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Z1005-17

Incident investigation

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Z1005-17July 2017

Title: Incident investigation

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Incident investigationZ1005-17


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Z1005-17 Incident investigation

July 2017 © 2017 CSA Group 1

ContentsTechnical Committee on Incident Investigation and Prevention 3

Preface 6

0 Introduction 80.1 General 80.2 Guiding principles of successful incident investigation and prevention 80.3 Organization of this Standard 9

1 Scope 91.1 General 91.2 Terminology 101.3 Units of measure 10

2 Reference publications 10

3 Definitions and abbreviations 113.1 Definitions 113.2 Abbreviations 12

4 Incident investigation and prevention program (IIPP) 124.1 General 124.2 Management commitment and leadership 134.2.1 Responsibility, authority, and accountability 134.2.2 Management representatives 134.2.3 Worker participation 144.3 Incident investigation and prevention policy 144.4 Requirements 144.4.1 General 144.4.2 Legal and other requirements 154.4.3 Business continuity 154.4.4 Documentation and record management 154.5 Investigation initiation criteria 16

5 Pre-incident planning 165.1 General 165.2 Incident response — Planning 165.3 Incident investigation resources — Planning 165.3.1 General 165.3.2 External resources 165.4 Incident investigation personnel — Planning 175.4.1 Roles and responsibilities during an investigation 175.4.2 Investigation team competence 175.4.3 Additional factors that affect personnel 175.4.4 Psychological injury prevention and incident stress management 175.5 Incident investigation communication — Planning 185.6 Incident investigation — Planning 19




5.6.1 Scene control — Planning 195.6.2 Witness support and management — Planning 205.6.3 Data collection — Planning 205.6.4 Data analysis — Planning 205.6.5 Development of action — Planning 205.6.6 Debriefing — Planning 215.6.7 Incident investigation report — Planning 21

6 Incident response 21

7 Conducting investigations 217.1 General 217.2 Investigation initiation 237.2.1 Pre-investigation 237.2.2 Investigation initiation 237.2.3 Investigation plan 237.3 Investigation 247.3.1 Scene management 247.3.2 Other considerations 247.3.3 Final hazards assessment and scene release 257.3.4 Investigation team communication and coordination 257.3.5 Data collection 257.3.6 Documentation and record management 267.3.7 Analysis 267.3.8 Risk assessment 267.3.9 Hazards related to deficiencies 267.3.10 Findings 267.4 Post investigation 277.4.1 Investigation team recommendations 277.4.2 Incident investigation report 27

8 Action plan and validation 27

9 Verification and validation 28

10 Continual improvement 28

Annex A (informative) — Principles for incident investigation 29Annex B (informative) — Investigation team competencies 31Annex C (informative) — Working with photographs and videos 33Annex D (Informative) — Investigator bias 35Annex E (Informative) — Development and implementation of a corrective action plan 37Annex F (informative) — Interviewing 39Annex G (informative) — Data analysis 43Annex H (Informative) — Using a systems approach to identify causal and contributing factors 47Annex I (informative) — Sources of incident investigation data 54




Technical Committee on Incident Investigation and Prevention

T. Winters Canadian Union of Public Employees, Ottawa, Ontario Category: User Labour

Chair

P. Sturm Sturm Consulting Inc, Mississauga, Ontario Category: Business Interest

Vice-Chair

K. Bennett WorkSafeNB / Travail sécuritaire NB, Saint John, New Brunswick Category: Regulatory Authority

K. Bondy Unifor, Toronto, Ontario Category: User Labour

D.J. Brown Workplace Safety North, Thunder Bay, Ontario Category: General Interest

C. Budzich Proactive Consulting Services Limited, Regina, Saskatchewan Category: Business Interest

P. Carolan Government of Nunavut, Iqaluit, Northwest Territories Category: Regulatory Authority

J. Chappel Canadian Centre for Occupational Health and Safety (CCOHS), Hamilton, Ontario Category: General Interest

J. Colman WorkSafe BC, Richmond, British Columbia Category: Regulatory Authority

J. Downey Bell, Mississauga, Ontario

Associate




V. Gagner NOVA Chemicals (Canada) Ltd. , Sarnia, Ontario Category: User Management

F.X. Hardy Electrical Safety Authority, Mississauga, Ontario Category: Regulatory Authority

A. Harkness Workplace Safety and Prevention Services (WSPS), Mississauga, Ontario Category: General Interest

B. Henry Fanshawe College of Applied Arts and Technology, London, Ontario Category: General Interest

M.W. Hill Maury Hill and Associates, Inc, Carp, Ontario Category: General Interest

R. Jarvis Ford Motor Company of Canada, Limited, Oakville, Ontario Category: User Management

H. Kahle WorkSafe BC, Richmond, British Columbia

Associate

A. Matheson British Columbia Safety Authority (BCSA), New Westminster, British Columbia

Associate

N. McCormick Corporate Health Works Inc., Winnipeg, Manitoba

Associate

A. Peart Public Service Alliance of Canada (PSAC), Ottawa, Ontario Category: User Labour

R.J. Petersen Brenntag Canada Inc, Toronto, Ontario Category: User Management

L. Polley C&R Engineered Solutions Inc, Georgetown, Ontario Category: Business Interest




R. Reid Technical Standards & Safety Authority (TSSA), Toronto, Ontario Category: Regulatory Authority

D.T. Roberts Schneider Electric, Mississauga, Ontario Category: Business Interest

D. Robertson Dilys Robertson & Associates, Cobourg, Ontario Category: Business Interest

R. Roy Stantec Consulting Ltd, Saint John, New Brunswick

Associate

D. Short The Redlands Group Inc, Oakville, Ontario Category: Business Interest

K. Somers Syncrude Canada, Fort McMurray, Alberta Category: User Management

L. Stoffman UFCW/CLC and LDS Limited, Vancouver, British Columbia Category: User Labour

E. Triggs Alberta Health Services, Calgary, Alberta Category: User Management

C. Vannier Hydro-Québec, Montréal, Québec Category: User Management

K. Woodcock Ryerson University, Toronto, Ontario Category: General Interest

J. Collins CSA Group, Toronto, Ontario

Project Manager




Preface This is the first edition of CSA Z1005, Incident investigation. This Standard replaces CAN/CSA-Z796, Accident information, published in 1998.

This Standard outlines incident investigation and prevention principles and requirements, the purpose of which is to determine causes and to prevent work-related incidents. As used in this Standard, the term “incident” refers to an occurrence, condition or situation arising in the course of work that resulted in, or could have resulted in, injury, illness, damage to health, or fatality. As used in this Standard, the term “data” refers to information collected during an incident investigation for reference or analysis.

CSA Z1005 adheres to management system principles, such as those set out in CSA Z1000, Occupational health and safety management. Use of Z1005 is not contingent on an organization having an occupational health and safety management system (OHSMS); however, it does specify a Plan-Do- Check-Act cycle to ensure that management system deficiencies are identified and addressed.

CSA Z1005 also complements CSA Z1002, Occupational health and safety – Hazard identification and elimination and risk assessment and control. When hazards are identified and eliminated, and when risk is assessed and controlled in accordance with the principles in CSA Z1002, then the number of work- related incidents can be reduced or prevented. CSA Z1005 encourages the use of these investigative principles as a prevention tool. Principles in this standard are designed to be used before, during, or after an event to effectively respond to – or ideally, proactively eliminate – that event, similar events, or other safety deficiencies identified during the investigation, taking investigative principles beyond the traditional approach. The principles of this Standard are intended to be scalable.

This Standard was prepared by the Technical Committee on Incident Investigation and Prevention, under the jurisdiction of the Strategic Steering Committee on Occupational Health and Safety, and has been formally approved by the Technical Committee.Notes: 1) Use of the singular does not exclude the plural (and vice versa) when the sense allows.2) Although the intended primary application of this Standard is stated in its Scope, it is important to note that it

remains the responsibility of the users of the Standard to judge its suitability for their particular purpose.3) This Standard was developed by consensus, which is defined by CSA Policy governing standardization — Code

of good practice for standardization as “substantial agreement. Consensus implies much more than a simple majority, but not necessarily unanimity”. It is consistent with this definition that a member may be included in the Technical Committee list and yet not be in full agreement with all clauses of this Standard.

4) To submit a request for interpretation of this Standard, please send the following information to [email protected] and include “Request for interpretation” in the subject line: a) define the problem, making reference to the specific clause, and, where appropriate, include an

illustrative sketch;b) provide an explanation of circumstances surrounding the actual field condition; andc) where possible, phrase the request in such a way that a specific “yes” or “no” answer will address the

issue.Committee interpretations are processed in accordance with the CSA Directives and guidelines governing standardization and are available on the Current Standards Activities page at standardsactivities.csa.ca.

5) This Standard is subject to review within five years from the date of publication. Suggestions for its improvement will be referred to the appropriate committee. To submit a proposal for change, please send the following information to [email protected] and include “Proposal for change” in the subject line: a) Standard designation (number);b) relevant clause, table, and/or figure number;




c) wording of the proposed change; andd) rationale for the change.




Z1005-17Incident investigation

0 Introduction

0.1 GeneralThis incident investigation and prevention Standard has been developed to modernize CAN/CSA-Z796 and to incorporate a strong focus on the prevention of work-related incidents. Despite an ongoing and increasing focus on occupational health and safety in Canada, work-related incidents are continuing to occur.

This Standard is designed to be used with related occupational or technical standards. It is intended to be referenced by other Standards as the primary set of requirements for the management of occupational health and safety incident investigation and prevention.

This Standard can be incorporated into an existing occupational health and safety management system (OHSMS) or used independently by an organization to proactively and systematically plan for and respond to incidents.

While not specifically addressed in this Standard, some incidents might require a regulatory or criminal investigation. In these instances, the organization needs to be aware that all data captured through the course of the investigation could be considered evidence in a regulatory enforcement or criminal proceeding. Organizations need to be aware of any legislation that could apply, or local authorities that need to be notified.

Incident investigation legislation differs from jurisdiction to jurisdiction in Canada. It is the user’s responsibility to determine how applicable legislative requirements relate to this Standard.

0.2 Guiding principles of successful incident investigation and preventionThis Standard is based on the following guiding principles:a) legislated incident investigation requirements are a minimum standard of practice;b) incident investigation provides the greatest opportunity for improvement when it is used as a tool

for prevention;c) it is preferable to use risk assessment principles early in the design of a work system, rather than

use incident investigation to solve issues afterwards;d) it is preferable to utilize a systems approach to identify and determine the influence of the

workplace system on the occurrence of the incident (see Annex H);e) worker participation is essential to the success of incident investigation and prevention;f) effective investigations analyze all possible factors, and present findings and recommendations as

an opportunity to prevent further occurrences or to improve the practices and processes within the organization; and

g) the effectiveness of an incident investigation and prevention program is maximized when it is integrated into the organization’s OHSMS, where one exists.




0.3 Organization of this StandardThis Standard specifies requirements for and provides guidance on the activities required to manage all aspects of incident investigation in accordance with the plan-do-check-act cycle and management system principles, such as those set out in CAN/CSA-Z1000.

