52E40Guide

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Incident Investigation Reference Guide(52E40 Incident Investigation Report)

52E40 (R04/13) Page2 of 3

Incident Investigation Report (continued)

Employer name Employer number

AnalysisFromthesequence of events, identify whateventsmayhave beensignificant inthis incident occurring. Ananalysis of theseeventswillass ist indeterminingthe underlyingor causalfactors intheoccurr ence. Pleaserefer tothe“Incident InvestigationReferenceGuide”for assistancewhencompleting this report. Theguideis availableon WorkSafeBC.com .

Statement of causes ref:s.17 4(2)(a)–(b)WCAand s. 3.4(f)OHS Regulation

List anyunsafeconditions, acts, orprocedures that inany mannercontributedto theincident. Pleasereferto the“IncidentInvestigationReferenceGuide” forassistancewhen completingthis report. Theguideis availableon WorkSafeBC.com .52E40 Workers’ Compensation Board of B.C. (R04/13) Page1 of 3

INCIDENTINVESTIGATIONREPORT

Thisformisp rovidedtoemployersfor thepurpose ofdocumentingthe employerʼsinve stigationintoa workplaceincident. Pleaseattachaseparate sheet if necessary.Call Cen tre Aft er- ho urs healt hand Fax Mailing add ressPhone 604 276-3100 safetyemergency 604 276-3247 WorkSafeBCT ol l -f re e 1 8 88 6 21 -S AF E ( 72 33 ) P ho ne 6 04 2 73 -7 71 1 P O B ox 5 35 0 St n Te rm in al

Toll-free 1866922-4357 (WCB-HELP) VancouverBC V6B 5L5


Employerheadoffice address

City Province Postal code

Incident occurred ref: s. 3.4(a)Occupational Health and Safety Regulation (OHS Regulation) Address whereincident occurred

City (nearest) Provi nc e Pos tal c ode

Dateof incident (yyyy-mm-dd) Timeincident occurred a.m.p.m.

Injured person(s) ref:s. 3.4(b)OHS Regulation Last name First name Job title/Occupation

1)

2)

Witnesses ref:s.174 (4)WorkersCompensation Act(WCA)and s.3.4(c)OHSRegulation

Last name First name

1)

2)

3)

Incident description ref:s.3.4(d)–(e) OHSRegulation

Briefly describewhat happened, includingthes equenceof events preceding theincident. Pleasereferto the“IncidentInvestigationReferenceGuide” forassistance whencompletingthis report. Theguideis availableon WorkSafeBC.com .

When is an investigation required?

Employers are required to immediately undertake an investigation into any accident or other incident that: • Is required to be reported under section 172 of the Workers Compensation Act, or • Resulted in injury requiring medical treatment, or • Did not involve injury to a worker or involve a minor injury that did not require medical treatment but had

the potential for causing serious injury, or

• Was an incident required by regulation to be investigated.

Who should conduct the investigation? • Incidents must be investigated by people knowledgeable about the type of work involved at the time of the

incident.

• If reasonably available, investigations must be carried out with the participation of one employerrepresentative and one worker representative.

What is the purpose of an investigation?The purpose of an investigation is to determine the cause or causes of the incident, to identify any unsafeconditions, acts, or procedures that contributed to the incident, and to recommend corrective action toprevent similar incidents.

Who receives copies of the report?Incident investigation reports required by the WCA must be provided to the joint health and safety committee

or worker representative as applicable, and to WorkSafeBC.

What follow-up action is required after an incident investigation?After an investigation, the employer must without undue delay undertake any corrective action required toprevent recurrence of similar incidents and must prepare a report of the action taken. The report must beprovided to the joint health and safety committee or worker representative as applicable. The follow-up reportdoes not have to be provided to WorkSafeBC unless requested by a WorkSafeBC officer.

