An incident investigation training presentation covered the following key points: - Incident investigations aim to identify causal factors to prevent future occurrences, not assign blame. The process involves fact-finding, interviews, analyzing contributing physical, human, and system failures using a "why tree" approach. - Recommendations target systemic improvements like training, procedures, inspections, rather than individual factors. Near misses also warrant investigation to drive continuous improvement. - A sample incident of an employee falling from scaffolding during maintenance identified causal factors like incomplete guardrails and plank, inadequate scaffold builder training, and lack of inspection programs. Recommendations included training, replacing defective equipment, and establishing safety programs.

1. MARIO DESHAIES,
HEALTH AND SAFETY H&S MANAGER/EXPERT/EXECUTIVE ADVISOR STRATEGY,
CULTURE AND EMPLOYEE ENGAGEMENT
COURRIEL : MARIODESHAIES@GMAIL.COM
1
Incident Investigation
“Working to Prevent Recurrence

2. OVERVIEW
• Why investigate?
• Incident Investigation process
• Causal Factors
• “Why Tree” analysis
• Training Exercise
• Breakout Exercise

3. WHAT REQUIRES INVESTIGATION?
• All recordable occupational injuries and illnesses
• Fires
• Exceeds fire system design capability
• System aborts material out of process
• Process line goes down due to potential fire
• Visible/smell smoke
• Incidents with property damage > $1,000.
• Incidents with business interruption > $1,000.
• Significant “Near Misses”- an incident with clear potential for undesirable
consequences (e.g. adverse impact on people, property, the environment, or the business)
even though no actual consequence occurred. e.g.
• Falls
• Electrical contact

4. Trailing
Indicators
Leading
Indicators
Small
Differences
Attack the
Base
Near Miss Investigations Drive
Continuous Improvement

5. WHY INVESTIGATE INCIDENTS?
• Moral obligation
• Legal obligation
• Prepare for litigation…sometimes
• Identify physical and environmental conditions/failures,
• Identify/recognize human and behavioral issues/failures,
and
• To use causal analysis to identify system failures and
breakdowns.
• Determine corrective actions
• Prevent recurrence - share lessons learned – leverage key
learnings
NOT INTENDED TO DETERMINE OR PLACE BLAME

6. PRINCIPLES
• Atmosphere of open reporting of incidents and “Near
Misses” is essential.
• Most incidents are symptoms of system failures and not just
physical or human failures.
• Few incidents occur as the result of a single causal factor.
• Teamwork within functional groups (operations,
maintenance, engineering, contractors) is essential for
understanding and prevention of incidents.
• Communication of corrective actions and key learnings
aimed at systemic improvements are the most effective
means to prevent similar incidents.
WORK TO ELIMINATE THE FEAR FACTOR IN REPORTING

7. BENEFITS
• Promotion of an atmosphere of openness through
improving reporting, communications and
understanding.
• Identification and implementation of actions to
prevent recurrence.
• Identification of conditions that contribute to future
incidents and opportunities to share information
broadly.
• Input for development and improvement of Safety
and Health training, policies, procedures, guidelines
and standards.
• Improved employee attitude, moral and productivity.

8. TRAINING OF KEY PERSONNEL
• Establishing event facts and chronologies
• Physical item collection and preservation
• Interview techniques
• “Why Tree” failure analysis techniques
• Identification of causal factors
• Determining and writing recommendations
• Final report writing and documentation
• Completion and closure of recommendations

9. INITIAL RESPONSE
• Preserve the incident scene and physical items to the
degree possible.
• Barricade and/or secure the scene including protection
from the weather.
• Assess the scene of incident before physical evidence is
disturbed.
• Evaluate all aspects of that area that may be contributors
to the incident.
• Collect, identify, and properly store (preserve) physical
items and data records.
• Create visual records (sketches, photographs, notes) -
photograph the scene and equipment as necessary.
• Document/review sources of information – SOPs, JHAs,
permits, job plans.

