Incident Investigation Guide-OSHA PDF

Preview

Summary

Download Incident Investigation Guide-OSHA PDF

Description

1

2

3

Preserve/ Document Scene

Collect Information

Determine Root Causes

UnitedStatesDepartmentofLabor OccupationalSafetyandHealthAdministration

4 Implement Corrective Actions

 TABLEOFCONTENTS   PURPOSEOFTHEGUIDE–WHYINVESTIGATE?...............................................................................................1 PRINCIPLESOFINCIDENTINVESTIGATIONS.....................................................................................................1 TheLanguageofIncidentInvestigations..................................................................................................1 InvestigateAllIncidents,Including“CloseCalls”......................................................................................2 InvestigatePrograms,NotBehaviors........................................................................................................3 FocusontheRootCauses,NotBlameorFault.........................................................................................4 ESTABLISHANINCIDENTINVESTIGATIONPROGRAM.........................................................................................4  CONDUCTINCIDENTINVESTIGATIONS–AFOUR‐STEPSYSTEMSAPPROACH..........................................................6 Step1.Preserve/DocumenttheScene.....................................................................................................7 Step2.COLLECTINFORMATION......................................................................................................................8 Step3.DETERMINEROOTCAUSES..................................................................................................................9 Step4.IMPLEMENTCORRECTIVEACTIONS.....................................................................................................10 RESOURCES...........................................................................................................................................12 REFERENCES..........................................................................................................................................14  APPENDIXA:INCIDENTINVESTIGATIONFORM....................................................................................................A‐1 APPENDIXB:INCIDENTINVESTIGATOR’SKIT.......................................................................................................B‐1 APPENDIXC:TIPSFORVIDEO/PHOTODOCUMENTATION......................................................................................C‐1 APPENDIXD:SKETCHTHESCENETECHNIQUES...................................................................................................D‐1 APPENDIXE:COLLECTINFORMATIONCHECKLIST.................................................................................................E‐1 APPENDIXF:SAMPLEQUESTIONSFORIDENTIFYINGINCIDENTROOTCAUSES...........................................................F‐1   D ISCLAIMER: ThisguidewasdevelopedbyOSHA'sDirectorateofTrainingandEducationandisintendedtoassistemployers,workers,andothersasthey strivetoimproveworkplacehealthandsafety.Thisguideisadvisoryinnatureandinformationalincontent.Itisnotanewstandardor regulationanddoesnotcreateanynewlegalobligationsoralterexistingobligationscreatedbyOSHAstandardsorregulationsorthe OccupationalSafetyandHealthActof1970(OSHAct).PursuanttotheOSHAct,employersmustcomplywithsafetyandhealthstandardsand regulationsissuedandenforcedeitherbyOSHAorbyanOSHA‐approvedstateplan.Inaddition,theOSHAct’sGeneralDutyClause,Section 5(a)(1),requiresemployerstoprovidetheirworkerswithaworkplacefreefromrecognizedhazardslikelytocausedeathorseriousphysical harm.Implementationofanincidentinvestigationprograminaccordancewiththisguidecanaidemployersintheireffortstoprovideasafe workplace.



December2015



i

Incident[Accident]Investigations:AGuideforEmployers Yourcompanyexperiencedanincidentthatresulted(oralmostresulted)inaworker injuryorillness…Nowwhat? Asaresponsibleemployer,youneedtoreactquicklytotheincidentwithaprescribed investigationprocedureforfindingtherootcausesandimplementingcorrectiveactions. Quickandplannedactionsdemonstrateyourcompany’scommitmenttothesafetyand healthofyourworkers,andyourwillingnesstoimproveyoursafetyandhealth managementprogramtopreventfutureincidents.

P URPOSEOFTHEGUIDE–W HYINVESTIGATE?  ThepurposeofthisIncidentInvestigation Guideistoprovideemployersasystemsapproachtohelp themidentifyandcontroltheunderlyingorrootcausesofallincidentsinordertopreventtheir recurrence. WHYINVESTIGATE?  Incidentinvestigations TheBureauofLaborStatisticsreportsthatmorethanadozen helpemployers: workersdiedeverydayinAmericanworkplacesin2013,andnearly4  Preventinjuriesand millionAmericanssufferedaseriousworkplaceinjury.Andtensof illnesses thousandsaresickenedordiefromdiseasesresultingfromtheir  Savelives chronicexposurestotoxicsubstancesorstressfulworkplace  Savemoney conditions.Theseeventscausemuchsufferingandgreatfinancial  Demonstrate losstoworkersandtheirfamilies,andalsoresultinsignificantcosts commitmenttohealth toemployersandtosocietyasawhole.Manymore“nearmisses”or andsafety “closecalls”alsohappen;theseareincidentsthatcouldhavecaused  Promotepositive seriousinjuryorillnessbutdidnot,oftenbysheerluck.Practicallyall workplacemorale oftheseharmfulincidentsandclosecallsarepreventable.  Improvemanagement  Allincidents–regardlessofsizeorimpact–needtobeinvestigated.Theprocesshelpsemployerslook beyondwhathappenedtodiscoverwhyithappened.Thisallowsemployerstoidentifyandcorrect shortcomingsintheirsafetyandhealthmanagementprograms.  OSHAcreatedthisGuidetohelpemployersconductworkplaceincidentinvestigationsusingafour‐step systemsapproach.ThisprocessissupportedbyanIncidentInvestigationForm,foundinAppendixA, whichemployerscanusetobesurealldetailsoftheincidentinvestigationarecovered.Additionaltools toassistwiththeinvestigationprocessarefoundinAppendicesBthroughF.