The requirements of this Standard are organized into four main topics as follows (see Figure 1):a) PLAN — Clauses 4 and 5 specify the elements of an incident investigation and prevention program,

pre-incident planning, and a prepared approach;b) DO — Clauses 6 and 7 specify requirements for immediate incident response, and conducting

incident investigations with a prevention focus;c) CHECK — Clauses 8 and 9 specify requirements related to corrective actions and reviews within the

incident investigation and prevention program; andd) ACT — Clause 10 specifies requirements for continual improvement in both the incident

investigation and prevention program and the OHSMS.

This Standard contains Annex material which provides tools and guidance for many parts of the Standard. The reader is encouraged to refer to the Annexes to gain a deeper understanding of the purpose and intent for Standard clauses for which guidance has been provided.

Figure 1 Organization of this Standard

(See Clause 0.3.)

PLANIncident investigation and

prevention program (IIPP) — Clause 4Pre-incident planning — Clause 5

CHECK

DOACTIncident response — Clause 6

Conducting investigations — Clause 7Continual improvement — Clause 10

Action plan and validation — Clause 8Verification and validation — Clause 9

1 Scope

1.1 GeneralThis Standard specifies requirements for an occupational health and safety (OHS) incident investigation and prevention program (IIPP).

This Standard can be applied by organizations of any size or type.

This Standard is intended to address investigations related to occupational health and safety.




This Standard does not specify requirements for criminal or regulatory enforcement investigations.Notes: 1) The investigation principles of this standard can be applied to non OHS investigations such as environmental

incidents.2) Some investigations will involve, or evolve into, a criminal or regulatory investigation. Organizations need to

plan for this possibility.

1.2 TerminologyIn this Standard, “shall” is used to express a requirement, i.e., a provision that the user is obliged to satisfy in order to comply with the standard; “should” is used to express a recommendation or that which is advised but not required; and “may” is used to express an option or that which is permissible within the limits of the standard.

Notes accompanying clauses do not include requirements or alternative requirements; the purpose of a note accompanying a clause is to separate it from the text explanatory or informative material.

Notes to tables and figures are considered part of the table or figure and may be written as requirements.

Annexes are designated normative (mandatory) or informative (non-mandatory) to define their application.

1.3 Units of measureThe values given in SI units are the units of record for the purposes of this Standard. The values given in parentheses are for information and comparison only.

2 Reference publicationsThis Standard refers to the following publications, and where such reference is made, it shall be to the edition listed below, including all amendments published thereto.

CSA GroupCAN/CSA-Z796-98 (R2013) Accident information

CAN/CSA-Z1000-14 Occupational health and safety management

CAN/CSA-Z1002-12 Occupational health and safety — Hazard Identification and elimination and risk assessment and control

CAN/CSA-Z1003-13/BNQ 9700-803/2013 Psychological health and safety in the workplace – Prevention, promotion, and guidance to staged implementation

Z1004-12 (R2017) Workplace ergonomics — A management and implementation standard

Z1010 (under development) Management of work in extreme conditions




Z1600-14 Emergency and continuity management program

3 Definitions and abbreviations

3.1 DefinitionsThe following definitions shall apply in this Standard:

Authority having jurisdiction — an organization or their representative responsible for administering legislation.

Causal factors — the condition(s), event(s), omission(s), deficiency(ies) or action(s) that contributed directly to the incident.

Contributing factors — the condition(s), event(s), omission(s), deficiency(ies) or action(s) that contributed indirectly to the incident. Note: Contributing factors are those factors, if eliminated, that would not necessarily prevent the incident, but could help prevent future incidents.

Competence — the demonstrated ability to apply OHS knowledge and skills to the incident investigation processes.

Data — information collected during the course of an investigation for reference or analysis. Notes: 1) Data can be in the form of document(s), record(s), statement(s), interview(s), picture(s), video(s), material(s),

equipment, tool(s), information, statistic(s), etc.2) In some investigations, data may be referred to as evidence.3) Data can include discovery of non-incident related data that, although not directly related to the incident,

could potentially pose a hazard or identify a deficiency.

Document — a medium containing data relevant to the IIPP.

Emergency responders — the external persons who ensure public safety and health by addressing emergencies [e.g., fire, police, emergency medical services (EMS)].

Event — an occurrence that is related to the incident.

First responder(s) — the individual(s) authorized, trained, and qualified to act first at a scene to provide a primary response to an incident.

Incident — an occurrence, condition, or situation arising in the course of work that resulted in, or could have resulted, in injuries, illnesses, damage to health, or fatalities.

Health — a state of complete physical, social, and mental well-being, and not merely the absence of disease or infirmity. Source: World Health Organization (WHO).

Investigation team — the person or people assigned by an organization to perform investigations as described in this Standard.




Legal requirements — the applicable OHS federal, provincial/territorial, and municipal laws, regulations, and bylaws, and where applicable, provisions of the organization’s collective agreements that relate to health and safety.

Other requirements — the other OHS provisions required by the organization. Note: These requirements could include codes, standards, policies, procedures, or collective agreements.

Procedure — a documented method to carry out an activity.

Process — a set of interrelated or interacting activities that transforms inputs into outputs.

Program — a documented set of interrelated requirements that direct activity toward a goal.

Record — a document that states results achieved or provides evidence of activities performed.

Senior management — the person(s) at the highest level of an organizational structure responsible for leading, managing, and/or directing an organization.

Scene — the location where an incident occurred.

Worker — a person employed by the organization or a person under the day-to-day control of the organization, whether paid or unpaid. Note: This definition of “worker” includes employees, supervisors, managers, team leaders, contractors, service providers, volunteers, agency workers, and students or others actively engaged in undertaking activities for benefit to the organization.

Worker representative — a non-managerial worker who is a) a member of a workplace health and safety committee;b) a representative of other workers according to the requirements of law or collective agreements;

orc) selected by non-managerial workers for other reasons.

Workplace — any location in which work-related activities under the control of the organization are performed.

3.2 AbbreviationsThe following abbreviations shall apply in this Standard:IIPPI —I incident investigation and prevention programOHSI —I occupational health and safetyOHSMSI —I occupational health and safety management systemPPEI —I personal protective equipment

4 Incident investigation and prevention program (IIPP)

4.1 GeneralThe organization shall establish, implement and maintain a documented IIPP in accordance with the requirements of this Standard. The IIPP shall be integrated into, or compatible with, the other management systems in the organization, where they exist or if they exist.




4.2 Management commitment and leadership

4.2.1 Responsibility, authority, and accountabilityThe organization shall designate one or more representatives of senior management to provide leadership for an IIPP that is in accordance with the requirements of this Standard. Senior management shall assume overall responsibility, authority, and accountability for the IIPP. Senior management responsibilities shall includea) establishing, implementing, and maintaining an incident investigation policy (Clause 4.3);b) defining roles, assigning responsibilities, establishing accountability, and designating authority to

establish, implement, and maintain the IIPP (Clauses 4.2.2 and 4.4.1);c) identifying competing demands and setting priorities to ensure compliance with the IIPP;d) defining the competencies required by person(s) performing the roles in the IIPP and confirming

that each is competent to perform assigned duties and responsibilities (Clause 4.2.2);e) establishing, implementing and maintaining a process for the active participation of workers (and

worker representatives where they exist) in the establishment and maintenance of the IIPP and during an investigation (Clause 4.2.3);

f) emphasizing the importance of incident prevention in the IIPP (Clause 4.4.1);g) maintaining documents and records in accordance with the requirements of this Standard

(Clause 4.4.4);h) providing supervision to protect workers’ health and safety during incident investigation

(Clause 5.6.1.2);i) providing financial, human, and organizational resources to plan, implement, check, review and

correct the IIPP (Clauses 5.3 and 8);j) establishing, implementing and maintaining a process to identify deficiencies and develop and

monitor the effectiveness of corrective actions implemented to address those deficiencies (Clause 8); Note: The IIPP should identify organizational issues that could impact other organizational systems or processes. (e.g., staffing, fatigue, purchasing). The IIPP should link to these other systems in a manner that supports organizational continual improvement.

k) establishing, implementing, and maintaining a process for continual improvement of the IIPP (Clause 10); and

l) reviewing the organization’s IIPP at planned intervals (Clause 10).

4.2.2 Management representativesThe organization shall designate one or more representatives, including one from senior management, who, irrespective of other responsibilities, have defined roles, responsibilities, and authority for ensuring that an IIPP is established, implemented, and maintained in accordance with the requirements of this Standard.

These responsibilities shall includea) establishing processes to develop, implement and manage the IIPP;b) establishing processes to plan, initiate and oversee incident investigations;c) reporting on the findings, conclusions and recommendations of incident investigations;d) supporting active participation of workplace parties;e) developing, implementing, and validating corrective actions; andf) providing feedback to the organization’s prevention, validation, and continual improvement

process.




The organization shall ensure that the person performing each of the roles in the IIPP is competent to perform their assigned duties and responsibilities.

4.2.3 Worker participationWorkers, or worker representatives, where they exist, represent an essential aspect of the IIPP. The organization shall ensure workers and worker representativesa) are informed and provided with an opportunity to be consulted and participate in the planning,

implementation, evaluation and continual improvement of the IIPP;b) are provided with an opportunity to participate in the planning of an investigation, incident

response, investigation process, establishment of recommendation(s), implementation and validation of the corrective action plan;

c) are provided opportunities to participate by providing mechanisms that identify and remove barriers to participation including time and resources; and

d) are informed, and given an opportunity to be consulted and participate in aspects of the IIPP associated with their work or the workers they represent or where they are impacted by recommendations contained in the corrective action plan.

4.3 Incident investigation and prevention policyThe organization shall establish, implement and maintain an incident investigation and prevention policy.

The organization shall ensure that the policya) is appropriate to the nature and scale of the organization and OHS hazards and risk associated with

its activities;b) includes a commitment to

i) comply with applicable OHS legal requirements and other requirements;ii) use incident investigation findings, conclusions and recommendations to prevent further

incidents, and to protect and enhance worker health, safety, and well-being in the workplace; and

iii) continual improvement of the incident investigation and prevention program and its performance;

c) supports the objectives and targets in the organization’s OHSMS where one exists;d) is documented, communicated, and available to internal stakeholders;e) is available to external stakeholders as appropriate; andf) is reviewed on a planned and periodic basis.

4.4 Requirements

4.4.1 GeneralThe IIPP shalla) be appropriate to the nature and scale of the organization and OHS hazards and risk associated

with its activities;b) have a process to identify, implement and maintain prevention measures for the organization;c) include a process to establish the goals and objectives, including a plan for implementation,

monitoring, and measuring the extent to which the goals and objectives are achieved;d) identify investigation team protocols, resources, and methodologies; ande) have a process to identify potential barriers to the investigation (e.g., conflict of interest,

confidentiality, or trade secrets).




4.4.2 Legal and other requirementsThe organization shall establish, implement, and maintain a process to identify and ensure compliance to legal requirements and other requirements within the IIPP.

