Lecture notes, lecture 2 supplement notes, Investigate WHS Incidents PDF

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Work Health and Safety Practitioner

Learning Guide

INVESTIGATE OHS/WHS INCIDENTS

January 2013

Department of Commerce Published by WorkSafe, PO Box 294, WEST PERTH WA 6872. E-mail: [email protected]

Original Authors: Bryan Russell and Stephen Lynch Reviewed and updated by: Dr Geoff Dell Protocol Safety Management Pty Ltd, PO Box 2069, Taylors Lakes, Vic 3037 Edited 2012 by Amanda Day

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The SafetyLine Institute material has been prepared and published as part of Western Australia’s contribution to national work health and safety skills development.

www.safetyline.wa.gov.au/institute

© 2013 State of Western Australia. All rights reserved. Details of copyright conditions are published at the SafetyLine Institute website. Before using this publication note should be taken of the Disclaimer, which is published at the SafetyLine Institute website.

Contents OVERVIEW...................................................................................................................... 5 INTRODUCTION ............................................................................................................ 12 ELEMENT 1: ENSURE INITIAL RESPONSES TO THE INCIDENT ARE PROPERLY CARRIED OUT ............................................................................................................................. 19 1.1 Prepare and implement a workplace procedure for incident investigation .20 1.2 Ensure site of the incident is safe and secured and that the immediate needs of those involved in the incident are met ................................................ 23 1.3 Ensure OHS/WHS legislative requirements are met...................................... 27 1.4 Ensure other actions are performed to meet requirements of relevant workplace policies, procedures, processes and systems ..................................... 30 Case Study 1 ....................................................................................................... 42 ELEMENT 2: DEVELOP AN INVESTIGATION PLAN .......................................................... 45 2.1 Apply knowledge of OHS/WHS legislation and workplace policies, procedures and systems to assist with identifying duty holders and ensure requirements of OHS/WHS legislation and workplace policies, procedures, processes and systems are met by the investigation plan .................................. 46 2.2 Form an appropriate investigation team ..................................................... 53 2.3 Define the scope and purpose of the investigation and ensure they are appropriate to the scope and nature of the incident........................................... 57 2.4 Ensure participation of, and consultation with, individuals and parties as part of the planning process and specify agreed participation and consultation processes to occur during all phases of the investigation .................................... 59 2.5 Identify, document and obtain necessary resources to conduct the investigation, including expert advice, if required............................................. 63 2.6 Identify, address and document barriers to investigation ............................ 66 2.7 Ensure planning includes agreed timelines, objectives, responsibilities, roles, documentation, actions and outcomes ..................................................... 73 Case Study 2 ....................................................................................................... 78

ELEMENT 3: COLLECT INFORMATION AND DATA .......................................................... 81 3.1 Identify and access sources of information and data .................................. 81 3.2 Inspect incident site, equipment and other evidence and document outcome of inspection........................................................................................ 85 3.3 Gather information and data in ways that ensure objectivity, confidentiality, validity and accuracy ................................................................ 89 Case Study 3 ..................................................................................................... 104 ELEMENT 4: ANALYSE INFORMATION AND DATA GATHERED TO IDENTIFY IMMEDIATE AND UNDERLYING CAUSES AND PRACTICAL PREVENTION MEASURES .......................... 107 4.1 Ensure the investigation team understands, identifies and applies the conceptual basis for the analysis...................................................................... 108 4.2 Construct timeline of events leading up to incident ................................. 111 4.3 Investigate causative event/s, conditions and circumstances .................... 114 4.4 Develop actions, interventions or measures to prevent the re-occurrence of the incident and to address root causes ........................................................... 120 4.5 Specify recommended actions, interventions or measures and plans for their implementation and evaluation .......................................................................... 122 Case Study 4 ..................................................................................................... 127 ELEMENT 5: COMPILE AND COMMUNICATE INVESTIGATION REPORT ........................... 130 5.1 Prepare a report on the investigation ........................................................ 130 5.2 Phrase report in objective terms and cite evidence and basis for conclusions and recommendations ................................................................... 133 5.3 Communicate the report to individuals and parties as appropriate.............. 139 Case Study 5 ..................................................................................................... 144