P RINCIPLESOFINCIDENTINVESTIGATIONS TheLanguageofIncidentInvestigations  EmployerswillnoticethisGuideusestheterm“incident”,not“accident”,todescribeaworkplaceevent. Thisisbecausetheword“accident”hascometobeconsideredasarandomeventthat“oh,well,itjust

December2015



1

IncidentInvestigations:AGuideforEmployers happened”andcouldnothavebeenprevented.However,thevastmajorityofharmfulworkplace eventsdonot“justhappen.”Onthecontrary,mostharmfulworkplaceincidentsarewhollypreventable.  Inshort,thebasicprincipleisthatincidentsdonothavetooccur;theycanbepreventedbyaddressing theshortcomingsintheprogramsthatmanagehealthandsafetyintheworkplace.  Thefollowingarethekeytermsthatareusedthroughoutthisguide:  Incident:Awork‐relatedeventinwhichaninjuryorill‐health(regardlessofseverity)orfatality occurred,orcouldhaveoccurred.  RootCauses:Theunderlyingreasonswhyunsafeconditionsexistorifaprocedureorsafetyrule wasnotfollowedinaworkplace.Rootcausesgenerallyreflectmanagement,design,planning, organizationaloroperationalfailings(e.g.,adamagedguardhadnotbeenrepaired;failureto usetheguardwasroutinelyoverlookedbysupervisorstoensurethespeedofproduction).  CloseCall:Anincidentthatcouldhavecausedseriousinjuryorillnessbutdidnot;alsocalleda “nearmiss.” Investigatingaworksiteincident—afatality,injury,illness,orclosecall—providesemployersand workerstheopportunitytoidentifyhazardsintheiroperationsandshortcomingsintheirsafetyand healthprograms.Mostimportantly,itenablesemployersandworkerstoidentifyandimplementthe correctiveactionsnecessarytopreventfutureincidents. Incidentinvestigationsthatfocusonidentifyingandcorrectingrootcauses,notonfindingfaultor blame,alsoimproveworkplacemoraleandincreaseproductivity,bydemonstratinganemployer’s commitmenttoasafeandhealthfulworkplace. InvestigateAllIncidents,Including“CloseCalls”  OSHAstronglyencouragesemployerstoinvestigateallworkplaceincidents—boththosethatcause harmandthe“closecalls”thatcouldhavecausedharmunderslightlydifferentcircumstances. Investigationsareincident‐preventiontoolsandshouldbeanintegralpartofanoccupationalsafetyand healthmanagementprograminaworkplace.Suchaprogramisastructuredwaytoidentifyandcontrol thehazardsinaworkplace,andshouldemphasizecontinualimprovementinhealthandsafety performance.Whendonecorrectly,aneffectiveincident investigationuncoverstherootcausesofthe incidentor‘closecall’thatweretheunderlyingfactors.Mostimportant,investigationscanprevent futureincidentsifappropriateactionsaretakentocorrecttherootcausesdiscoveredbythe investigation.  Effectiveincidentinvestigationsaretherightthingtodo,notonlybecausetheyhelpemployersprevent futureincidents,butbecausetheyhelpemployerstoidentifyhazardsintheirworkplacesand shortcomingsintheirsafetyandhealthmanagementprograms.Investigationsalsosaveemployers money,becauseincidentsarefarmorecostlythanmostpeoplerealize.TheNationalSafetyCouncil estimatesthat,ontheaverage,preventingaworkplaceinjurycansave$39,000,andpreventinga fatalitymorethan$1.4million,nottomentionthesufferingoftheworkersandtheirfamilies.Themore obviousfinancialcostsarethoserelatedtoworkers'compensationclaims,buttheseareonlythedirect