4.4.3 Business continuityThe organization shall implement strategies and activities to prepare for and respond to incidents that could impact the continuity of operations.Note: See CSA Z1600 for further information in this area.

4.4.4 Documentation and record managementNote: Documents and records are essential for auditing, assessing, and measuring continual improvement efforts in an IIPP.

4.4.4.1 ConfidentialityThe organization shall ensure that any collection, use, storage, and distribution of incident investigation data complies with legal and other requirements, collective agreements, and organizational policies regarding confidentiality and privacy.

4.4.4.2 Control of documentsThe organization shall establish, implement, and maintain a procedure for controlling documents related to the IIPP. The procedure shall meet the requirements of applicable laws, standards, codes, and guidelines and includea) approving documents prior to issue;b) periodically reviewing, updating, or withdrawing documents as necessary;c) ensuring that changes to, and the current revision status of, documents are identified;d) ensuring that relevant versions of applicable documents are available at points of use;e) ensuring that documents remain legible and readily identifiable;f) ensuring that documents of external origin determined by the organization to be necessary for the

planning and operation of the IIPP are identified and available; andg) preventing the unintended use of obsolete documents, and identifying such documents if they are

retained for any purpose.

4.4.4.3 Control of recordsThe organization shall establish and maintain records to provide evidence of conformity to the IIPP requirements and of the effective operation of the IIPP. Records shall remain legible, readily identifiable, and retrievable. Procedure(s) shall be established to provide the controls needed for the identification, secure storage, protection, retrieval, retention, and disposition of records.

Records shall includea) records arising from the implementation of the IIPP;b) the organization’s IIPP policy and performance measures;c) the assignment of IIPP duties and responsibilities for the implementation of the IIPP;d) supporting records needed by the organization to ensure the effective planning, implementation,

operation, and control of its IIPP;e) records of incident investigations;f) records of recommendations, changes, or improvements arising from incident investigations;g) records arising from legal requirements;h) procedures required by this Standard; and




i) other records required by this Standard, including those needed to prove compliance with legal requirements.

Note: These records could provide a reference source for future investigations. The establishment of a database containing the data derived from incident investigations is an important consideration as it allows for quantitative and qualitative statistical analyses which help to identify trends and help identify causal and contributing factors to incidents. Such analyses can identify effective prevention strategies, and validate existing prevention strategies.

4.5 Investigation initiation criteriaThe organization shall establish, implement, and maintain a procedure for reporting the occurrence of incidents and determining the scope of the investigation required whena) an incident occurs; orb) a hazardous situation or condition exists that if left unattended could lead to injury, ill health, or

death.Note: While the main intent of this Standard is to address OHS investigations, property damage is recognized as a potential outcome of incidents.

5 Pre-incident planning

5.1 GeneralTo ensure the success of the organization’s investigation process, planning in advance is critical. The organization shall develop a procedure to provide guidance for a range of investigations that vary in complexity, potential impact, or potential severity and with the goal of risk reduction. The procedure shall be scalable such that either a single investigator or an investigation team can use the appropriate guidance to proceed with any investigation.Note: Clauses 5.2 through 5.6 describe the steps in the investigation planning process in a linear fashion. In actuality the investigation process is iterative in nature and follows a more fluid and less sequential flow.

5.2 Incident response — PlanningThe organization shall establish, implement, and maintain a procedure for response to a reported incident including, where necessary, the means for dispatching first responders and emergency responders to the scene.Notes: 1) See CSA Z1600 for guidance on emergency response.2) The scope of the response can be predetermined to match multiple levels of incident severity.

5.3 Incident investigation resources — Planning

5.3.1 GeneralThe organization shall identify, provide, and maintain resources and investigation tools to respond to and conduct investigations, in accordance with the requirements of this Standard.

5.3.2 External resourcesThe organization shall establish, implement, and maintain a documented process for ensuring external resources can be brought to the scene to providea) an adequate response where an on-site emergency response is not possible, or not sufficient in

relation to the nature of the incident; andb) external investigation resources as required.




5.4 Incident investigation personnel — Planning

5.4.1 Roles and responsibilities during an investigationThe organization shall establish, implement, and maintain a procedure for determining the composition of the investigation team and the roles and responsibilities of the team members, in accordance with the scope of the investigation.

The organization shall establish, implement, and maintain a procedure for the investigation team toa) confirm that no proposed team member has a conflict of interest or bias that cannot be addressed;

and Notes: 1) See Annex D for further information on types of investigator bias.2) The conflict should be declared, and, if necessary, described. A decision can then be made regarding the

removal of the individual from the investigation team if necessary.b) identify the investigation team leader(s) (if not previously determined).

5.4.2 Investigation team competenceThe organization shall establish, implement, and maintain a procedure to define the competence requirements of the investigation team that, at a minimum shall includea) applicable IIPP requirements including procedures for conducting an incident investigation;b) legal and other requirements; andc) hazard identification, risk assessment, and risk control principles.

Where gaps in investigator team competence are identified, the organization shall develop an action plan to address those gaps.Notes: 1) The use of external resources could be necessary to augment competency requirements. See Clause 5.3.2.2) See Annex B for guidance in the area of investigation team competencies.

5.4.3 Additional factors that affect personnelThe organization shall establish, implement, and maintain a procedure to identify the personnel factors linked to the investigation and implement any necessary actions to address these factors.

Personnel factors could includea) first responder fatigue;b) shift change considerations;c) unauthorized workers attempting to access the scene; andd) access to personal belongings that remain at the scene.Note: Extreme events might be overwhelming for a workplace’s resources during the initial response and the investigation. The identification in advance of external parties that can provide support is beneficial. See Clause 5.3.2.

5.4.4 Psychological injury prevention and incident stress managementThe organization shall establish, implement, and maintain a psychological injury prevention and incident stress management process toa) assess the impacts of incidents to psychological health and safety of the investigation team and

other affected personnel;b) manage incidents in a manner that reduces psychological harm to the extent possible and supports

ongoing psychological safety;




c) provides response and support, including consideration of specialized external supports;d) provides related training for personnel involved in incident response; ande) provides opportunities for debriefing and for revising guidelines for incidents as applicable.Note: See CAN/CSA Z1003/BNQ9700-803 for additional information.

5.5 Incident investigation communication — PlanningFor incidents, conditions, or situations, the organization shall establish implement and maintain a process toa) document a list of, and contact information for, internal and external stakeholders for

communication;b) identify the reporting requirements for each stakeholder;c) determine the identity, accountability, and responsibilities of the person(s) who will provide the

communication;d) determine what information will be communicated (e.g., initial fact-based announcement,

recommendation(s) for immediate safety action(s), interim investigation report, final investigation report, recommendations, etc.);

e) determine when communications will occur (e.g., before, during and after incident is reported);f) determine how communications will occur;g) determine how confidentiality and privacy will be maintained;h) determine how communications will be documented and confirmed; andi) determine how communication requirements will be periodically re-evaluated.Notes: 1) Communication needs could change based on a number of factors, including the size and scope of the

incident, conditions, or situations, the hazards present, the level of injury, etc.2) Stakeholders could include but are not limited to

a) injured worker(s) and family members;b) management;c) supervisors;d) workers and worker representatives;e) trade union(s);f) emergency services;g) regulatory bodies;h) media;i) community members or neighbouring organizations;j) the public at large;k) outside technical services;l) legal counsel;m) insurance agencies; andn) public utilities.

3) Information released at the reporting milestones can include, a) at start of the investigation,

i) scope;ii) objectives; andiii) point of contact for the investigation;

b) during investigation, as applicable; andc) at the conclusion of the investigation,

i) findings; andii) recommendations.




5.6 Incident investigation — Planning

5.6.1 Scene control — Planning

5.6.1.1 GeneralThe organization shall establish, implement and maintain a procedure to ensure that the scene is secured, that only authorized personnel are permitted to enter the scene, and that the data that could be relevant to the investigation are preserved (see Clause 5.6.3 and Annex C).Note: Regulatory requirements could determine when the scene needs to be secured until the authority(s) having jurisdiction takes control over (and then releases) the scene.

5.6.1.2 Hazard identification, risk assessment, and controlThe organization shall establish, implement, and maintain a procedure to identify hazards, and assess and control risk for individuals involved in the incident response.

This procedure shall be donea) before allowing anyone to enter the scene unless access is required for the purposes of

identification of hazards and risk assessment;b) while the incident is being investigated (on an ongoing basis); andc) before work is allowed to resume at the scene.Note: See CSA Z1002 for further guidance in the area of hazard identification, risk assessment, and control.

5.6.1.3 Incidents occurring at scenes outside of the organizations controlThe organization shall establish, implement, and maintain a procedure to coordinate investigations under the authority of an alternate organization. Where coordination of the investigation is not possible, the organization shall investigate using the data available.

5.6.1.4 Incidents involving authority having jurisdiction

5.6.1.4.1 GeneralThe organization shall establish, implement, and maintain a procedure to coordinate investigation of incidents with the authority having jurisdiction (e.g., police, inspectors, regulators, etc.). This coordination may include the authority having jurisdiction taking control of the incident scene.Note: Coordination could be the identification of additional training of personnel, additional equipment requirements, the use of additional resources and personnel that could be dedicated to the investigation, etc.

5.6.1.4.2 Release of scene from authority having jurisdictionThe organization shall establish, implement, and maintain a procedure to coordinate scene release from the authority having jurisdiction.

The procedure shall includea) conducting a hazard identification and risk assessment before authorized personnel enter the

scene;b) documenting anything that was removed from the scene; andc) determining which personnel are authorized to access the scene.




5.6.2 Witness support and management — Planninga) The organization shall establish, implement, and maintain a witness support procedure that

addresses reactions to an incident. Note: Witness support could include situational defusing, debriefing, an employee assistance program (EAP), and association or union support.

b) The organization shall establish, implement, and maintain a witness management procedure that i) limits interactions between witnesses;ii) provides a safe location for witnesses;iii) makes provision for confidential interviews; andiv) addresses administrative factors such as shift change when scheduling witness interviews.

See Annex F for additional guidance on interviewing witnesses.

5.6.3 Data collection — Planning

5.6.3.1 Collection and preservation of perishable dataThe organization shall establish, implement, and maintain a procedure to document the scene and preserve perishable data (see Annex I). The procedure should include methods to ensure thata) hazards posed by the data collected are identified and the risk controlled;b) the data gathered is identified, labelled, documented, kept secure, and disposed of in accordance

with Clause 4.4.4;c) the data gathered is transferred to the central investigation point;d) time-sensitive and perishable data is maintained; ande) only authorized personnel handle data and have access to storage locations.Notes: 1) The initial data gathered typically contains the more perishable or easily accessed data such as weather

conditions, eye witness accounts, initial physical data, and photographs.2) See CSA Z1010 for guidance in working in areas in extreme conditions.

5.6.3.2 Ongoing data collectionThe organization shall establish, implement, and maintain a procedure to identify, gather, document, and preserve data in accordance with the IIPP (see Clause 4.4.4).Note: See Annex I for guidance about sources of incident investigation data.