10. INITIAL RESPONSE
• Determine what incident-related items should be
preserved
• Identify the people who can contribute to the
investigation – witnesses
• Interview people as soon as possible
• Document interviews of any key personnel
• Reconstruct/reenactment – “have personnel show or tell
what happened”
• Do exposure assessments when hazardous materials are
involved
TIMELY RESPONSE AND INVESTIGATION IS IMPORTANT

11. INTERVIEWING
• ASAP, one at a time or as a group, depending on
circumstances
• Away from incident scene – office or conference room
• Explain objective
• Fact finding, not laying blame
• Ask one question at a time, then LISTEN
• Take the statement, review it with them
• Remind them of confidentiality
• Thank them for participating

12. TEAM LEADER RESPONSIBILITIES
• Control the scope of team activities to ensure comprehensive
and timely investigation.
• Ensure the appropriate team membership and participation
(e.g. technical, operations, maintenance, external resources,
“Why Tree” resource).
• Schedule and preside over meeting.
• Inform line management of the status of the investigation (s).
• Ensure the adequacy of the report.
LEADERSHIP LEADS TO A SUCCESSFUL PROCESS

13. INVESTIGATION TEAM MAKE-UP
• Team membership should include those who can
contribute and play a role in the investigation and can vary
according to the incident being investigated.
• At least one member of the team should be experienced and/or
trained in conducting incident investigations.
• A first-line supervisor from the affected area.
• Individuals who have first hand knowledge of the incident.
• Operations, maintenance, engineering and technical resources as
needed.
• Appropriate safety and safety committee personnel.
• A manager or senior member of operations where the incident
occurred.
KEEP THE TEAM SIZE AT A REASONABLE NUMBER

14. INVESTIGATION PROCESS
• Write a failure statement
• Determine the facts
• Establish chronological order of events
• Do “Why Tree” causal analysis
• Determine systems that need to be strengthened
• Develop corrective and preventive actions
• System to ensure that all corrective and preventive actions are
followed through to completion in a timely manner
• Document and communicate the findings
• System to ensure broad communications and leveraging of key
learnings
CLEAR AND CONCISE ARE KEY

15. CAUSAL FACTORS
• Circumstances that contribute to or may be
reasonably believed to have contributed to the
incident’s occurrence.
• These circumstances may include human,
physical, or operating/managing systems that are
found to be deficient or otherwise capable of
being improved.

16. CAUSAL FACTORS
• Physical – failures or conditions that allow an incident to
occur. e.g. something breaks or fails - tools, equipment,
machines. Includes environmental impact conditions such
as heat, cold, slippery conditions due to ice or snow.
• Human - human errors, misjudgments, omissions,
oversights, poor decision making, inattention, lack of
awareness, shortcuts, or failure to follow safe work
practices.
• Operating/Managing Systems - system deficiencies that
allow incidents to occur. e.g. procedures, training,
orientations, audits.

17. OPERATING/MANAGING SYSTEMS
• S&H (tool box) Meetings
• SS&H Orientations
• Safe Work Practices
• S&H Procedures (SOPs)
• Lockout
• Fall Protection
• PPE
• Confined Space
• Permits
• Hot Work
• Excavations
• Job Hazards Analysis
• Quality Assurance/Mech.
Integrity
• Pre-Startup Safety Reviews
• Procedures
• Operations
• Maintenance
• S&H Training
• Mandated
• Awareness
• Refresher
• Progression
• Equipment Inspections &
Testing
• Incident Investigations
• Emergency Action Plans & Drills
• Audits/Inspections
• Employee participation &
involvement
• Awareness, Publicity &
Recognition programs
• Discipline

18. Affect 1 Failure
Affect 1 Person
Root Cause
Human failure
Root Cause
Affect the Whole Organization
Change Status Quo
Operating/Managing
Systems Failure
Root Cause Physical failure
The Leveraging Effect of Root Cause