December2015



2

IncidentInvestigations:AGuideforEmployers costsofincidents.Theindirectcostsarelessobvious,butverycommonlygreater,andincludelost production,scheduledelays,increasedadministrativetime(foremergencyresponse,investigations, claimprocessingandothers),lowermorale,trainingofnewortemporarypersonnel,increased absenteeism,anddamagedcustomerrelationsandcorporatereputation. InvestigatePrograms,NotBehaviors  Asstatedpreviously,incidentinvestigationsthatfollowasystemsapproacharebasedontheprinciple thattherootcausesofanincidentcanbetracedbacktofailuresofthe programsthatmanagesafety andhealthintheworkplace.Thisapproachisfundamentallydifferentfromabehavioralsafety approach,whichincorrectlyassumesthatthemajorityofworkplaceincidentsaresimplytheresultof “humanerror”or“behavioral”failures.Underasystemsapproach,onewouldnotconcludethat carelessnessorfailuretofollowaprocedurealonewasthecauseofanincident.Todosofailsto discovertheunderlyingorrootcausesoftheincident,andthereforefailstoidentifythesystemic changesandmeasuresneededtopreventfutureincidents.Whenashortcomingisidentified,itis importanttoaskwhyitexistedandwhyitwasnotpreviouslyaddressed. For example:

  

Ifaprocedureorsafetyrulewasnotfollowed,whywasthe procedureorrulenotfollowed? Didproductionpressuresplayarole,and,ifso,whywere productionpressurespermittedtojeopardizesafety? Wastheprocedureout‐of‐dateorsafetytraininginadequate? Ifso,whyhadtheproblemnotbeenpreviouslyidentified,or,if ithadbeenidentified,whyhaditnotbeenaddressed?

“Onecentralprinciple…isthe needtoconsiderthe organizationalfactorsthat createthepreconditionsfor errorsaswellasthe immediatecauses.” ‐SidneyDekker(2006)

 Asystemsapproachalwayslooksbeyondtheimmediatecausesoftheincident.Ifaworkersuffersan amputationonatablesaw,theinvestigatorwouldaskquestionssuchas:  Wasthemachineadequatelyguarded?Ifnot,whynot?  Wastheguarddamagedornon‐functional?Ifso,whyhadn’titbeenfixed?  Didtheguarddesigngetinthewayofthework?  Hadtheemployeebeentrainedproperlyinthe procedurestodothejobsafely?  Inasystemsapproach,investigationsdonotfocusprimarilyonthebehaviorsoftheworkersclosestto theincidents,butonthefactors[programdeficiencies]thatpromptedsuchbehaviors.Thegoalisto changetheconditionsunderwhichpeopleworkbyeliminatingorreducingthefactorsthatcreate unsafeconditions.Thisistypicallydonebyimplementingadequatebarriersandsafeguardsagainstthe factorsthatcauseunsafeconditionsoractions.  Rootcausesofteninvolvemultipledeficienciesinthesafetyandhealthmanagementprograms.These deficienciesmayexist,forexample,inareassuchasworkplacedesign,culturalandorganizational factors,equipmentmaintenanceandothertechnicalmatters,operatingsystemsandprocedures,

December2015



3

IncidentInvestigations:AGuideforEmployers staffing,supervision,training,andothers.Eliminatingtheimmediate causesislikecuttingweeds,while eliminatingtherootcausesisequivalenttopullingouttherootssothattheweedcannotgrowback. FocusontheRootCauses,NotBlameorFault  Asuccessfulincidentinvestigationmustalwaysfocusondiscovering therootcauses.Ifaninvestigationisfocusedonfinding fault,itwill alwaysstopshortofdiscoveringtherootcauses.Itisessentialto discoverandcorrectallthefactorscontributingtoanincident,which nearlyalwaysinvolveequipment,procedural,training,andothersafety andhealthprogramdeficiencies.

Eliminatingtheimmediate  causesislikecuttingweeds, whileeliminatingtheroot causesisequivalenttopulling  outtherootssothattheweed cannotgrowback.

Addressingunderlyingorrootcausesisnecessarytotrulyunderstand whyanincidentoccurred,todeveloptrulyeffectivecorrectiveactions,andtominimizeoreliminate seriousconsequencesfromsimilarfutureincidents. Moreover,ifaninvestigationisunderstoodtobeasearchfor“someonetoblame,”bothmanagement andlaborwillbereluctanttoparticipateinanopenandforthrightmanner.Workerswillbeafraidof retaliationandmanagementwillbeconcernedaboutrecognizingsystemflawsbecauseofpotential legalandfinancialliabilities.  EffectiveIncident Investigationsthatfocusonidentifyingandcorrectingthereal InvestigationPrograms: underlyingcausesnotonlypreventfutureincidents,butcanalso  Clearlystateeasy‐to‐follow improveworkplacemoraleandproductivity,bydemonstratingan writtenprocedures  Provideforpersonneltobe employer’scommitmenttoasafeandhealthfulworkplace.

