The Dynamics of Incident Reporting and Investigation and .... Scot… · The Dynamics of Incident Reporting and Investigation and Root Cause Dr. W. E. Scott, PhD, MPH, CSP, CIH. November

The Dynamics of Incident Reporting and Investigation and Root Cause

Dr. W. E. Scott, PhD, MPH, CSP, CIH

November 29-30, 2016

National Safety Council

MISSION: The National Safety Council saves lives by preventing injuries and deaths at work, in homes and communities, and on the roads, through leadership, research, education and advocacy.

› Founded in 1913› Partners with business,

government, the public› 15+ years international

service

› More than 51,000 members› Reaching 8.5 million employees› 5,000 Active Volunteers› Nationwide Chapter Network

November 29-30, 20163

Objectives

Incident Reporting

Root Cause Analysis

Incident Investigation


Definitions

• Root cause: Underlying condition/behavior that will, once corrected, prevent similar incidents from occurring

• Direct cause: Condition or behavior that was immediate cause of incident


Safety

The control or elimination of recognized workplace hazards to attain an acceptable level of risk


Hazard

An existing or potential condition in the workplace that, by itself or by interacting with other variables, can result in deaths, injuries, property damage, and other losses


Risk

A measure of the probability and severity of adverse effects


Incident

The term currently used to describe any unplanned event that either results in personal injury or damage to property, equipment, or the environment, or has the potential to result in such consequences


Near-Miss Incidents

Incidents that could result in

injury or loss next time


Accident

A term no longer used by NSC because it implies that causal factors are beyond immediate control or understanding


Direct or Insured Costs

• The tangible, visible costs of an injury or incident


Indirect or Uninsured Costs

• The intangible, more hidden costs of an injury or incident


Root Cause Analysis or Causal Factor Analysis

Analysis that uses experience, logic, and reasoning to determine which conditions or events—if eliminated —will prevent the recurrence of an incident


Fact Versus SuppositionFACT

– Truth, reality, incontrovertible proof

SUPPOSITION– An assumption of truth, a premise, an

hypothesis—but not proof of the truth


Importance of Incident Investigation

1. Legal (OSHA) requirement2. Insurance (workers’ compensation) requirement3. Consequences of not investigating incidents4. Understanding of how incident investigation

leads to improved prevention and safety systems5. Costs of incidents


Heinrich’s Incident Ratios

Disabling Injury or Fatality

Serious Injuries

Minor Injuriesor Near Misses

Hazards

1

29

300

3,000


What to Investigate

1. Incidents involving injury

2. Incidents involving work-related illness

3. Incidents involving property damage

4. “Near-misses”

What to Investigate


Types of Incidents• Injury/illness• Property Damage• Mishaps

– Class A >$200k• 8 hour shutdown• Fatality/Permanent disability

– Class B $100k-$200k• Inpatient hospitalization

– Class C $50k-$100K• >45 LWD• Hazardous Materials Release


The Five W’s of Incident Investigation

• Where?• When?• Who?• What?• Why?

?


What Are We Doing Now?

1. What types of incidents do we investigate now?

2. Disadvantages to investigating only incidents that have caused serious injury or damage?

3. Benefits of investigating near-miss incidents?


Supervisor Roles & Responsibilities

• Training employees on importance of reporting incidents, including near-misses

• Conducting incident investigations to gather facts

• Writing initial incident investigation reports


Emergency Response Planning

• Injuries or life-threatening illnessessuch as heart attacks

• Fires/explosions• Natural disasters• Hazardous chemical spills


What is the Cause?

• Root cause: Underlying condition/behavior that will, once corrected, prevent similar incidents from occurring

• Direct cause: Condition or behavior that was immediate cause of incident


Finding Root CauseRoot Cause

Unsafe: ACTIVITY

ROOTCAUSE

Fatality

Lost Time

Recordable Injury

First Aid Case

Near Miss Property Damage

• Design• Policy• Training• Purchase

End Result or

Consequence

PracticeProcedureOr Condition

• Inspection• Standards• Involvement• Enforcement


Sources for Root Cause

EQUIPMENT

ENVIRONMENTPEOPLE

MANAGEMENT


Problem Solving Approach

• Specify the problem completely• List possible causes• Identify possible root causes• Test to determine if the root causes have

been identified


Analysis• Use of experience, logical reasoning, and

intuitive creativity to bring all the pieces of information from an investigation together

• The results of a careful analysis can lead to identification of the root causes of an incident


Reviewing Paperwork

• First aid reports• Incident investigation report• Supplementary record of occupational

injuries and illnesses• Supervisor’s report• Injury and illness record of employees• OSHA log 300 and 301


Practical Application


An Incident

Office employees routinely stack items on top of file cabinets. Storage space is available, but they prefer to stack items.

When an employee slams a drawer, a stacked item falls and hits the employee. An injury requires five stitches.


Procedure for Incident Investigation

1. Take immediate action, following emergency plan.

2. Secure site.

3. Preserve and document evidence.

4. Identify witnesses.

5. Conduct interviews.

6. Write incident investigation report.

7. Document corrective actions.


1. Take Immediate Action

• Get medical attention.

• Minimize impact of emergency.


Respond Immediately to the Incident

• Provide emergency response• Secure the area• Use an incident investigation kit


Investigation Sources

• The incident scene• Witnesses• Relevant paperwork


2. Secure the Site

• Keep unauthorized personnel out of area until all evidence has been recorded.

• Do not remove anything from area.

• Keep site as it was at time of incident.


3. Document Evidence

• Collect/preserve equipment pieces.

• Photograph from many angles.

• Use coins/other objects to give sense of scale.


Inspecting The Incident Scene• Look at the overall scene. Does anything

seem odd or out of place?• Collect transient or perishable

evidence immediately• Get samples of all possible material

at the site• Find all equipment pieces• Get photos from all sights and angles• Determine the extent of the damage

to equipment, material, or building facilities


4. Identify Witnesses

• Injured employee, anyone in area, and“ear witnesses”

• Eye and “ear” witnesses

• Anyone with knowledge or information


5. Conduct Interviews

• Do so in private.• Use open-ended questions.• Do not interrupt. • Take notes.• Review notes with witness.• Look for facts, not fault.


6. Write Incident Report

• Do so as soon as possible.

• Identify causes.

• Plan root cause abatement.



7. Document Completion of Corrective Actions

• Prevents future injuries

• Complete actions and document

• No completion, more incidents



Implement Recommendations

• Get buy in• Understand the forces supporting and

opposing you• Communicate the recommendations and

the changes they will require• Standardize the changes


Summary

1. Types of incidents to investigate

2. Reasons for investigating all incidents

3. Steps for investigating

4. Identifying and interviewing witnesses

5. Preparing an incident investigation report

6. Completing corrective actions

7. Roles/responsibilities for a supervisor in this facility

Questions

Thank You

[email protected]

Documents

The Dynamics of Incident Reporting and Investigation and .... Scot… · The Dynamics of Incident Reporting and Investigation and Root Cause Dr. W. E. Scott, PhD, MPH, CSP, CIH. November