19. WHY TREE
In order to drive to the causal factors of a failure, whether
chronic or sporadic, we use a tool known as a WHY TREE.
It’s called a “WHY” tree because we keep asking “WHY?”
to get to the causal factors.
WHY
WHY
WHY
WHY
WHY
WHY
WHY
WHY
WHY

20. “WHY”
• By repeatedly asking the question "Why" (five is a
good rule of thumb), you can peel away the layers of
symptoms which can lead to the root cause of a
problem. Very often the professed reason for a
problem will lead you to another question.
• Although this technique is called "5 Whys," you may
find that you will need to ask the question fewer or
more times than five before you find the issue related
to a problem.

21. Incident Statement
Why
Why
Why
Why
Why
System
causal factor
Physical factors
Human factors

22. “WHY TREE” ANALYSIS - PROCESS
 Gather facts and information about the failure and
bring it to the “why tree” meeting (PROBE).
 Understand, agree upon, and write the failure
statement.
 List observations related to the failure statement.
 Prioritize the observations.
 Put the highest priority observation on the “why tree”
and begin the process of asking “why” or “how can”.
Stop when the system causal factor(s) is determined.
 Repeat step five until all observations are explained.
 Continue looking for the cause of each possible factor
identified until the system base end point is reached.

23. Pre – “Why Tree” Fact Gathering
PROBE
People – what was seen, smelled, felt, and heard; what
people were doing; condition or appearance of people
relative to PPE, clothing, etc.
Records – the history, previous repairs, operating
conditions at the time, process charts, data bases, logs,
etc.
Orientation – where people and parts were before &
after the failure occurred; positions of valves, gauges,
switches; be sure to capture this information on film, in
drawings, computer models, etc.
Beliefs – the paradigms, mindsets, or attitudes that may
have played a role in the incident or failure.
Equipment – equipment condition, building structures,
damaged parts.

24. “WHY TREE” ANALYSIS - PROCESS
• End points are considered to be Causal Factors and end points
are often operating or managing systems such as training or
auditing.
• After identifying all causal factors, test the theories against the
chronology and other pertinent facts.
• Modify conclusions to fit the facts.
• Develop recommendations based on the causal factors
identified.
• Avoid making recommendations for issues not directly related
to the investigation causal factors.

25. INCIDENT: EMPLOYEE SLIPPED ON WET SPOT
ON FLOOR AND SPRAINED ANKLE
 Question
• Why was the floor wet?
• Why did the pipe leak?
• Why did it corrode?
• When was the wrong
material installed?
• Why was the wrong
material installed?
 Response
• Leak from pipe.
• Corrosion.
• Wrong material of
construction
• Original installation.
• QA procedures were
inadequate and did not
require inspection by
qualified person.

26. INCIDENT: A FORKLIFT TRUCK BEGAN TO LEAK
OIL
• Question
• Why did the FLT leak?
• Seal was just replaced.
Why did new seal leak?
• Where did incorrect seal
come from?
• Why did purchasing order
the incorrect seal?
• Why was the specification
incorrect?
• Response
• There was a bad seal.
• Wrong Seal was used.
• Ordered by purchasing.
• Specification was incorrect
• Only had one specification
for all FLTs, and this brand
of truck requires different
seal than others

27. CAUSAL FACTORS – EXERCISE(HAVE CLASS TO
IDENTIFY)
• Experienced, trained operator did not follow the SOP for
correcting board jam on product line?
• Fire-water pump bearings failed resulting in overheating and
fire?
• Shutdown and lockout procedures for laminator equipment
operation not included in the current operator training
program?
• Powered hoist and trolley ran off the end of a beam resulting
in the hoist and trolley falling to the floor?
• Employee fell while working from an incomplete scaffold?