E STABLISHANI NCIDENTI NVESTIGATIONP ROGRAM

trainedonincident investigationandcompany procedures Offercollaboration betweenworkers,worker representatives,and management Focusonidentifyingroot cause(s),noton establishingfault Emphasizecorrectingroot cause(s) Implementtimely correctiveactionsbasedon investigationfindings Provideforanannual programreviewtoidentify andcorrectprogram deficienciesandidentify incidenttrends

  Whenaseriousincidentoccursintheworkplace,everyonewillbebusy dealingwiththeemergencyathand.Therefore,itisimportanttobe preparedtoinvestigateincidentsbeforetheyoccur. Anincident  investigationprogramshouldincludeaclearlystated,easy‐to‐follow writtenplantoincludeguidelinesfor:   Howandwhenmanagementistobenotifiedoftheincident   NotifyingOSHA,whichmustcomplywithreporting requirementsthatare: o Allwork‐relatedfatalitieswithin8hours  o Allwork‐relatedinpatienthospitalizations,all amputations,andalllossesofaneyewithin24hours  Whoisauthorizedtonotifyoutsideagencies(i.e.,fire,police, etc.)  Whowillconductinvestigationsandwhattrainingtheyshouldhavereceived  Timetablesforcompletingtheinvestigationanddeveloping/implementingrecommendations  Whowillreceiveinvestigationrecommendations

December2015



4

IncidentInvestigations:AGuideforEmployers 

Whowillberesponsibleforimplementingcorrectiveactions

 Althoughasupervisorsometimesconductsincidentinvestigations,tobemosteffectiveinvestigations shouldbeconductedby ateaminwhichmanagersandemployeesworktogether,sinceeachbrings differentknowledge,understanding,andperspectivestoaninvestigation.Workingtogetherwillalso encourageallpartiesto“own”theconclusionsandrecommendationsandtojointlyensurethat correctiveactionsareimplementedinatimelymanner.  Wheretheincidentinvolvesatemporaryworkerprovidedbyastaffingagency,boththe staffingagency andthehostemployershouldconductanincidentinvestigation.Wheretheincidentinvolvesamulti‐ employerworksite,theincidentinvestigationshouldbesharedwitheachemployerattheworksite.Itis afundamentalprincipalthattemporaryworkersareentitledtothesameprotectionsundertheOSHAct asallothercoveredworkers.Therefore,ifatemporaryworkerisinjuredandthehostemployerknows aboutit,thestaffingagencyshouldbeinformedpromptly,sothestaffingagencyknowsaboutthe hazardsfacingitsworkers.Equally,ifastaffingagencylearnsofaninjury,itshouldinformthehost employerpromptlysothatfutureinjuriesmightbeprevented,andthecaseisrecordedappropriately. Boththehostemployerandstaffingagencyshouldtrackandwherepossible,investigatethecauseof workplaceinjuries.  Aswenowknow,investigationsaretofocusonidentifyingrootcauses,notestablishingfault.Employers canreinforceasystemsapproachbystressingitintheirwrittenprogramaswellastheirinvestigation procedures.Identifyingandcorrectingrootcausesshouldalwaysbethekeyobjective.  

December2015



5

IncidentInvestigations:AGuideforEmployers C ONDUCTINCIDENT INVESTIGATIONS– A FOUR‐STEPS YSTEMSAPPROACH   “Humanerrorisnotthe Oneofthebiggestchallengesfacingtheinvestigatorsisto conclusionofaninvestigation. determinewhatisrelevanttowhathappened,howithappened, Itisthestartingpoint.” andespeciallywhyithappened.Thisinvolvesconductingasystems ‐SidneyDekker(2006) approachincidentinvestigation “Errorsareseenas thatfocusesontherootcauses consequencesratherthan oftheincidenttoreallyhelppreventthemfromhappeningagain. causes”  ‐JamesReason(2000) Thissectionoftheguideassiststheemployertoimplementafour‐ stepapproachtoconductasuccessfulincidentinvestigation.Included isasetofappendicesthatcanserveastoolsforemployerstousewhenconductinginvestigations.They are:  AppendixA:IncidentInvestigationForm–previouslyintroduced;willbeusedtowalkthe employerthroughthefourincidentinvestigationsteps  AppendixB:IncidentInvestigator’sKit–liststheequipmentrecommendedtohavereadyatall timestobepreparedtoconducttheinvestigation  AppendixC:TipsforVideo/PhotoDocumentation  AppendixD:SketchtheSceneTechniques  AppendixE:CollectInformationChecklist  AppendixF:SampleQuestionsforIdentifyingInc...