5.6.4 Data analysis — PlanningThe organization shall establish, implement, and maintain a process to analyze the data gathered in accordance with the requirements of this Standard. (See Clause 7.3.7 for the steps involved and Annex G for further guidance in this area.)Notes: 1) Developing conclusions is an iterative process and can take many iterations to reach an appropriate

hypothesis or final decision.2) See Annex H.

5.6.5 Development of action — PlanningThe organization shall establish, implement, and maintain a process toa) identify and document causal and contributing factors (Clause 7.3.10.2);b) identify and document factors that, while not being causal or contributing, represent deficiencies

(Clause 7.3.10.3); andc) develop and document an action plan to address all identified factors. (See Clause 8).




5.6.6 Debriefing — PlanningThe organization shall ensure that the investigation team sets up a debriefing procedure contingent on the size and scope of the investigation.

5.6.7 Incident investigation report — PlanningAn incident investigation shall be documented in a report.

The incident investigation report should containa) a synopsis;b) factual data including

i) a description of the incident including date, time, location, and preceding events;ii) an investigative team;iii) where supporting documentation and records can be found;iv) diagrams/photographs; andv) assumptions and constraints;

c) an analysis including i) causal factors;ii) conclusions; andiii) a description of the analysis process utilized;

d) findings related to i) causal and contributing factors [See Clause 7.3.7 f)]; andii) additional prevention activities (See Clause 7.3.9); and

e) recommendations as established in Clause 7.4.1.

The investigation report should be provided to identified stakeholders for review.Note: A draft report could be prepared and reviewed by the investigation team for the purposes of information sharing, validation, and review of data.

6 Incident responseWhen an incident or hazardous situation or condition is reported in accordance with Clause 4.5, the organization shalla) follow the incident response procedure in accordance with Clause 5.1; andb) initiate an incident investigation in accordance with the requirements of this Standard.

7 Conducting investigations

7.1 GeneralThe investigation team shall investigate incidents in accordance with the requirements of Clause 7 (see Figure 2 and Annex A) and shall includea) investigation initiation (Clause 7.2);b) investigation (Clause 7.3); andc) post investigation (Clause 7.4).Notes: 1) Incident investigation starts after the notification of an incident has been received or a decision has been

made to proceed to investigate in accordance with Clause 4.5.2) Clause 7 describes the investigation process in a linear fashion. In actuality the investigation process is

dynamic and iterative in nature and follows a more fluid and less sequential flow. Data gathering




(Clause 7.3.5), analysis (Clause 7.3.7), and debrief (Clause 7.3.4) often take place continually and concurrently as opposed to in discrete, consecutive stages. Clause 5 describes the requirements for planning to effectively carry out this process. Clause 7 describes the action necessary to identify and address causal and contributing factors including deficiencies not related to causal or contributing factors or additional weaknesses.

Figure 2 Conducting investigations

(See Clause 7.1)

Datacollection

Otherconsiderations

Scenemanagement

Documentand

recordmanagement

Investigationteam

communicationand coordination

Conducting investigations

A—Investigation initiation (Clause 7.2)

B—Investigation (Clauses 7.3.1 to 7.3.6)

C—Analysis and findings (Clauses 7.3.7 to 7.3.10)

D—Post investigation (Clause 7.5)

• Pre-investigation• Investigation initiation• Investigation plan

• Investigation team recommendations• Incident investigation report

Findings

AnalysisRisk

assessment

Hazardsrelated to

deficiencies




7.2 Investigation initiation

7.2.1 Pre-investigationThe investigation team shall:a) assess the data reported to determine the scope and documentation requirements of the

investigation in accordance with the procedure established in Clause 4.5;b) deploy and replenish investigation resources in accordance with Clause 5.3;c) identify and deploy additional external resources in accordance with the process established in

Clause 5.3.2;d) follow the internal and external communication and notification procedures established in

accordance with Clause 5.5;e) follow the procedure established in accordance with Clauses 5.6.1.1, 5.6.2, and 5.6.3.1 for

i) securing the scene;ii) determining which personnel are authorized to interact with scene;iii) witness support and witness management; andiv) initial data collection and preservation.

7.2.2 Investigation initiationThe investigation team shall initiate the investigation bya) confirming the members of the investigation team have been selected in accordance with

Clause 5.4.1;b) performing a risk assessment in accordance with the procedure established in accordance with

Clause 5.6.1.2;c) controlling the risk associated with these hazards as required to protect the safety of the

investigation team;d) determining how the investigation team will coordinate their work;e) initiating and complying with the communication procedure in accordance with Clause 5.5;f) providing access to investigation resources and tools in accordance with Clause 5.3.1 (e.g.,

investigation kit, cameras, and recording devices);g) reviewing the scope of the investigation to be undertaken (See Clause 7.2.1) and validating,

adjusting, or refining as necessary;h) assessing the need for additional investigation resources (e.g., internal or external subject matter

experts, additional team members, etc.); andi) identifying investigation team competence requirement gaps and other factors that could impact

the investigation team’s ability to carry out the investigation (See Clauses 5.4.2 and 5.4.3).

7.2.3 Investigation planThe investigation team shall prepare an incident investigation plan specific to each incident. The plan and documentation requirements shall be scaled in accordance with the scope of the investigation identified in Clause 7.2.1. The plan may include, but is not limited to, identifying and managing the following elements:a) what data is required (See Annex I);b) where and how the data will be obtained and maintained;c) how to preserve data that might be altered or destroyed;d) measures that will be taken to ensure the continued health and safety of the investigation team;e) other stakeholders (e.g., police, other organizations, authority having jurisdiction, etc.) and the

possibility of joint or concurrent investigations;




f) investigation team scene access issues or limitations (e.g., operating hours, potential scene hazards);

g) scene access restrictions to ensure scene preservation; andh) the effect of business continuity on the incident investigation.

7.3 Investigation

7.3.1 Scene management

7.3.1.1 Scene controlThe organization shall follow the procedure established in accordance with Clause 5.6.1 to ensure thata) the scene is secured and all incident data is preserved as appropriate; andb) only authorized personnel have access and are permitted to enter the scene or handle collected

incident data.

7.3.1.2 Scene assessmentThe investigation team shall perform a scene assessment that includesa) performing a hazard identification and risk assessment in accordance with Clause 5.6.1.2;b) implementing any necessary control measures to ensure the safety of the investigation team;c) verifying the initial incident information, and, if necessary, modifying the investigation plan

established in accordance with Clause 7.2.3. The following items shall be considered: i) evaluation of new, different, or changing circumstances that could require additional or

specialized resources to respond;ii) verification that all external agencies, as documented in the notification procedure in

accordance with Clause 5.5, are contacted, as applicable, and provided with the required details of the incident; and

iii) cooperation with any regulatory or emergency services personnel.

7.3.1.3 Witness management and supportThe investigation team shall follow the witness management support and management procedures established in accordance with Clause 5.6.2.

7.3.1.4 Psychological injury prevention and incident stress managementThe investigation team shall follow the processes established in accordance with Clause 5.4.4 to identify the hazards and assess the risk to the psychological health and safety of the investigation team.

7.3.2 Other considerations

7.3.2.1 Scene authority

7.3.2.1.1 Incidents occurring at scenes outside of the organizations controlWhen the scene of the incident is at a location not under the control of the organization, the investigation team shall coordinate the investigation with the scene authority following the procedure established in accordance with Clause 5.6.1.3.




7.3.2.1.2 Authority having jurisdiction

7.3.2.1.2.1 GeneralIf an authority having jurisdiction takes control of the scene, the investigation team shall coordinate the investigation with the authority having jurisdiction following the procedure established in accordance with Clause 5.6.1.4.1.

7.3.2.1.2.2 Release of scene from authority having jurisdictionIf an authority having jurisdiction has control of the scene, the investigation team shall coordinate the release of the scene from the authority having jurisdiction following the procedure established in accordance with Clause 5.6.1.4.2.

7.3.2.2 Impact of other factorsThe investigation team shall follow the steps outlined in accordance with Clause 7.2.2 that ensures the investigation team identifies factors that might impact their ability to fully carry out the investigation.

7.3.3 Final hazards assessment and scene releaseThe investigation team shall follow the procedure for hazard identification and risk assessment and control before work is allowed to resume at the scene in accordance with Clause 5.6.1.2 c).

7.3.4 Investigation team communication and coordinationThe investigation team shall follow the process as established in accordance with Clause 5.6.6 and respond to new data as received.

The investigation team shall adapt the process to best suit the incident circumstances and establish the ongoing debriefing needs.

The investigation team should consider the following as it relates to the debriefing needs:a) frequency;b) method;c) investigation progress, assumptions, and constraints;d) scene status;e) data validation and communication flow;f) any further data to be gathered in accordance with Clause 5.6.3.2;g) necessary next steps actions, tasks, and accountability;h) modifications to manpower requirements and other resources;i) modifications to timeline or sequence of events established in accordance with Clause 7.3.7 as

required;j) documentation and record management requirements (Clause 4.4.4); andk) psychological injury prevention and support as required (Clause 5.4.4).

7.3.5 Data collection

7.3.5.1 Collection and preservation of perishable dataThe investigation team shall follow the procedure established in accordance with Clause 5.6.3.1 to immediately document the scene and gather, document, and preserve perishable data.




7.3.5.2 Ongoing data gatheringThe investigation team shall follow the procedure established in accordance with Clause 5.6.3.2 to gather, document, and preserve data (Clause 7.2.3).

7.3.6 Documentation and record managementThe investigation team shall follow the documentation and records management procedures established in accordance with Clause 4.4.4.

7.3.7 AnalysisThe incident investigation team shall analyze the data gathered in accordance with Clauses 7.3.5.1 and 7.3.5.2.

The steps to be taken in the analysis process shall be as follows (see Annex H):a) test the data for validity and accuracy;

Note: Data can be validated by finding corroborating information or by examining conflicting data, where it exists.

b) identify and document assumptions and constraints of the data; Note: Some assumptions can include the degree of confidence in the accuracy of the data.

c) organize the data in a logical manner such as a timeline or sequence of events;d) analyze the data to determine its completeness;e) address any gaps or deficiencies in the data and where possible obtain additional data;f) use the data to identify all causal and contributing factors of the incident(s), condition(s), or

situation(s); andg) perform an iterative identification of causal and contributing factors to identify those factors which

are deficiencies that need to be corrected.Note: Data gathering and analysis is a process that can take many iterations to identify all causal and contributing factors to the incident condition or situation.

7.3.8 Risk assessmentThe incident investigation team shall conduct a risk assessment for each causal and contributing factor identified in Clause 7.3.7. (See CSA Z1002.)

7.3.9 Hazards related to deficienciesHazards identified by the incident investigation team during the investigation that are determined not to be causal or contributing factors shall bea) documented and communicated to the organization by the incident investigation team; andb) addressed by the organization by means of a risk assessment.Note: This step is taken to provide opportunities for prevention or continual improvement.

7.3.10 Findings

7.3.10.1 GeneralThe incident investigation team shall establish and document findings. Findings should be based on the data available and the risk assessment conducted in accordance with Clause 7.3.8.

Findings should be stated in a concise manner, with the description of the deficiencies and the relevant data.