28. INCIDENT: EMPLOYEE TRIPPED AND FELL 15’ FROM A
SCAFFOLD RESULTING IN MULTIPLE FRACTURES TO ARMS AND
LEGS.
• Observation Fact: Scaffold
guardrails incomplete (physical)
• Why
• Why
• Why
• Observation Fact: Employee
not utilizing fall arrest
equipment (human)
• Why
• Why
• Why
• Why
• Scaffold erectors failed to install all
guardrails (human)
• Scaffold erectors inadequately
trained - not competent (system)
• Scaffold builder training
program inadequate
(system)
• Employee did not recognize
missing guardrails (human)
• No daily inspection tag from
erector to indicate missing rail
(human)
• Employee had not had scaffold
user training (system)
• No scaffold user training
program (system)
End Points – System Factors
Failure Statement: Employee fell from a scaffold platform.

29. INCIDENT: EMPLOYEE TRIPPED AND FELL 15’ FROM A SCAFFOLD
PLATFORM RESULTING IN MULTIPLE FRACTURES TO ARMS AND LEGS.
• Observation Fact: Scaffold platform
had uneven surface (physical)
• Why
• Why
• Why
• Why
• Warped/damaged plank
installed by scaffold erector
(human)
• Scaffold planks not inspected
before installation (human)
• Scaffold planks not included
in inspection/testing program
(system)
• No inspection/testing
program for scaffold
components (system)
End Point – System Factor
Failure Statement: Employee fell from a scaffold platform.

30. CAUSAL
FACTORS/RECOMMENDATIONS
• Human Factor (s)
• None
• Physical factor (s)
• Defective scaffold plank.
• Incomplete guardrails.
• Siding line oven board jam was
the initiating event.
• System Factor (s)
• Scaffold builder training program
inadequate.
• No inspection/testing program for
scaffold components.
• No scaffold user training program.
1. Complete scaffold guardrails and
replace defective plank before
work continues.
2. Investigate board jam issue for
determining causal factors and
corrective actions.
3. Review and revise scaffold builder
training program to meet
regulatory and standard
compliance.
4. Develop and implement scaffold
component inspection and testing
program.
5. Develop and implement a scaffold
“user” training program.

31. BREAKOUT SESSION
• As a team:
• Review the factual information in the sample incident investigation report.
• Write a failure statement for the incident.
• List observations related to the failure statement.
• Do a “Why Tree” causal analysis to determine he causal factors.
• Develop recommendations for corrective actions.
• Report Back.

32. INCIDENT:
• Observation Fact:
• Why
• Why
• Observation Fact:
• Why
• Why
• Observation Fact:
• Why
• Response
End Point – System Factor
Failure Statement:

33. CAUSAL FACTORS/RECOMMENDATIONS
• Human Factor (s)
• Physical factor (s)
• System Factor (s)
•Rec #1
•Rec #2
•Rec #3

34. INCIDENT: EMPLOYEE TRIPPED AND FELL 15’ FROM A SCAFFOLD
PLATFORM RESULTING IN MULTIPLE FRACTURES TO ARMS AND LEGS.
Failure Statement: Employee fell from oven framework.

35. CAUSAL FACTORS/RECOMMENDATIONS
• Human Factor (s)
• Employees recognized fall hazard
but did not take measures to
minimize.
• Physical factor (s)
• No fixed steps or work platforms
for elevated work on siding line.
• Siding line oven board jam was the
initiating event.
• System Factor (s)
• Inadequate work at height hazard
awareness and analysis process.
• No written SOP addressing safe
access and safe work platform for
clearing board jams.
Recommendations
• Conduct employee training on
safe practices for work at heights.
• Design/install fixed steps & safe
work platforms at designated
access points for clearing jams.
• Investigate board jam issue for
determining causal factors and
corrective actions.
• Perform site wide elevated work
assessment for determining
additional exposures and needs
for corrective measures.
• Develop and implement siding
line board jam SOP addressing
elevated work hazards – train.

36. QUESTIONS?