on a
construction site?
Traffic accident?
Manufacturing?
Introduction to Incident Investigation

59. Secure the scene
Numerous health
exposures at plant
Boiler Explosion – What would
you be concerned about?
Plastic Plant
Explosion Introduction to Incident Investigation

60. “Investigation Kit”
Camera
equipment
First aid kit
Video recorder
Gloves
Tape measure
Large envelopes
Caution tape
Report forms
Scissors
Graph paper
Scotch tape
Sample containers
with labels
Personal protective
equipment
Introduction to Incident Investigation

61. Step 2 – Collect the Facts through
Interviews
When is it best to interview?
Whom should we interview?
Where should we interview?
Introduction to Incident Investigation

62. Take Photos
Take photos or videos
a) 360 of scene
b) Debris
c) Site/Road Conditions &
visibility
d) Lighting &
Ground/Surrounding
Conditions
e) Vehicle and Property
Damages
Take photos and
video before
digging
2011, worker fell on
the roof.
Off 4 years.
Introduction to Incident Investigation

63. Fact Finding
Witnesses and physical
evidence
Employees/other witnesses
Position of tools and equipment
Equipment operation logs, charts, records
Equipment identification numbers
Introduction to Incident Investigation

64. Fact Finding
Take notes on environmental
conditions, air quality
Take samples
Note housekeeping and
general working environment
Note floor or surface
condition
Take many pictures
Hazards?
Introduction to Incident Investigation

65. Record the Facts
Record:
• Pre-accident conditions
• Accident sequence
• Post-accident conditions
Document victim
location, witnesses,
machinery, energy
sources and other
contributing factors.
Even the most
insignificant detail may
be useful!
Introduction to Incident Investigation

66. Record the Facts
Take different angles of
the scene
Introduction to Incident Investigation

67. Quiz
Quiz
1. What's the most practical
way to secure an accident
scene?
2. What might be the result
if the investigation is not
initiated as soon as
possible?
3. If a workplace fatality or
hospitalization of three or
more employees occurs,
the affected employer
must notify OSHA within
_____.
4. When documenting the
scene, one of the biggest
challenges facing the
investigator is to:
Introduction to Incident Investigation

68. Interviewing Techniques
What should we say?
What should we do?
What should we not
say?
What should we not do?
Introduction to Incident Investigation

69. Exercise
Purpose. Gaining as much
information as possible about
an incident is extremely
important.
Interviewing witnesses is both
a science and an art, and can
make the difference between
a failed or a successful
accident investigation.
Introduction to Incident Investigation

70. INTERVIEWING QUESTIONS
Who?
What?
Where?
Why?
When?
How?
Introduction to Incident Investigation

71. Talk to the Injured
Injured are treated different
from witnesses
Try to get them to write out
the incident in their own
handwriting if possible.
Or have two people witness.
Get their sequences of events.
Employees will be especially
uncooperative if they perceive
that investigations are being
used as a technique to find a
scapegoat.
Do not have the injured
employee fill out reports
beyond what is required by law
420 U.S. 251 (1975), upheld a National
Labor Relations Board (NLRB) decision
that employees have a right to union
representation at investigatory
interviews. These rights have become
known as the Weingarten Rights.
Introduction to Incident Investigation

72. Interviewed the Injured
Introduction to Incident Investigation

73. Introduction to Incident Investigation

74. Interviews
Video interviews
Introduction to Incident Investigation

75. Listening Habits
Following are ten habits that
might occur during listening of
listening.
Check those listening habits
that you are sometimes guilty
of committing when
communicating with others.
 Did they interrupt often or try
to finish the other person’s
sentences?
 Did they jump to conclusions?
 Were they overly parental and
answer with advice, even
when not requested?
 Did the person appear to make
up their mind before they had all
the information.
 Were they a note taker?
 Did they give any response
afterward?
 Were they impatient?
 Did they exhibit body language
when hearing things they didn’t
agree with?
 Did they change the subject to
something that relates to their
own experiences?
 Did they about the reply while
the other person is speaking than
what he or she is saying.Introduction to Incident Investigation

76. Interview All
Interview all witnesses as
soon as possible
Separate Witnesses
Take signed statements
Too many miss the universe
of people, because they went
home or are on vacation.
Introduction to Incident Investigation

77. Interview Witnesses
Choose a private place to talk
Ask open ended questions
Interview promptly after the
incident
Ask some questions you know
the
answers to
You can also write the
statement of the injured or
witness and have them initial
or sign it.
Introduction to Incident Investigation