7.3.10.2 Findings related to causal and contributing factorsThe investigation team shall follow the process established in accordance with Clause 5.6.5 a) to document causal and contributing factors.

7.3.10.3 Findings related to deficienciesThe investigation team shall follow the process established in accordance with Clause 5.6.5 b) to document factors that, while not being identified as causal or contributing factors to the incident, represent deficiencies as identified in Clause 7.3.9.

7.4 Post investigation

7.4.1 Investigation team recommendationsThe investigation team shall document recommendations to address causal and contributing factors and deficiencies that are identified as not being causal or contributing factors.

7.4.2 Incident investigation reportThe incident investigation shall be documented in a final report in accordance with Clause 5.6.7.

8 Action plan and validationThe organization shall establish and implement an action plan based on the incident investigation report (Clause 7.4.2). The organization shall consider the immediate and interim actions taken as a result of the incident, and identify deficiencies and opportunities for improvement.

The action plan shalla) establish the priorities for implementing corrective actions taking into account

i) the hazard or hazards and the associated level of risk;ii) opportunities for immediate action;iii) long term effective risk control measures following the hierarchy of controls;iv) implementation according to the hierarchy of controls as follows (see CSA Z1002):

1) eliminate the hazard;2) substitute other materials, processes, or equipment;3) engineering controls;4) systems that increase awareness of potential hazards;5) administrative controls, e.g., training, procedures, instructions, and scheduling; and6) PPE, including measures to ensure its appropriate selection, use, and maintenance;

b) document risk control measures to be taken;c) communicate risk control measures to be taken to relevant internal and external stakeholders;d) allocate appropriate resources and address barriers and obstacles to implementation and take

steps to achieve consensus for implementation of corrective actions (see Annex F);e) determine if similar incidents and nonconformities have occurred, and incorporate steps to address

them;f) address legal and other requirements;g) assign responsibility, establish a time line, and provide resources for the implementation of

immediate, interim, and long term actions;h) verify that the corrective actions adequately address the intent of the investigation team

recommendations;




i) provide mechanisms for communication with other stakeholders, and to obtain feedback on the success of the implementation;

j) determine the metrics and measurements to be used to monitor the effectiveness of the corrective action plan;

k) monitor that corrective actions have been implemented, followed, and are working effectively to eliminate the hazard or control the residual risk;

l) review and re-examine the corrective actions to determine if and what additional measures are required to address the causal and contributing factors and deficiencies that are identified as not being causal or contributing factors; and

m) verify that any new hazards created by the corrective actions are identified and adequately controlled.

The organization shall document and maintain records to demonstrate conformance to this Clause.

9 Verification and validationFollowing the completion of an incident investigation the organization shall review and ensure thata) documents were collected in a timely and appropriate manner;b) all legal requirements were met; andc) incident investigation procedures met the requirements of this Standard.

10 Continual improvementThe organization shall carry out a review of the IIPP in consultation with the stakeholders for the purposes of achieving continual improvement.

This review shall be conducted at planned intervals. The review shall include all elements of the IIPP as outlined in this Standard. The organization shall review the impact of the IIPP on the OHSMS, where one exists.




Annex A (informative)Principles for incident investigationNote: This Annex is not a mandatory part of this Standard.

A.1 Principles of incident investigationThe following principles should be applied to the process of incident investigation:a) Prevention focus — All incident investigations should focus on prevention as the major objective.

The end result of the investigation should not be simply the identification of causal and contributing factors but rather the identification of effective prevention measures for all identified deficiencies in the system of work.

b) Fact-finding, not fault-finding — Everyone involved in the incident investigation (investigation team, witnesses, supervisors, colleagues, management, etc.) should be made aware that the information obtained during the investigation will not be used to lay blame on any individual or group of individuals. Furthermore, the intent of the investigation is to understand the causal and contributing factors leading to the incident in order that future incidents or injuries might be prevented. Once the organization believes and demonstrates this objective to be true, data will be easier to obtain.

c) Objective — It is common for investigation teams to identify noncompliances or nonconformances with existing legislation, site rules, safe work practices, etc. Although this is relevant and important, this can bias the investigation and limit completeness. An investigation is not an audit and it must stay focused on what actually happened and why.

d) Confidentiality — The investigation team must ensure that everyone who participates in the investigation are aware that confidentiality is to be maintained where possible. This practice will help ensure that information relevant to the incident is forthcoming. Persons conducting analyses of workplace incident data must respect confidentiality. Signed non-disclosure agreements can be used so that those compiling organizational statistics can view the full data set but are prevented from disclosing information that would identify particular individuals or organizations.

e) Consultation — Affected internal and external stakeholders should be consulted with in the incident investigation process to ensure that the investigation is thorough.

f) Communication — While respecting the anonymity of persons and confidentiality of personal information, affected employees, including managers, supervisors, and worker representatives, should be provided with information about the investigation process. During the investigation, this communication includes the investigations purpose, the process, timing, and who might be required to be interviewed. When completed, the investigation team should communicate the findings, and related corrective action plans.

g) Systematic approach to fact-finding — The incident investigation model chosen should be customized to be relevant to the specific organization, be compatible with the principles outlined in Clause 0.2, and ensure that causal and contributing factors are thoroughly investigated and reviewed during analysis.

h) Education and training — Incident investigation teams are more effective when those involved have the general knowledge, skills, and abilities to carry out their duties. For further guidance in this area see Annex B.

i) Investigation triggers — An organization should identify what constitutes triggers for incident investigations based on regulatory requirements, organizational requirements, industry best practices, potential for severity, potential for recurrence or further loss, potential for occurrence due to unsafe conditions, or other applicable requirements and standards. When identifying triggers for conducting an investigation, an organization should consider the effects of interaction




and potential interactions between a worker, the property, and the environment. For example, an explosion which caused property or environmental damage (since such incidents can involve safety deficiencies with the potential for harm to individuals) that might or might not have caused injury to a worker could trigger an investigation.




Annex B (informative)Investigation team competenciesNote: This Annex is not a mandatory part of this Standard.

B.1 IntroductionThis Annex outlines the skills and knowledge required by the person involved in the IIPP and is provided to assist organizations in determining overall required competencies. The level of these attributes required by an individual (or team) will also be determined by the level of complexity of the incident being investigated. Organizations can prepare individuals to be competent in the IIPP by facilitating the appropriate education, training, skills development, and experience. Methods of gaining experience can include mentorship, assisting senior investigators, scenario based training, observation, etc.

B.2 Skills and abilitiesPersons involved in the investigation process should have skills and abilities appropriate toa) identify hazards and understand the range of hazards (i.e., chemical, biological, physical,

environmental, mechanical, musculoskeletal, psychosocial, etc.) (See CSA Z1002 for more information on types of hazards.);

b) understand risk assessment and hazard control;c) work independently and in a team environment;d) organize and manage priorities to ensure tasks are completed in a timely manner;e) identify, compile, safeguard, catalogue, assess, analyze, verify, and record relevant data based on

observation, scene review, interviews, inquiries, record review, documentation, and inspections;f) conduct interviews (see Annex F);g) use written communication skills, such as the ability to

i) prepare written materials such as incident reports, emails, presentations, etc.;ii) critique procedures for accuracy, clarity, and consistency with organizational policies; andiii) convey findings at a level appropriate to the various audiences involved;

h) use aural communication skills (the ability to actively listen), including the ability to listen to information and concerns, and to clarify and validate received messages;

i) interact with other parties, agencies, or outside authorities, as applicable;j) provide leadership, including the ability to calmly and thoroughly take control of a situation;k) provide direction to others during the investigation;l) interact with potentially upset, difficult, or uncooperative people in a respectful and objective

manner;m) use verbal communication skills, including the ability to convey information both from and to

groups and individuals;n) manage and preserve a scene to conserve data and ensure the safety of others;o) record the scene (photography, video, sketch, etc.); andp) possess knowledge of investigation biases. (See Annex D.)

B.3 General knowledgeThe investigation team should have knowledge of or access to person(s) with such knowledge ofa) applicable acts, regulations, and other legislation, standards, codes, and guidelines;b) occupational health and safety fundamentals, principles, rights, duties, and responsibilities;c) applicable industry best practices, procedures, processes and equipment, or be able to identify

resources to assist;




d) scientific and/or technical principles and processes applicable to the incident;e) workplace procedures and processes, including health and safety requirements, safety techniques,

and equipment;f) conflict resolution, interview, and mediation techniques and approaches;g) human resource management practices, including knowledge about the occupational health and

safety internal responsibility system, and knowledge about the roles of outside parties; andh) requirements for document control, record keeping, data collection, and confidentiality.




Annex C (informative)Working with photographs and videosNote: This Annex is not a mandatory part of this Standard.

C.1 Scene preservationThe scene of any incident should only be disturbed to attend to the injured person, to prevent further injuries, or to protect property. A complete series of photographs or video should be generated before any items are moved, altered, or disturbed. This recording includes scene markers. Ideally priority should be given to perishable items such as tire tracks, foot prints, marks in dusty surfaces, blast/fire debris, or areas exposed to weather such as rain, snow, or direct sunlight if applicable. Investigators must be knowledgeable regarding scene preservation requirements in accordance with the authority having jurisdiction.

C.2 When a scene is not preservedIn some cases, incidents can occur and business continues out of necessity for example it is unsafe to others if the work stops, or if the scene is not preserved through lack of knowledge to do so. In these circumstances, the scene should be reconstructed as best as possible from witness accounts and obtaining pertinent information.

C.3 GeneralThe investigation team should aim to tell a story with the photographs or videos. The starting place should be the capturing of the overall scene (big picture), this will provide the needed context to the work that was taking place. The team should then move to capture the scene itself and all of the components that the worker was interacting with.

C.4 Capturing the sceneIn capturing the scene with photography or video, the investigation team should consider the following:a) Overall scene —

i) Capture the whole scene. Capture aerial views where possible.ii) Ensure photographs/video are taken from far enough away to be able to get perspective on

where the event occurred.iii) Show the scene in relation to its surroundings.

b) Mid-range scene — i) Begin to emphasize key pieces of information within the scene.ii) The photographs/video should allow the viewer to relate the pertinent components to the

larger scene (i.e., in relative distances compared to objects in the vicinity).iii) Photographs/video should be taken from various vantage points: front, back, left side, and

right side of the scene, where appropriate.c) Close-up scene —

i) Include any identifying marks (e.g., serial numbers on equipment).ii) Scales such as rulers, line measures, and height references should be employed so that the

distances between objects and the relative sizes of the objects can be interpreted when the photographs are viewed.