OVERVIEW Welcome to the Unit of Competence – Investigate OHS/WHS incidents. ‘OHS/WHS’ and ‘work health and safety’ are used in this guide because following harmonisation of legislation these terms are progressively replacing the use of ‘OHS’ and ‘occupational health and safety’. This unit specifies the outcomes required to participate in the planning, conduct and reporting of incidents which may have resulted in, or have the potential to result in, injury to people or damage to property and equipment. The process of investigating why an incident occurred is part of a systematic approach to managing health and safety. The lessons learned from an incident and recommendations developed as a result will, when properly implemented, contribute to preventing their recurrence in the future. In this way, the investigation of incidents is part of an organisation’s program for continuous improvement. In order to participate effectively in the investigation of incidents, you will need to have an understanding of the features and application of OHS/WHS management systems, especially the concepts and processes for the effective management of risk. The methods described in this learning guide may be applied to straightforward investigations as well as to investigations of complex situations. Similarly, incidents may occur in an organisation of any size and, as such, this guide has application to small, medium or large organisations. The investigation of incidents is a sequential process involving a series of steps. This learning guide takes you through the processes involved in: conducting an initial assessment of the situation; establishing the scope and legal parameters of the investigation; gathering relevant information and data; conducting a systematic analysis of the information gathered; and

reporting on the outcomes of the investigation. The unit of competence consists of five elements and 22 performance criteria, which are reflected in the format of this learning guide. Each section covers a competency element and each sub-section covers a required performance criterion. You can access a copy of the actual competency unit from: www.training.gov.au

How to use this learning guide The learning guide is designed to lead you through each of the elements and performance criteria. It introduces you to the key knowledge and information. Competency checks are listed at the end of each element and a case study is given to show how the knowledge would be applied in practice. The case study builds up through each element to show how the process and knowledge is cumulative. You may use this learning guide as general reading on the topic but if you are using it to develop and demonstrate competency and you plan to be formally assessed you need to be organised. Some suggestions for getting organised are given below. Make sure you have some study space and create a directory on your computer to keep all the material for this unit of competency together. Have a folder for keeping all your hard copy material together, you may wish to put some dividers in the folder. You should begin your studies by printing out the learning guide and associated Readings and Resources from the SafetyLine web site. Now you are ready to tackle the learning guide. 1. Read the Overview. Make notes; use a highlighter; whatever is your way of helping you understand new knowledge.

2. Read the assessment guide so that you have an understanding of what is required of you at the end of your study on this topic. 3. Then start working through each element. Make sure you read and understand the case study for each element. 4. Understanding terminology is a key part of your learning; the glossary will help you here. As you work through the elements and do some extra reading you may wish to expand the glossary with additional words and their definitions. 5. You should also collect any examples of your work that enable you to demonstrate competency in any of the elements or performance criteria. This may be memos, reports you have written, training programs written or delivered, other notes and supporting information that demonstrate the necessary knowledge and understanding. This information should be collated in a folder under the appropriate element and performance criteria. For any key reports, training material, etc you should, where possible, obtain a statement from the workplace that it was your own work or, if you worked in a team, your role in the team and your contribution to the activity. When collecting material, please ensure that you protect the confidentiality of colleagues, workers and other persons, and block out any sensitive information. If you have any doubts about confidentiality issues, contact the organisation concerned. Where possible you should have a OHS/WHS professional as a mentor or coach to assist you to develop the practical skills to apply your knowledge. The case studies in this learning guide will enable your mentor or coach to take you through a workplace example of the whole element to show you how to achieve the performance criteria and apply the required knowledge and skills. The learning guides have been developed to facilitate self-paced and independant learning, but this does not mean you should attempt to learn in isolation. Your learning will be enhanced if you arrange regular contact with a coach, mentor or trainer.