78. Selective Listening
Selective listening is the act of
hearing and interpreting only
parts of a message that seem
relevant to you, while ignoring or
devaluing the rest.
Often, selective listeners will form
arguments before they’ve heard
the full story, making them not
only poor listeners, but poor
speakers too!
$400 million dollar project
Answer five questions after
watching the video.
Introduction to Incident Investigation

79. Five Questions
What were they doing when
the deck collapsed?
How many hospitalized
overnight?
Where did the other casino
collapse happen?
What did the Ironworker
superintendent say about
inspections?
When was the casino schedule
to open?
Introduction to Incident Investigation

80. Quiz
1. What relevant information might be obtained by reviewing the
OSHA Injury and Illness records?
2. What is the purpose of the interview process. How do you best
achieve that purpose?
3. Which of the following is an effective interview techniques?
a. Ask "why-you" questions
b. Ask open-ended questions
c. Interview in a crowd
d. Encourage fault-finding
4. Why is it important to repeat the facts and sequence of events
back to the interviewee?
Introduction to Incident Investigation

81. Step 3 - Develop the Sequence
of Events
Analyze by breaking
down the investigation
processes into
component parts
Events prior to …
Event during …
Events immediately after …Introduction to Incident Investigation

82. Step 3 - Develop the Sequence
of Events
Each event in the process describes one:
• Actor - Individual or object that is initiating
action.
• Action - The thing being done
"Bob unhooked the lifeline from the harness.“
Introduction to Incident Investigation

83. Group Exercise: Develop the Sequence
List sequence on
the workbook
page from the
video
Introduction to Incident Investigation

84. Timelines
Set Timelines
An initial incident report will
be conducted with 24 hours of
the date of the accident.
An incident analysis will be
completed within one week of
the date of the accident
“Too often the report is down
by the Supervisors &
employee asap so the
employee can get on his/her
way to get needed medical
attention”
Fire in hospital from worker
in hallway using torch
setting papers on paper.
Sprinklers put fire out.
Introduction to Incident Investigation

85. Quiz
An “event” occurs when one _______ performs an _______.
Developing the sequence of events is critical in the accident
“analysis” process to:
a. Find out who to interview
b. Fix the system
c. Place the blame
d. Document the scene
Introduction to Incident Investigation

86. Step 4 - Determine Causes
Single Event Theory
The Domino Theory
Multiple Cause Theory-Systems
Injury results from a completed sequence of
factors; ignores system weaknesses
Contributing factors, events and system
weaknesses combine to cause accidents;
uncovers root causes to prevent a recurrence
“Blame the victim”
Introduction to Incident Investigation

87. Is the Root Cause Identified?
Hit by Pulley
Event Date: 07/27/2010
Employee #1 was struck in
the head by a metal pulley
when the nylon sling to
which it was connected
broke.
The pulley was being used
to drag felled trees.
When the rigging was put
under tension, the nylon
sling broke, releasing the
pulley, hitting the employee
in the head.
Introduction to Incident Investigation

88. Introduction to Accident Investigation
Introduction to Accident Investigation
Root Cause
Analysis
Introduction to Incident Investigation

89. September 2017
In the past five years, 15 workers suffered
amputations at the Chicago plant.
OSHA cited XXXX Corporation for five
repeated and five serious safety violations
of machine safety procedures and placed
the company in its Severe Violator
Enforcement Program.
$503,000
Introduction to Incident Investigation

90. Why Determine Root Cause?
Prevent problems from recurring
Reduce possible injury to personnel
Reduce rework and scrap
Increase competitiveness
Promote happy customers and stockholders
Ultimately, reduce cost and save money
Introduction to Incident Investigation

91. Look Beyond the Obvious
Invariably, the root cause of a
problem is not the initial reaction or
response.
It is not just restating the Finding
Introduction to Incident Investigation

92. Often the Stated Root Cause
is the Quick, but Incorrect Answer
For example, a normal response is:
Equipment Failure
Human Error
Initial response is usually the symptom, not the root cause
of the problem. This is why Root Cause Analysis is a very
useful and productive tool.
Introduction to Incident Investigation

93. Most Times Root Cause
Turns Out to be Much
More
Such as:
Process or program failure
System or organization failure
Poorly written work instructions
Lack of training
Introduction to Incident Investigation