C.5 Creating contextThe investigation team should ensure that context is provided to the viewer when photographs/video are relied upon during the investigative process. There are several tools that can be used to provide context, such as the following:a) Scene markers — Markers, such as tents, flags, or other contrasting means should be used to

highlight the location of items of interest in the scene photographs. Once the markers are placed, they should not be moved for the duration of the photography. A map, index, or legend of what the markers are representing should be completed before the markers are removed.

b) Object facets — Objects, small and large, that are integral to the investigation should be completely photographed on all facets whenever possible. For example, if a tool box is being photographed, then all sides, as well as the top and bottom should be photographed face on along with a scale marker (six photos should be taken). In this way, a complete record of the object will be preserved.

c) Worker perspective — Capturing the incident from the perspective of the worker is an important element towards understanding potential causal or contributing factors. For example, if a worker was driving a forklift, what could be seen from the worker’s perspective in the driver’s seat (i.e., blind spots, line of sight, etc.) should be photographed. Environmental conditions at the time of the incident should be considered and efforts should be made to capture the same conditions (e.g., if the worker was facing into the glare from the sun or entering into a dark building from bright light conditions).

C.6 Photograph and video integrityThe investigation team should ensure that a complete set of all photo and video data generated during an incident be included in the investigation. This data can include data from witness cell phones, surveillance, first responders, and other agencies.

The investigation team should consider the following to ensure the integrity of investigation photography and video data:a) When photographs and video are copied, they can be inadvertently altered and important data can

be lost. Whenever possible, copies of electronic media should only be removed from storage systems by persons qualified to do so.

b) Continuity, log, and storage — A clean copy of original photos, once generated, should be logged and preserved to ensure continuity of the data. The log should include a date and time stamp for the photograph/video as well as the name and contact information of the individual who took the photo. Any alteration, enhancement, and additional processing is only to take place on copies of the originals.

c) Surveillance data can be lost if not obtained before the footage is over-written or deleted so timely action might be necessary.

d) Any collection of data should comply with all privacy requirements, legislation, collective agreements, and policies.




Annex D (Informative)Investigator biasNote: This Annex is not a mandatory part of this Standard.

D.1 Investigation team bias

D.1.1 GeneralThe investigation team should be aware that all individuals, regardless of experience level, can be potentially affected by biases in both their thought and decision making processes.

The investigation team should understand that biases are not an intentional misrepresentation of the facts, but rather a natural mechanism that is developed by individuals to help understand the near infinite amount of information the mind is asked to deal with on a daily basis. There is often a general, but limiting, tendency to see a worker as contributing to the cause more than situational variables.

All investigators are susceptible to rendering biased decisions and all investigation teams are susceptible to bias, regardless of how objective an individual or team believes they are.

While investigators should be conscious of the types of potential bias as specified in Clause D.1.2, organizations should invest in training for their investigators regarding bias, as well as develop working procedures to reduce bias for the investigative process.

Investigations teams should be aware that they could potentially be biased toa) see suboptimal actions as more causal than suboptimal conditions;b) make judgements that benefit parties that the investigation team is invested in protecting; andc) allow an initial hypothesis, which might be informed by Items a) or b), to have a disproportionately

high influence in the investigation via confirmation bias.

An individual’s observations and decisions might be biased yet they will maintain a feeling of being impartial and objective. Bias can come from a variety of sources such as previous experience with a certain types of event, prior knowledge of a person or equipment, allegiances, or personal motivations. The list of potentially biasing factors is diverse yet the result is singular—decisions that lack objectivity.

D.1.2 Types of biasThe following list specifies the potential types of investigation team bias:a) Confirmation bias — a bias where people tend to seek and interpret information consistent with

their preconceived notions and ignore or discredit information inconsistent with their initial opinion. For example, in a complex chemical explosion, an investigator who has developed a theory about the mixing of reactive chemicals may disregard or render irrelevant the findings of a report about deficiencies in electrical systems.

b) Allegiance or affiliation bias — a motivational bias where one tends to favour a perspective in which they are invested. For instance, if the investigator knows that their organization favours human error causes, the investigator might be more likely to overemphasize human error causes. Alternatively, if they are investigating an event in which a good friend was central, they might be more inclined to see a situational factor as highly causal.




c) Hindsight bias — the tendency to interpret (or reinterpret) information in light of current knowledge and perceive an event as more predictable, inevitable, and foreseeable after the outcome becomes known than it truly was at the time of the happening. It is important not to i) underestimate the uncertainty a worker faced at the time of the event; andii) overestimate causality of the person’s actions, i.e., that the adverse event was the only

outcome of the preceding action.d) Correspondence bias — the tendency to draw inferences about a person's dispositions (e.g.,

dedication to safety, attentiveness, motivation) arising from behaviors that can be explained by the situations in which the behaviour occurs. For example, seeing a car driving erratically and deducing that the person behind the wheel is reckless, rather than considering that there is something malfunctioning with the vehicle.

e) Anchoring or focalism bias — a cognitive bias that describes the common human tendency to rely too heavily on the first piece of information offered (the "anchor") when making decisions.

f) Observer bias — the tendency to distort or influence situations or events and make them fit with their preconceptions having unintended effect upon the situation or event.

D.2 Resources — Investigation team biasThe following is an additional resource on the topic of investigation bias:

MacLean, C. and Dror, I.E. (2016). “Psychology and Cognitive Bias”. In A. Kesselheim & C. Robertson (Eds.), Blinding as a Solution to Bias (Chapter 1, pp 13-22). Elsevier. http://nebula.wsimg.com/ 2d9304f85ab9c993ef5c510d59d79e44?AccessKeyId=09634646A61C4487DFA0&disposition= 0&alloworigin=1


http://nebula.wsimg.com/2d9304f85ab9c993ef5c510d59d79e44?AccessKeyId=09634646A61C4487DFA0&disposition=0&alloworigin=1





Annex E (Informative)Development and implementation of a corrective action planNote: This Annex is not a mandatory part of this Standard.

E.1 Guidance on development and implementation of a corrective action planThe systematic approach to implementing an IIPP, which is embedded in this Standard, is based on collaborative and participatory processes of discussion and decision making. Clause 7 requires the organization to take steps to achieve consensus for implementation of corrective actions and Clause 4.2.3 details the participatory and consultative nature of the process with the workers, worker representatives, and management representatives.

The intended result is achieving consensus on effective corrective actions in order to prevent recurrence of incidents and improve overall health and safety in the workplace.

Participation and consultation of workers and their representatives are different terms describing the different methods and degrees of involvement in decisions taken when designing, implementing, and evaluating the IIPP. Consultation includes analysis of information collected in the IIPP processes, discussion of the findings, and in the development of recommendations for corrective actions. Consultation involves the organization’s taking into account the views and recommendations before it makes a decision, whereas participation involves workers and/or their representatives in the decision making. Participation is an effective means to achieve consensus. If there are identified barriers to effective participation, there is a higher likelihood that consensus will be difficult to achieve.

Removing barriers to participation in developing the corrective action plan should includea) the provision of information regarding the scope and objectives of the IIPP including commitments

to continual improvement and the development of both immediate and longer term corrective actions;

b) the communication of operational information including knowledge of identified hazards, hazard elimination, risk assessments, and risk control opportunities;

c) the fostering and supporting of organizational mechanisms which promote and enable effective participation including health and safety committees and the provision for selection of worker representatives through worker/union organizations;

d) the implementation of a thorough validation process that includes consultation with all affected workers and seeks their input in evaluating the effectiveness of corrective actions;

e) the provision for adequate time and resources to accomplish Items a) to d);f) encouraging workers to report hazardous situations; andg) the protection from reprisals, including disciplinary or other diverse measures, for participation in

Items a) to f).

Removing barriers to participation is essential to ensure the ongoing effectiveness of the IIPP. Fostering a positive occupational health and safety organizational culture through the implementation of Items a) to g) will assist the organization in establishing consensus-building processes that can serve as a dispute resolution mechanism embedded in the system itself. Participatory mechanisms such as the workplace health and safety committee and labour/management committees will assist organizations throughout the implementation of all the above processes.




There are resources available describing organizational responsibilities and opportunities for developing consensus and resolving disputes in occupational health and safety. The Canadian Centre for Occupational Health & Safety (CCOHS) is an excellent source of some of this information.




Annex F (informative)InterviewingNote: This Annex is not a mandatory part of this Standard.

F.1 GeneralIn many incident investigations, interviewing the people who were at the scene, or who worked in the area, will be the only way to gather pertinent data about how the incident took place. The interview process should be well planned. It is also often an iterative process whereby some people might need to be interviewed several times to ensure all the necessary data is collected.

This Annex provides information on the key considerations that should be made before the team begins to interview those involved in incidents.

F.2 Planning, timeframe, and processThe following items are some of the initial considerations that investigation teams should make when setting up the interview process:a) Interviews should be conducted as soon as possible, and the people should be kept from

communicating with each other before the interview takes place.b) The mental state of the interviewee(s) should be taken into account. If the interviewee(s) are

experiencing trauma or shock from the event, the investigation team should ensure that they are provided the appropriate resources to ensure their health and safety before beginning the interview.

c) Interviews should be conducted in a safe, comfortable place that is private (away from other interviewees) and frequent breaks should be provided if needed.

d) Anonymity for should be provided for the interviewee if requested. Witnesses might request anonymity or might wish to limit the number of people who know that they are the source of some information. Situations can arise, however, where the investigation team is compelled to disclose the source of information. If disclosure is unavoidable (e.g., during legal proceedings), the investigation team should discuss such possibilities with the person who requested anonymity and agree on the limits of the request.

e) Investigators should understand collective bargaining agreement representation requirements in unionized organizations and comply with any requirements.

f) If interviews are conducted by two members of the investigation team i) it should be decided before the interview how the work will be divided amongst the

investigation team members and what the roles each member will play (i.e., who will be the primary speaker, who will take notes, etc.); and

ii) if it is determined that both members of the investigation team will speak, care should be taken around interrupting pauses;

g) It might be the case that there are special circumstances that will alter the interview process. The investigation team should develop a process for special case interviews. Some special considerations that might arise include i) phone interviews when face to face is not available or possible;ii) age considerations (e.g., young or elderly);iii) impairment (e.g., drugs or alcohol);iv) cognitive issues;v) hearing impaired individuals;vi) language concerns where language interpretation could be required;




vii) multicultural considerations;viii) emotionally distraught individuals;ix) seriously injured individuals; andx) next of kin in serious or fatal incidents.

F.3 Who to interviewThe investigation team should interview any individual who was involved in the incident, was a witness to the incident, who can contribute relevant information to the causal or contributing factors, and subject matter expert(s).

Examples of these individuals could includea) injured worker(s);b) eye witnesses to the event;c) union representative(s) if applicable;d) family members of the injured worker(s);e) co-workers (with and without knowledge of the work);f) manager(s) or supervisor(s);g) senior management;h) workers who perform similar jobs in other departments or on different shifts;i) engineers or others who have organizational technical expertise;j) maintenance personnel;k) emergency personnel;l) first aid attendants;m) worker representatives;n) medical personnel;o) equipment suppliers;p) external experts (engineers, subject matter experts, consultants, etc.); andq) trainers, both internal and external (where possible).

