Representatives bring an understanding of workplace systems, health and safety, and experience in liaising with workers and supervisors.
Representatives may also be requested by a mines inspector to assist in a departmental investigation. Investigating incidents - information sheet for safety and health representatives - K b. This information sheet outlines procedures and principles on how an investigation will be run in an event of an incident.
How can safety and health representatives help improve safety and health? As such, the investigation or analysis must produce information leading to corrective actions to prevent or reduce the number of accidents in the workplace. Safety Resources, Inc. Every accident, even near misses, provides the opportunity to discover new ways to improve a safety program.
Frequency builds severity. Analyze the data, identify the root causes. Report the findings and recommendations. The organization would then: Develop a plan for corrective action. Implement the plan. Evaluate the effectiveness of the corrective action. Make changes for continual improvement. Figure 1: Incident Categories Task Here the actual work procedure being used at the time of the incident is explored.
Members of the investigation team will look for answers to questions such as: Was a safe work procedure used? Had conditions changed to make the normal procedure unsafe? Were the appropriate tools and materials available?
Were they used? Were safety devices working properly? Was lockout used when necessary? For most of these questions, an important follow-up question is "If not, why not? What caused it to fail? Was the machinery poorly designed? Were hazardous products involved? Were they clearly identified?
Was a less hazardous alternative product possible and available? Was the raw material substandard in some way? Should personal protective equipment PPE have been used?
Was the PPE used? Were users of PPE properly educated and trained? Work Environment The physical work environment, and especially sudden changes to that environment, are factors that need to be identified. For example, investigators may want to know: What were the weather conditions? Was poor housekeeping a problem? Was it too hot or too cold? Was noise a problem? Was there adequate light? Were toxic or hazardous gases, dusts, or fumes present?
Personnel The physical and mental condition of those individuals directly involved in the event must be explored, as well as the psychosocial environment they were working within. Some factors will remain essentially constant while others may vary from day to day: Did the worker follow the safe operating procedures?
Were workers experienced in the work being done? Had they been adequately educated and trained? Can they physically do the work? What was the status of their health? Were they tired? Was fatigue or shiftwork an issue? Were they under stress work or personal? Was there pressure to complete tasks under a deadline, or to by-pass safety procedures?
Management Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management and the role or presence of management systems must always be considered in an incident investigation. Ask questions such as: Were safety rules or safe work procedures communicated to and understood by all employees?
Were written procedures and orientation available? Were the safe work procedures being enforced? Was there adequate supervision? Were workers educated and trained to do the work? Had hazards and risks been previously identified and assessed? Had procedures been developed to eliminate the hazards or control the risks? Were unsafe conditions corrected?
Was regular maintenance of equipment carried out? Were regular safety inspections carried out? Had the condition or concern been reported beforehand? Was action taken? Physical Evidence Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses.
Based on your knowledge of the work process, you may want to check items such as: positions of injured workers equipment being used products being used safety devices in use position of appropriate guards position of controls of machinery damage to equipment housekeeping of area weather conditions lighting levels noise levels time of day You may want to take photographs before anything is moved, both of the general area and specific items. The extent of the policy and the requirements provided by it will depend on the nature and size of the organisation, as well as the hazards and risks likely to be encountered in the workplace.
There are differing views on who is best suited to undertake accident investigations. Ideally investigation is undertaken by a team rather than an individual, but the size of the team is best determined by the complexity and potential risk associated with the events. A team comprising safety practitioners and line managers will provide an adequate balance, providing they have been suitably trained.
It is also helpful to include those who can give practical expertise such as those who routinely perform the work or processes. In all cases, a properly trained safety professional can act as the focal point for the selection and direction of investigation methods and processes. In addition, the skills and knowledge of specialist staff or consultants may be used in the investigation process.
At least one workforce representative should be involved in the investigation. The level of involvement of various staff is often dependent upon the organisational arrangements, the type of incident and the potential risk associated with the incident eg injuries or damage that reasonably could have occurred. Great care must be taken to ensure that investigators are not hampered or influenced by internal pressure from within the management structure.
Some organisations prefer to use outside consultants for this reason. When an incident is reported to them by an employee under their supervision, which the employee believes indicates the presence of any danger to persons, plant or equipment. Incidents involving the death of, or personal injury to, anyone doing anything with or in relation to any activity carried out by the company.
Incidents which a department manager believes could have led to the death of, or personal injury to, any person. When specific skills, specialist knowledge or experience are required to carry out an effective investigation. However, legal advice should be sought before disclosing this information. There are various models which attempt to describe the stages of an accident investigation.