94. What is Root Cause
Analysis?
Root Cause Analysis is an in-depth
process or technique for identifying
the most basic factor(s) underlying a
variation in performance (problem).
Focus is on systems and processes
Focus is not on individuals
Introduction to Incident Investigation

95. When Should Root Cause Analysis
be Performed?
Significant or consequential events
Repetitive human errors are occurring during a specific process
Repetitive equipment failures associated with a specific process
Performance is generally below desired standard
Introduction to Incident Investigation

96. How to Determine the Real Root
Cause?
Assign the task to a person (team if
necessary) knowledgeable of the
systems and processes involved
Define the problem
Collect and analyze facts and data
Develop theories and possible causes -
there may be multiple causes that are
interrelated
Systematically reduce the possible
theories and possible causes using the
facts
Introduction to Incident Investigation

97. How to Determine the Real Root
Cause? (continued)
Develop possible solutions
Define and implement an action plan
(e.g., improve communication, revise
processes or procedures or work
instructions, perform additional
training, etc.)
Monitor and assess results of the action
plan for appropriateness and
effectiveness
Repeat analysis if problem persists- if it
persists, did we get to the root cause?
Introduction to Incident Investigation

98. Useful Tools For
Determining Root Cause
are:
The “5 Whys”
Pareto Analysis (Vital Few, Trivial Many)
Brainstorming
Flow Charts / Process Mapping
Cause and Effect Diagram
Tree Diagram
Benchmarking (after Root Cause is found)
Some tools are more complex than others
Introduction to Incident Investigation

99. Example of Five Whys for Root Cause Analysis
Problem - Flat Tire
Why? Nails on garage floor
Why? Box of nails on shelf split open
Why? Box got wet
Why? Rain thru hole in garage roof
Why? Roof shingles are missing
Introduction to Incident Investigation

100. Injury Analysis
Acoustic
Chemical
Electrical
Kinetic
Potential (Stored)
Radiant
Thermal
Direct Cause:
A harmful transfer of
energy that produces
injury or illness
Cuts
Burns
Strains
Accident Types
 Struck by
Struck against
Contact with
Caught on-in-between
Fall to surface-fall to below
Exposure
ExertionIntroduction to Incident Investigation

101. September 2017
An Indiana man’s head was crushed
during a fatal forklift accident at a
distribution center on Sunday, according
to WXIN.
According to the coroner, 59-year-old
Phillip L. Terry of Indianapolis sustained
multiple crushing injuries from the
incident.
The most significant injuries were to his
head and his torso, including multiple
skull fractures and injuries to his brain.
Why?
Why?
Why?
Why?
Why?
Introduction to Incident Investigation

102. Cause and Effect Diagram
(Fishbone/Ishikawa Diagrams)
EFFECT
CAUSES (METHODS) EFFECT (RESULTS)
“Four M’s” Model
MAN/WOMAN METHODS
MATERIALS MACHINERY
OTHER
Introduction to Incident Investigation

103. Cause and Effect Diagram
Loading My Computer
MAN/WOMAN METHODS
MATERIALS MACHINERY
OTHER
Cannot
Load
Software
on PC
Inserted CD Wrong
Instructions are Wrong
Not Enough
Free
Memory
Inadequate System
Graphics Card
Incompatible
Hard Disk Crashed
Not Following
Instructions
Cannot Answer
Prompt Question
Brain Fade
CD Missing
Wrong Type CDBad CD
Power Interruption
Introduction to Incident Investigation

104. EFFECT
“Four M’s” Model
MAN/WOMAN METHODS
MATERIALS MACHINERY
OTHER
Sep
2017
“He slipped and fell into a
ash type hopper full of the
dust/powder.”
Introduction to Incident Investigation

105. Behaviors of the 30%
30% of the workers will not report a
hazards
Examples:
– Failing to comply with rules
– Failing to report injuries
– Failing to supervise
– Ignoring hazards
Introduction to Incident Investigation

106. Step 5 – Develop Recommendations
Use Control Strategies
 Engineering Controls
 Management Controls
 Personal Protective Equipment
 Interim Measures
Introduction to Incident Investigation

107. Group Exercise: Recommending Corrective
Actions
In this exercise you’ll
develop and
recommend immediate
actions to correct the
causes of an incident
Develop and write a
recommendation to improve one or
more policies, plans, programs,
processes, procedures, and practices
related to the accident scenario.
Introduction to Incident Investigation