F.4 Interviewing strategiesThe investigation team should ensure that they get the full range of data that they require from the person being interviewed. The following techniques can assist in ensuring all relevant data is captured:a) Interviewing process —

i) Enough time should be allocated to carry out a proper interview.ii) The date and time of the interview and who was present should be recorded.iii) While the initial questions should be planned, the investigation team should not be too rigid in

their process, and should allow for flexibility to adapt to changes when new information is discovered.

iv) The investigation team should have the interviewee tell the whole narrative, from start to end without interruption. Note: The use of this technique assists in ensuring that the witness doesn’t deviate and miss details that they think are important. The investigation team should save any questions until the witness is finished.

v) The investigation team should note any contributing events, conditions, and actions for later focus and follow-up.

vi) Once the investigation team believes that they have gained all the data required, the investigation team should place the collected data into a logical sequential order. The investigation team should then retell the narrative to the interviewee and ask them to interrupt if anything is out of sequence or if any details are missing.




vii) A simple final question should always be asked (e.g., “Is there anything else that you would like to add that was not asked?”).

viii) If the interviewee is in agreement and circumstances permit, once the interview is completed, the investigation team should take the interviewee to the scene to assist in elaborating or clarifying any needed details. If conducting the interview on scene is not possible, the use of diagrams, maps, video, and pictures may be used during the interview to assist in clarifying elements.

ix) The investigation team should have the full statement of the interviewee documented and allow the witness the opportunity to review for accuracy.

x) The investigation team should advise the interviewee that they might be contacted again, and provide the contact information for the investigation team to the interviewee such that the interviewee will be able to contact the investigation team in the event that they recall any other relevant data they would like to communicate.

b) Interviewing tips — i) To assist in keeping the interviewee at ease, the investigation team should explain who they

are and that the interview is being conducted for further incident prevention purposes. The investigation team should develop a rapport with the interviewee and explain that they are seeking the facts related to the incident, not seeking to lay blame or punish. Note: The development of rapport between the interviewee and the interviewer will make the witness more comfortable during the interview process. Comfortable interviewees will generally provide more information.

ii) The investigation team should try to empathize with the interviewee. Note: The act of putting oneself in the other person’s shoes will aid in developing a more thorough understanding of the why and what that the interviewee is trying to communicate.

iii) Once the witness narrative is complete, the investigation team should ask one question at a time and provide time for the interviewee to answer before moving on to the next question. Note: Simple questions such as “and then what happened?” will often provide additional data.

iv) The interviewer should avoid using leading questions. Note: Leading questions are those that prompt the interviewee to answer in a particular manner resulting in potentially false or biased information. Open-ended questions will often provide additional data.

v) In most circumstances the interview process should avoid providing information about the incident to the interviewee.

F.5 Critical informationSome of the relevant data that the investigation team should attempt to gather should includea) relevant history of the injured worker(s) including

i) training;ii) experience; andiii) habits;

b) working styles and immediate history including a 72 h history and beyond; andc) the individual’s intentions, perceptions, and actions leading up to, during, and after the incident.




F.6 Sample interview questionsThe following is a list of questions that the investigation team could consider using for interviews:Note: This list is not exhaustive. Additional in depth questions might be necessary to uncover the causal and contributing factors and system deficiencies that have been identified, but are not causal or contributing factors.a) Initial narrative questions —

i) What happened? Get the witness to tell the full narrative story.ii) What did you see?iii) What did you hear?iv) What did you do?v) When did it happen?vi) Where did it happen?vii) Has this type of incident happened before?viii) What were the circumstances surrounding the incident?

b) More specific follow up questions — i) What training has been provided?ii) How much experience do you or the injured worker have?iii) What can you tell me about supervision?iv) What procedures are in place?v) What could have prevented the incident?vi) How or why did it happen?

Note: Asking “how” or “why” might to help gather information on any causal and contributing factors or system deficiencies that have been identified, but are not causal or contributing factors. This information might also allow interviewers to confirm that they have gathered the relevant data. For example, if there was an airborne chemical exposure (the fact) a series of “how did that happen” and “why did that happen” questions might elicit information about the hygiene or chemical management programs, and weaknesses or nonconformities that contributed to the incident.




Annex G (informative)Data analysisNote: This Annex is not a mandatory part of this Standard.

G.1 Data analysis and drawing conclusionsThe investigation team should create a detailed sequence of events based on observation of the scene, photographs, interviews with witnesses, and other collected data. Inconsistencies should be identified and, as necessary, further scene visits or witness interviews might need to be conducted. The investigation team should ensure that the data is analyzed in such a manner that it is free from investigator bias. (See Annex D.)

The analysis of data should aim to answer the key question of, “Why did the incident occur?” The investigation team should seek to find all possible answers to this question before making recommendations to reduce the likelihood of recurrences of similar incidents.

Upon completion of the analysis of the incident data, the investigation team should document a step- by-step account of what transpired, working back from the moment of the incident, listing all possible causal and contributing factors at each step.

Each finding generated should be verified to confirm ifa) it is supported by facts and data; andb) the data that support the findings are

i) direct (physical or documentary);ii) based on eyewitness accounts; oriii) based on assumptions.

After careful review of all data collected, the investigation team should have an understanding of what transpired and why and how it happened. If this data review uncovers gaps in the data collected or the investigation team’s understanding of the incident, the team should re-interview key witnesses or gather further data to fill these knowledge gaps.

G.2 Purpose of data analysisThe purpose of data analysis is toa) explain what occurred;b) explain why it occurred;c) draw factually based conclusions;d) identify safety and organizational system gaps; ande) demonstrate the need for corrective action.

G.3 Data analysis stepsThe steps in analysis of incident investigation data area) stating the problem or question;b) developing a theory;c) forming a hypotheses;d) testing the hypotheses;e) integrating factual information with scientific information;f) drawing logical interpretations of results; and




g) conveying the analysis in a report.

G.4 How data analysis works in practiceThe steps of data analysis in Clause G.3 are presented in a linear fashion. In actuality the investigation process is generally iterative in nature and typically follows a more fluid and less sequential flow. The steps of data gathering and analysis typically take place continually and concurrently as opposed to in discrete, consecutive stages.

The investigation team shoulda) use a systems approach and data collected to develop theories throughout the course of the

investigation;b) use existing data or gather more data to test the validity of the theories;c) draw logical interpretations of results; andd) clearly convey the analysis process in the incident investigation report.

G.5 Working from effects back to causal and contributing factorsThe investigation team should consider the following elements throughout the data analysis process:a) any particular effect that is noted could have many possible causes;b) it might be necessary to develop and investigate several theories simultaneously; and

Note: Examples are as follows: a) a broken part could be due to manufacturing error, metal fatigue, wear, etc.; andb) a missed item in a checklist could be due to high workload, worker distraction, fatigue, an adaptation of

the safety procedure, etc.c) care should be taken in deriving causal factors from effects to ensure the correct conclusion is

drawn.

G.6 Data analysis validationThe incident investigation team should consider the following questions in testing the validity of the data analysis:a) Is the logic sound (i.e., consistent, relevant, supportable)?b) Have assumptions been made?c) Have investigator bias or other cognitive obstacles been factors in the data analysis? (i.e., has the

investigation team drawn from their own experience but not backed it up with facts?)d) Are the events in the timeline necessary and sufficient?

Note: A useful way to determine this is to check the timeline in reverse.e) Can useful recommendations be produced based upon the data analysis performed?f) Has the simplest explanation been chosen that covers all of the available data?g) Is the investigation team aware of the specific conditions that apply to the theory that they are

using?h) Does the investigation team use the findings appropriately to draw conclusions?i) Has the analysis been reviewed?

Note: Investigators should ask peers to review their data analysis or carry out a reasonable person test.

G.7 Understanding human performanceHuman factors/ergonomics is the scientific discipline concerned with the understanding of interactions between humans and other elements of a system. It is also the profession that applies theory, principles, data, and methods to design in order to enhance human well-being and optimize overall




system performance (see CSA Z1004). For this reason, investigation teams should be aware of relevant research and information.

When a system is designed without determining the interactions between humans and other elements of the work system, incidents might result. During an investigation, expect variable performance among people and organizations and consider this in the investigation process.

G.8 Testing the hypothesisThe investigation team shoulda) use the data gathered from the field and the appropriate tools to analyze that data;b) research current literature and identify one or more hypothesis to explain the event;c) review the limitations of the relevant hypothesis; andd) review pertinent industry information and knowledge to identify data that is needed to test the

hypothesis.

G.9 Documenting analysis and findingsThe incident investigation team should use the following format to document incident investigation analysis and findings:a) a detailed list and synopsis of the specific data that was collected;b) the hypothesis that best explains the causal and contributing factors of the incident;c) a summary of how the data validates the hypothesis; andd) conclusions as to the causal and contributing factors of the incident.

G.10 Drawing conclusionsIn drawing conclusions the investigation team should consider the following:a) development of findings related to the causal factors of the incident classified as

i) direct or immediate;ii) underlying factors; andiii) undesirable conditions/actions;

b) development of findings related to the contributing factors of the incident;c) development of a description of the workplace including

i) all relevant policies and procedures including employee training and orientation;ii) a history of similar incidents; andiii) the organizational safety culture; and

d) verification that all findings are factually supported by investigation data.Note: Findings should be a) based on observation and measurement;b) objective;c) open to the public or applicable stakeholder groups;d) controlled and systematic;e) verifiable; andf) based on scientific reasoning.




G.11 Data analysis tips

G.11.1 Procedure if hypothesis disprovenIn circumstances where the incident investigation team finds itself in a situation where the hypothesis generated during the course of the investigation does not hold up to verification, the investigation team should do the followinga) pinpoint what data the hypothesis does not explain;b) review the decision logic;c) review all assumptions made;d) review the data collection methods for missed or overlooked data; ande) carry out a literature review for alternative hypothesis that could apply to the same or similar

issue.

G.11.2 Procedure if analysis disprovenIf the incident investigation team finds itself in circumstances where the data analysis carried out during the course of the investigation does not hold up to further data verification, the investigation team should do the following:a) ask for feedback from applicable stakeholders;b) review the incident investigation data for completeness;c) review the data collection methods for accuracy, errors, or oversights; andd) consider consulting subject matter experts.




Annex H (Informative)Using a systems approach to identify causal and contributing factors Note: This Annex is not a mandatory part of this Standard.

H.1 GeneralThis Annex describes a systems approach and the foundational components including the approaches, models, and tools employed to identify and assess causal factors, multi-causality, other investigative triggers, and contributing factors. Whatever approach, model, and/or tool that is selected by the organization, it should be compatible with the general investigative principles outlined in Clause 0.2, Annex A, and the organization’s specific needs.

Rather than define a specific model for utilization, this Annex provides guidance for a systematic approach for organizing the incident information collected during investigation.

H.2 Multi-causalityIncidents rarely have only one cause. The events leading up to incidents all have direct causes (causal factors) and each of these have contributing factors. For example, if a worker was injured during a fall, one of the events leading to this might be that the worker slipped on a broken rung of the ladder. For this particular incident, it would be necessary to consider the work procedure, maintenance deficiencies, inspection procedures, etc. Therefore, all of the causal and contributing factors in a sequence of events that leads to an incident need to be examined.