Use this guide when completing the 52E40 Incident InvestigationReport, in conjunction with the requirements of the WorkersCompensation Act (WCA), Part 3 Division 10, and the OccupationalHealth and Safety Regulation (OHS Regulation), section 3.4.

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What information should be included in the investigation report?An incident investigation report should answer the WHO, WHERE, WHEN, WHAT, WHY, and HOW questionswith regard to the incident.

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Incident description ref: s. 3.4(d)–(e) OHS Regulation Briefly describe what happened, including the sequence of events preceding the incident. Please refer to the “IncidentInvestigation Reference Guide” for assistance when completing this report. The guide is available on WorkSafeBC.com .

Employer information

Location where incident occurred

Date and time of the incident

Injured person(s)

Other person(s) involved inthe incident, and witnesses

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Incident occurred ref: s. 3.4(a) Occupational Health and Safety Regulatio n (OHS Regulation)

Address where incident occurred

City (nearest) Province Postal code

Date of incident (yyyy-mm-dd) Time incident occurred a.m.p.m.

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A brief description of the incident,including the sequence of eventsthat preceded the incident.

A sequence of events should highlight all of the events prior to the incident. This may include events fromthe day of the incident, however, may also extend back to years prior (e.g., installation of new machinery,changing ownership of company, product changes, etc). In addition, if activities which occurred after theincident, such as first aid or the evacuation process, need to be analyzed for future improvements you caninclude those events in your sequence.

When developing a sequence of events diagram, each event should:

• Indicate one action or decision (e.g., worker stops forklift on loading ramp A). • Never include something that did NOT happen (e.g., worker should have, could have, would have …),

as these actions or decisions cannot be analyzed (e.g., worker should have parked on level ground).

• Helpful to include date and time of action/decision.

Sequence of events diagram (sample)

Page 2 of 5 Incident Investigation Reference Guide

WHAT

WHO, WHERE, & WHEN

Worker stopsforklift on

loading ramp A

Worker exitsforklift

Worker runs overto truck driver on

loading ramp B

Forklift beginsto roll

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Employer head office address

City Province Postal code

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Injured person(s) ref: s. 3.4(b) OHS Regulation

Last name First name Job title/Occupation

1)

2)


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Witnesses ref: s. 174(4) Workers Compensation Act (WCA) and s. 3.4(c) OHS Regulation

Last name First name

1)

2)

3)

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I t t t t t t. .

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AnalysisFrom the sequence of events, identify what events may have been significant in this incident occurring. An analysis of theseevents will assist in determining the underlying or causal factors in the occurrence. Please refer to the “Incident InvestigationReference Guide” for assistance when completing this report. The guide is available on WorkSafeBC.com .

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The sequence of events illustrates “what”happened leading up to, and possibly after,the incident. In order to understand “why”the incident occurred, events in the sequenceneed to be analyzed.


When analyzing:1. Choose events that were either undesirable or somehow contributed to the incident occurring. In the

example above, one event has been selected for further analysis. This event is shown in bold .2. The analysis then involves asking “why” repeatedly until you end up at a workplace factor (e.g., tools,

equipment, process, procedures, environment, communication, etc.).3. Avoid stopping at personal factors, such as “he/she was complacent,” ”he/she was not paying

attention,” and/or “he or she did not follow procedures,” as they provide a limited opportunity toimprove safety in the workplace.

4. Ensure that your conclusions are based on information compiled during the investigation, and therefore

are objective, and not based solely on one’s personal opinion of the situation. Objective informationwill come from interviews, paperwork, observations, analysis of equipment, etc.

Analysis of an event (sample)

WHY

Worker stopsforklift on

loading ramp A

Why?

Why? * The worker forgetting is a personal factor. This is often where the investigation stops.

Why?Why? Why?