108. Engineering Controls
Eliminate/reduce hazard
by design, enclosure,
substitution,
replacement, etc.
3 principles
1. Removal or substitution
2. Enclosure
3. Barriers or local
ventilation
Introduction to Incident Investigation

109. Controls?
Common Forklift
Death
Introduction to Incident Investigation

110. Management Controls
Eliminate/reduce exposure
by providing training and
hazard recognition
Three primary strategies:
• Safety rules and safe work
practices/ procedures
• Scheduling
• Training
Introduction to Incident Investigation

111. Personal Protective Equipment (PPE)
Used along with
engineering and
management controls
Legal requirements
Limitations
Introduction to Incident Investigation

112. Preparing a Recommendation
1. Pinpoint the problem
• Hazardous condition, unsafe behavior, etc.
• System components
2. Find out problem history
3. Pinpoint the solution
• Engineering, administrative, ppe
• System improvements
4. Who is the decision maker?
Introduction to Incident Investigation

113. Preparing a Recommendation
5. What motivates the decision maker?
– Legal obligation
– Fiscal obligation
– Moral obligation
6. Determine cost/benefits of solving the
problem
Introduction to Incident Investigation

114. Effective Recommendations
Give Options –
1. If we have all the money in the world …
2. If we have limited funds …
3. The OSHA law requires…..
4. If we don’t have any money …
Introduction to Incident Investigation

115. Recommendations
Factors that Influence Success
Sizzle
Style
Content
Motivation
Presentation
Steak
Benefits/Consequences
Part of recommendation that
appeals to the wants and needs
that motivate (WII-FM)
What’s the problem
Steak is the content of your
recommendation that describes
the condition you want
changed Relationship
Your ability to
present
information that
says you know
what you are
talking about
Introduction to Incident Investigation

116. Recommendations
What Change Does a
Recommendation Promote?
Attitudes
Thoughts
Feelings
What the decision maker
decides to do.
Approve
Disapprove
Revisit
Revise
The Cause
Internal Transition
(Not Observable)
The Effect
External Changes
(Observable)
Recommendation
Persuasive
Communication
Introduction to Incident Investigation

117. Step 6 - Write Report
Section I. Background
Section II. Description of Accident
Section III. Findings
Section IV. Recommendations
Section V. Summary
Section VI. Follow-up Actions
Section VII. Attachments
Introduction to Incident Investigation

118. Group Exercise:
Putting it All Together
This exercise will give you practice in
completing using a lot of the information
gained from this course. Be thorough and
use extra paper if needed.
Introduction to Incident Investigation

119. The report is an open document
until all actions are complete!
Follow Up!
Take corrective action
Conduct follow up evaluation
Conduct annual review of reports
Introduction to Incident Investigation

120. Corrective Action
Fix it.
“When they do write a
corrective action they
don't follow it and get it
corrected.”
That is why they continue
to have repeated
accidents.
Introduction to Incident Investigation

121. Example
Walking along a metal grate, a
worker slipped on the loose
grating and fell 31 feet.
Several people knew about
the grate being loose and
never reported it.
There were no mechanisms
to report it as damaged
property.
If it was reported as damaged
property, the accident would
have never happened.
Introduction to Incident Investigation

122. Get Help?
Consider a professional investigator
Seriousness or circumstances of the
accident create the potential for
litigation.
A very high level of knowledge and
experience is necessary to adequately
prepare for legal contingencies.
If legal action is possible, you don't
want an amateur investigation.
A poor investigation could cause more
harm than good.
Introduction to Incident Investigation

123. Litigation?
If litigation is
anticipated, an attorney
should be consulted and
an incident analysis
conducted only if
approved and directed
by the attorney
Attorney Client Privilege
All reports go to the
attorney.
Combustible Dust Explosion
Introduction to Incident Investigation

124. Preserve Records
Date Stamp (Bate Stamp)
Equipment manuals
Discipline records
Inspection records
Training records
Previous related
incidents
Introduction to Incident Investigation

125. Criminal 2015
Marcus Borden was charged
with lying to OSHA about an
incident investigation of one of
his work sites in Cordova AL
more than two years ago.
He was sentenced to three
years of supervised probation
and 30 hours of community
service after pleading guilty to
one count of making false
statements to the U.S.
Department of Labor's
Occupational Safety and Health
Administration.
Introduction to Incident Investigation