For example, if an investigation team concludes that an incident was due solely to worker error and went no further in their investigative process, they have failed to identify the contributing factors to the incident and have not sought to understand the answer to other important questions relating to the significance of other workplace factors such as the following:a) Was the worker distracted? If yes, why was the worker distracted?b) Was a safe work procedure being followed? If not, why not?c) Were safety devices in order? If not, why not?d) Was the worker trained? If not, why not?

Further investigation that reveals answers to these and related questions will most likely uncover conditions or factors that are causal or contributing factors to the incident and will provide valuable information to the organization to assist in preventing reoccurrence of the incident or deficiencies in the system of work that could lead to other types of incidents.Note: The example in this Clause is based on, “Incident Investigation, Why look for the root cause?”, Canadian Centre for Occupational Health and Safety (CCOHS), http://www.ccohs.ca/oshanswers/hsprograms/investig.html

H.3 Identification of contributing factorsOnce the events and their direct causal factors have been identified, the next step is to explore those factors which contributed in any way to these causal factors. Such contributing factors should be considered in every aspect of the system of work, including the task or tasks, the work environment, materials and equipment, personal factors, and the organization of work.

Contributing factors are conditions that could influence the likelihood of the occurrence, accelerate the effect in time, or affect the severity of the consequences.


http://www.ccohs.ca/oshanswers/hsprograms/investig.html



In other words, once the incident sequence has been determined and the causal factors identified, the contributing factors that led to deviations can be explored.

Figure H.1 illustrates examples of contributing factors that could spring from one particular cause of the incident.




Figure H.1 Examples of contributing factors

(Clause H.3)

Incident

One event leading to the incident

One causal factor

Contributing factors

Very little clearance tobypass lumber stack

Lift truckimpacted the

lumber

Lift truckoperates nearlumber stack

Worker hit byfalling object

Why and how?

Lumber was stored inan overflow area

Supply chain hadexperiencedinterruptions

Transportation strikeresulted in excess

inventory of lumber onhand

Organization was unableto alter pre-bookedincoming orders of

lumber prior to strike

Lift truck operatorwas inexperienced

Senior lift truckoperators are booked

as out on vacation

Vacation schedulingallows for multipleoperator absence

Visual blind spots inthe lift truck

Design of the lift truckfor roll over protective

structures (ROPS)




H.4 Systems approach to analysis of incident investigation dataVarious methodologies exist for analyzing incident investigation data. This Clause describes an approach for categorizing the data collected for the purposes of incident investigation analysis and ensuring that all data is collected, as shown in Figure H.2 and further detailed in Table H.1. This approach illustrates the multi-causality of incidents. It groups the causal and contributing factors of any incident into five categories as follows:a) task;b) material and equipment;c) environment;d) personnel factors; ande) organization.

When evaluating each one of the categories, the investigation team should understand the interaction between the hazards, categories, and data collected (e.g., If it was a hot environment, how did that impact the worker? If the machinery was poorly designed how did it affect the worker’s ability to manage the task?).

When this approach is used, possible causal and contributing factors in each category should be investigated.

This approach could be used to provide guidance for uncovering all possible causal factors arising from the events leading to an incident and the contributing factors that underlie them. This approach ensures a systematic identification of all safety deficiencies involved. It should be noted that there is generally considerable overlap between categories; this reflects real life situations.

The sample questions detailed in Table H.1 suggest some direct causal factors and some possible underlying contributing factors that could lead from the events leading to the incident. The organization might find quite different issues depending on the data collected during a particular investigation.

The answer to each question shown in the categories will lead to more questions in the quest to uncover all possible contributing factors.

Each time the answer reveals a safety deficiency or gap, the investigation team should ask why this situation was allowed to exist and this then leads to additional contributing factors. Such contributing factors can span more than one of the categories.

Source: Based, with permission, on Incident Investigation, “What should be looked at as the cause of an incident?” Canadian Centre for Occupational Health and Safety (CCOHS), http://www.ccohs.ca/oshanswers/hsprograms/investig.html


http://www.ccohs.ca/oshanswers/hsprograms/investig.html



Figure H.2 Incident causation

(See Clause H.4)

Task

Environment

Mate

rial and equipment

Organizatio

nPersonnel factors

Table H.1Incident causation

(See Clause H.4)

Category Sample questions Sample contributing factors

1) Task(s) The incident investigation team will look for answers to questions such as the following:

If not, why not?

Here the actual work procedure(s) being used at the time of the incident are explored.

a) Was the correct safe work procedure used?

b) Had conditions changed to make the normal safe work procedure unsafe?

c) Were the appropriate tools and materials available for the task being performed?

d) Were the tools and materials used?e) Were safety devices working properly?f) Was energy isolation (lockout) used

when necessary?

• Work procedure not updated following changes to task.

2) Material and equipment The investigation team should ask questions such as the following:

If not, why not?

To seek out possible causal factors resulting from the equipment and materials used.

a) Was there an equipment failure?b) What caused it to fail?c) Was the machinery poorly designed?d) Was the correct machine guard in place?e) Were hazardous substances involved

and, if so, were they clearly identified?f) Was a less hazardous alternative

substance possible and available?g) Was the raw material substandard in

some way?h) Should PPE have been used?i) Was the appropriate PPE used?j) Were users of PPE properly trained in its

use?

• Regular maintenance not carried out at specified time.

(Continued)




Table H.1 (Continued)


3) Environment The incident investigation team should want to understand or identify

If not, why not?

The physical environment, and especially sudden changes to that environment, are factors that should be identified. The situation at the time of the incident is what is important, not what the “usual” conditions were.

a) what the weather conditions were at the time of the incident;

b) if poor housekeeping was a problem;c) if it was too hot or too cold;d) if noise was problem;e) if adequate light was available and

utilized; andf) if there were any toxic or hazardous

gases, dusts, or fumes present.

• Housekeeping procedures not enforced.

4) Personnel factors The investigation team should seek answers about personal factors that could be involved, such as the following:

If not, why not?

During an investigation, it is important to take into account hazards that might arise due to the interaction of people with the other factors. The psychosocial environment in the workplace and its influence on those individuals directly involved in the incident should be explored, but not for the purpose of establishing blame. The investigation will not be complete unless personal characteristics are considered in light of their interactions with the other factors listed in this Table. Some factors will remain essentially constant while others can vary from day to day. Considerations must be made for those that are proximal to the incident, and all other personnel including supervisors and management whose impact might not be as readily apparent.

a) Were the worker(s) physically able to carry out the work?

• List assists equipment that was broken, under maintenance, or otherwise not available.

• Tasks and procedures designed to take in to account different design requirements for different workers at the worksite.

b) Did work procedures adequately take into account worker characteristics and safe exposure limits to identified hazards?

• Regular worker was on holiday, alternate worker not trained prior to regular worker leaving for holiday.

c) Were the worker(s) experienced in the work being done?

d) Had the worker(s) been adequately trained to carry out the specific task(s)?

e) Were the worker(s) physically able to carry out the work?

• The task was designed with improper rest period.

f) Was worker(s) fatigue an issue? • Supervisors prevented worker from taking regular break.

g) Was shiftwork or shiftwork changes a factor?

h) Did the manager in charge of the operation provide required safety equipment for the operation?

• Senior management had not approved funds for the equipment.

i) Were the worker(s) under any undue stress (work or personal)?

• Workers were rushing to meet a deadline.

j) Did the operator follow incorrect safe operating procedures?

• Written safe operating procedures used for training had not been updated when task conditions changed.k) Were safe operating procedures

appropriate to the task and to the worker?

l) Plant management failed to relay important technical information relevant to the operation?

• Plant management unaware of important technical information relevant to the operation due to a communication issue with the corporate office.

(Continued)




Table H.1 (Concluded)


m) Worker did not follow correct shut off procedure?

• OHS information was not presented in language that all workers could understand.

5) Organization The investigation team should ask questions such as the following:

• Supervisor left the worksite for important meeting. Alternate supervisor not assigned.

Deficiencies in organizational processes, procedures or work systems could be factors in an incident. For example, training, safe working practices, rules, and procedures.

a) Were safety rules communicated to and understood by all applicable employees?

b) Were written procedures available to the worker(s)?

c) Were written procedures included in worker safety orientation(s)?

d) Were safety procedures being enforced at the worksite?

e) Was there adequate supervision at the time of the incident?

f) Were workers trained to carry out the work?

g) Had hazards been previously identified and risk assessed at the worksite?

h) Had procedures been developed to eliminate the hazards or control the risk?

i) Was regular and planned maintenance of equipment performed?

j) Were regular safety inspections carried out?

k) Had the workplace health and safety committee or worker representative(s) previously made recommendations relevant to the incident?

l) Had any relevant deficiencies in the OHS management system been reported (if applicable)?

m) Were drawings, manuals, and other relevant documents up to date and applicable to the equipment involved?

Notes: 1) The questions under each category are examples of what could be asked. Each workplace should use them as

a guide for the development of checklists related to their particular workplace or industry, or both. When the answer to any question indicates a safety deficiency, the question “why” should be asked and continue to be asked until all contributing factors have been uncovered.

2) The examples in this Table are designed to ensure that all aspects of the system are taken into consideration for fact finding during the investigation. However it is important to note that in most cases, there is interaction between two or more of the categories used in this Table in the sequence of events leading to an incident and hence in contributing factors which span several or all categories.




Annex I (informative)Sources of incident investigation dataNote: This Annex is not a mandatory part of this Standard.

I.1 General examples of types and sources of dataIncident investigation teams should consider all aspects of the scene when determining the data to collect and analyze. Aspects to consider should include the following:a) the people who carry out the work;b) the work that is being done;c) the organization where the work is being carried out; andd) the environmental characteristics (both the socio-economic environment and the physical

environment).

I.2 Examples of types and sources of dataThe following are some of the main sources of data required for incident investigation:a) statements from witnesses;b) examination and surveys of the scene;c) photographs and videos, including pictures taken by bystanders (see Annex B);d) mechanical or electrical investigations;e) experienced people — these people could be in the workplace (e.g., supervisors, health and safety

committee members, workers or worker representatives, health and safety professionals, engineers) or external to the workplace (e.g., suppliers, manufacturers, testing laboratories, safety associations, injured workers associations, insurance companies);

f) operating manuals, drawings, energy isolation documentation, and instructions — these items can often provide information about recommended procedures for use and maintenance;

g) manufacturers and suppliers — these groups could have knowledge about similar events or could have additional engineering or other data that are not generally part of the operating manual;

h) standards— these items could be workplace standards (such as standard operating procedures or health and safety policies and procedures) or they could be external standards applicable to procedures or equipment in the workplace (CSA, ISO, ANSI, and ASTM are examples of standard- developing bodies);

i) occupational health and safety laws and related regulations;j) previous incident reports. Prior experience in the workplace can suggest other lines of

investigation. First aid records, illness reports, maintenance records, work refusals, regulatory inspections, and safety inspection reports can all be useful in determining possible contributing factors;

k) other documents, records, and reports (e.g., log books, purchasing history, maintenance schedules, and warranty information);

l) oral and written communications;m) media reports;n) work scheduling;o) minutes of workplace health and safety committee meetings if applicable;p) use of simulations or re-enactments;q) employee orientation and training records;r) air sampling; ands) surveillance cameras.