Loading ramp Bwas full

Schedulingerror

Schedulingsoftware

limitations

Varying staffinvolved with

schedulingprocess

Quick expansionof business

Worker wascomplacent*

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An incident investigation report shouldrecommend corrective actions, based oncontributing or causal factors, to prevent thesame or similar incidents from recurring. Somepoints to remember when you are investigating:

• Avoid focusing on what you feel the workersshould have been able to anticipate. Ourgoal as investigators is to understand whythe worker’s actions made sense to them atthe time. Understanding why it made senseto the worker will help you to identify whatworkplace factors need to be changed toreduce the likelihood of recurrence.

• There is often more than one cause, orcontributing factor, to an incident occurring.Drawing conclusions prematuraly can limit

the information you collect, thereby limitingyour ability to identify other causes orcontributing factors.

• Analyze the information until you identifyworkplace factors. Remember that stoppingat personal factors limits the opportunity toimprove workplace safety.


HOW

APPROVAL AND SUBMISSION

Statement of causes ref: s. 174(2)(a)–(b) WCA and s. 3.4(f) OHS Regulation

List any unsafe conditions, acts, or procedures that in any manner contributed to the incident. Please refer to the “IncidentInvestigation Reference Guide” for assistance when completing this report. T he guide is available on WorkSafeBC.com .

Recommendations ref: s. 174(2)(c) WCA and s. 3.4(g) OHS Regulation Identify any corrective actions that have been taken and any recommended actions to prevent similar incidents.

Recommended corrective action Action assigned toCompletion date

or expectedcompletion date

(yyyy-mm-dd)

1)

2)

3)

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Persons conducting investigation ref: s. 3.4(h) OHS Regulation

Representative of Name (please print) Signature (optional) Date signed(yyyy-mm-dd)

Employer

Worker

Employer Worker Other

Date Incident Investigation Report submitted to WorkSafeBC ref: s. 175(2)(b) WCA(yyyy-mm-dd)

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The names of the worker and employerrepresentatives that conducted theinvestigation must be provided on the form.If the employer wishes to have these personssign the report, it must be printed then signed,as the form will not accept digital signatures.Employers must submit a copy of theirincident investigation reports to WorkSafeBC.

The date provided should indicate the date the

report was submitted by email, fax, or any othermeans.

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Tips • Avoid focusing on what you feel the workers should have been able to anticipate. Our goal as investigators is

to understand why the worker’s actions made sense to them at the time. Understanding why it made senseto the worker will help you to identify what workplace factors need to be changed to reduce the likelihoodof the incident recurring.

• If you develop a theory about what happened early in the investigation, ensure you do not collect data toprove the theory. There is more than one cause, or underlying factor, and by narrowing the data you arecollecting early on in the investigation you limit your ability to identify other causes or contributing factors.

DefinitionsSequence of events: A chronology of actions/decisions leading up to, and possibly occurring after, an incident.

Unsafe acts: An unsafe act is an action, or lack of action, made in the presence of a hazard. For example, aworker uses a grinder without a guard, works on energized equipment, or doesn’t wear PPE, etc.

Unsafe conditions: May include things like the work environment (e.g., congested work area, poorhousekeeping, poor visibility) or equipment (e.g., lack of safeguarding, poor maintenance).

Procedure: When looking at the procedures, there are some important considerations:1. Were procedures present?

2. Were procedures utilized?3. Were procedures applicable to this equipment, work task, etc.?4. Were the procedures adequate?5. Were the procedures understood?

Some of the questions that may come from the above considerations:

• Were the procedures written? • How were the procedures communicated to the worker? • Where is the procedural information kept? • How long ago was the information communicated?

• Were the procedures understood by the worker (e.g., procedures provided in English to workers withEnglish as a second language)? • How do you know that the procedures were understood? • Have there been any changes to the equipment, product, or work process since procedures were

implemented? These changes may affect one’s ability to continue to follow the procedures.

• Are there any maintenance issues with the equipment? Often, if machines are not maintained regularly,workers will adapt the way they perform their task in order to ensure the equipment continues to run.

• Can they follow procedures and still complete the job


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52E40Guide