126. Notify the Family
September 2013
NBC says he took off his
harness to reach a confined
space.
His widow says she found out
about it on Facebook with
people making fun of him,
saying why was he working in
a sewer?
She said he was working
because the company told him
to work.
How do you let the family
know?
Introduction to Incident Investigation

127. ThoughtsTeresa sobbed, "You have no idea
how it feels to know I could not
give my little girl her last gift.
I still can’t afford a head stone for
my baby.
I can’t go out and visit the grave
because nothing is there.”
He was my dad, thank you
everybody, I am McKenzie Lane
Lentz, 16.
Harry's youngest daughter .
I hold them 1OO% responsible
I miss him with all my heart .
I can never see his face again .
He was my everything .
www.usmwf.org works with
families after a workplace
tragedy.
Introduction to Incident Investigation

128. Best Practices
Save any personal effects.
Go to the visitation
Be supportive and talk to the
family
It is natural have to the
feeling of fear of the families
reaction
Bring a support person
Danielle and Nicole lost their
father Sherman on the job in
February 2011 while working at
K&K Forest Products in Evart,
Michigan. He died after being
struck by a felled tree.

129. "Holy (blank). Holy (blank). This is
terrifying."
Declan Sullivan’s tweet from
on top the aerial lift.
Winds were 51 mph.
Wind alert last two days.
What was the safe wind for
this aerial lift?
Declan, age 20, was slated to
go off to study in China next
semester.
Introduction to Incident Investigation

130. Notre Dame Response
Open letter to all by Rev. John Jenkins
“We are conducting an investigation
and we must be careful not to pre-
judge its results, but I will say this:
Declan Sullivan was entrusted to our
care, and we failed to keep him safe.
We at Notre Dame — and ultimately
I, as President — are responsible.
Words cannot express our sorrow to
the Sullivan family and to all
involved.”
It was not our first impulse to go out
and hire a lawyer. That's not the way
we're wired," Barry Sullivan said.
2014
Kelly was a speaker at "No
Ordinary Evening," a
celebration of the life of Declan
Sullivan
The event supported the
Declan Drumm Sullivan
Memorial Fund, which has
raised more than $1.2 million
the past two years for Horizons
for Youth.
Introduction to Incident Investigation

131. IL Incident – Struck by Trailer
August 4, 2003
Temporary employee was
killed when his head was
pinned and crushed between
the back of a 53-foot trailer
and the wall of a loading
dock.
What is your procedures to back
up trucks?
Introduction to Incident Investigation

132. Response
Brought in counselors
Memorial at the
warehouse
Let workers put up a
shrine.
Introduction to Incident Investigation

133. Other Responses
After a confined space death
Encourages everyone to go to
visitation and funeral at
company expense.
Paid for all employees to take
a day long confined space
refresher class
Witnesses had free counseling
provided.
Revises the confined space
program
After a fatal fall
Had a safety stand down
Bought everyone new fitted
body harnesses.
Implemented 100% fall
protection.
Introduction to Incident Investigation

134. Safety Lessons Learned
Physical & System Factors: Glassware cuts are more
common than might be expected and can be very serious.
Root Cause: Broken edge of beaker sliced finger.
Final Actions: Revisit review of glove wear to determine if
heavy gloves should be worn when washing glassware by
hand. Supv QC Lab will purchase, supply, train employees
to wear cut resistant gloves when washing glassware.
Review of chipped glassware inspection program – as
chips weaken glassware and increase the risk of injury.
Reminder to all before working with glassware, always
inspect it for flaws and all glass should be pulled from
service if defects are present.
Review “Safe Handling of Laboratory Glassware”
procedure.
Event Type: Laceration
Date, Time: 02-05-14, 12 noon
Case Classification: First Aid Case
Location: Quality Control Lab
Event Description: Employee was washing, by hand,
daily testing beakers – glass 2000 ml & beaker tapped
against sink & broke. Laceration to finger.
Human Factors: Reported to Supervisor. Sought
medical treatment.
Promoting Safety at WORK & at HOME!
Place pictures here
Introduction to Incident Investigation

135. Summary
During this session, you have been introduced to:
– Accident investigation definitions and
characteristics of an effective program.
– The six-step approach to accident
investigation/analysis:
1. Preserving and documenting the scene
2. Collecting the facts through interviews
3. Developing sequence
4. Determining causes
5. Developing effective recommendations
6. Writing the report
Introduction to Incident Investigation