They all have the same principles and commence with the site of the accident itself. Identify reference material such as procedural documents, training manuals, risk assessments, etc. It is vital that the scene of an accident is left undisturbed once any significant residual risks have been controlled until the investigation has been completed or at least until all of the physical evidence has been gathered and accurately recorded.
The earlier an investigation begins, the less chance there is of evidence being destroyed and the scene of the accident being disturbed.
It will not always be possible to interview all witnesses immediately after an event, but there is great merit in completing the information-gathering process as soon as possible after an accident has taken place. When deciding on the amount of resources to commit to any investigation, it is helpful at an early stage to review the relevant risk assessments in the light of the accident or incident. For example, it may be quite apparent which risk factors within the earlier assessment should be focused on in any further investigation, or the discovery of a mistake in the assessment may save time in investigating why certain measures had failed.
The investigator s should keep an open mind and not be unduly influenced by what should have happened as it is important to determine what actually happened. It is important to remember that apportioning blame is not an objective of the investigation. This may arise as part of the investigation findings, but should not be emphasised at this stage.
For reasons of safety, only the absolute minimum number of people should be allowed into the accident scene area. They must be made aware of the unique circumstances that exist during the very important period of time immediately after the occurrence of an accident.
Wherever possible, the investigation method should provide for confirmation of any evidence — especially any human witness evidence received. It is useful to use a plan or outline of the area and equipment, etc involved, as well as any available photographs to prompt the memory processes and assist in locating the evidence both spatially and temporally. Witnesses should be handled with care. If traumatised by the incident, it is generally better to obtain just overview impressions early on, eg by asking witnesses to briefly write down where they were and what they were doing at the time of the event.
They can then be interviewed in depth later on when they have had time to adjust to the circumstances and reflect on the situation. Photographs, videos, sketches and plans are a useful method of recording the physical evidence and conditions at the location. Samples may also be taken and equipment removed for further investigation and examination. Any equipment, etc involved may need to be examined to determine what part it played in the accident. In some cases, this may not be easily determined in the early stages of the investigation and it is generally good practice to undertake such examinations as early as possible, even though subsequently the evidence may be discounted.
This is especially so in those cases where evidence may be lost because the plant has to be brought back on line or destruction has to take place to secure safety, as in the case of a partially collapsed wall. Detailed photographs, technical reports and sample examinations may be required and prove useful at a later stage in the investigation. Expert assistance may be required for this. At all times the liabilities of suppliers and manufacturers must be considered.
This has an important bearing on any action that might subsequently be taken for breaches of contract or third-party actions. The analysis of evidence is based on the methods employed in any investigation. A number of methods are available. It is essential to use a robust method to achieve:. Before being able to say what caused any accident or what gave rise to the circumstances in which an accident occurred, it is necessary to know, as far as possible, the sequence of events leading up to and including the observable outcome s.
This is regardless of whether the outcome was a minor injury, a major injury or a fatality. In fairly simple accidents, the sequence may be derived from the collation of witness statements and writing down a commentary of the accident events as if replaying them. For anything more than the simple cases it is important to have a rigorous methodology to analyse the sequence of events.
Information obtained in any investigation may sometimes be contradictory, the observations of witnesses are subject to vagaries and inconsistencies and the information provided must be checked and cross referenced for verification wherever possible. A method based on sequential timed event plotting STEP for devising a sequence of events may be helpful to investigators. Across the top, the times at which various events occurred or were seen are listed in sequence.
This type of event plotting not only assists in determining a clear picture of the sequence but also provides a means of ascertaining corroboration of evidence and the identification of further areas for investigation. The major purpose of accident investigation is to establish what has happened in order to reduce the risk of recurrence.
The conclusions arising from any accident investigation must be presented in a form which allows management to create appropriate action plans.
In drawing conclusions, the apportioning of blame should be avoided. The results of investigations should solely be to create opportunities for prevention and identify causes for which a solution can be found. Reports and their conclusions should be concise, clear and relevant. One particular conclusion that must be drawn is the underlying, or root cause of the incident.
The report outlines the principles, structure and application of each identified technique and groups these into classes. During any investigation, it is important to have adequate administration procedures in place that can keep control of any documentation produced. This will include witness statements, information on items of plant and equipment, etc and any communication with employee safety representatives and enforcement officers. It is also important to keep track of any briefings held with senior managers and any details provided to the press and other outside bodies.
The continuity of evidence is maintained if a written statement is provided each time an item of evidence is collected or passed from one person to another, eg an item of equipment given to a specialist technical examiner.
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