Required readings and resources The on-line Readings and Resources section at the SafetyLine Institute web site provides additional essential material to help you gain the required knowledge for this unit.

Further information Each OHS/WHS jurisdiction in Australia has an Internet site to allow easy access to relevant OHS/WHS legislation and information. In some jurisdictions mining and petroleum safety is administered by a separate government authority, each with its own web site. Other web sites that may be of interest are: www.safeworkaustralia.gov.au – Safe Work Australia: national government work health and safety body www.comcare.gov.au –Commonwealth workplace safety, rehabilitation and compensation Regulator www.amsa.gov.au – Australian Maritime Safety Authority - maritime safety Regulator www.arpansa.gov.au – Australian Radiation Protection and Nuclear Safety Agency - nuclear and radiation safety Regulator www.atsb.gov.au – National Independent Transport Accident Investigator - air safety, rail safety and marine safety investigation www.nopsa.gov.au – national offshore petroleum safety authority - oil and gas safety Regulator www.seacare.gov.au – Seacare Authority Australian seafarer’s work health and safety authority www.austlii.edu.au – Australian Legal Information Institute for Commonwealth, state and territory work health and safety acts and regulations www.standards.com.au – the Australian standards organisation www.saiglobal.com – for copies of Australian and international standards and codes ohs.anu.edu.au – Australian National University’s National Research Centre for OHS Regulation

Other reference material, if desired Kase, D.W. and Wiese, K.J. (1990). Safety Auditing – A Management Tool. New York, John Wiley and Sons. Heilbron, G., et al. (2008) Introducing the Law 6th ed. Sydney, CCH. Standards Australia, AS/NZS 4804:2001. Occupational health and safety management systems – General guidelines on principles, systems and supporting techniques, Sydney, Standards Australia. Taylor, G.A., Easter, K.M., and Hegney, R.P. (2004) Enhancing Safety – A Workplace Guide, Chapter 5 Accident Prevention, Perth, West 1. Hopkins A. (2001) Safety Culture and Risk (CCH). Hopkins A (2002) Lessons from Longford: The Esso Gas Plant Explosion,,CCH. Hopkins A. (1999) Making Safety Work – Getting Management Commitment to OHS; Sydney, Allen & Unwin. Kletz T. (2001), Learning from Accidents, Oxford, ButterworthHeinemann ATSB (2010), Civil and Military Aircraft Accident Procedures for Police Officers and Emergency Services Personnel, Australian Transport Safety Bureau, Canberra, http://www.atsb.gov.au/media/1578568/civil&militaryaccidguide_v5.p df

There are also a range of relevant working papers which may also be of interest to OHS/WHS practitioners at the National Research Centre for OHS Regulation website http://ohs.anu.edu.au/publications/index.php.

Glossary of terms Make sure that you are familiar with the Glossary of terms before going any further. When they are first used, glossary terms are indicated with an asterisk* Causative event

The key event resulting in the particular outcome of injury or damage.

Condition

A permanent workplace situation such as the type of equipment or workplace layout.

Circumstance

A short-term situation which is relatively unusual eg a storm or when a key person is absent.

Hazard

Hazard, in relation to a person, means anything that may result in injury to the person or harm to the health of the person.

Incident

a) Unplanned consequence of events, or a missing or inappropriate response. b) Any occurrence/event arising out of and in the course of employment which results in personal or property damage.

Incident site preservation

In the event of a notifiable incident, it is the responsibility of the person with management or control of the workplace to ensure, so far as is reasonably practicable, that the site (including any plant, substance, structure or thing associated with the incident) is not disturbed until an inspector arrives or otherwise directs.

Investigation

A systematic process of gathering and analysing information to identify the cause(s) of an incident.

Jurisdiction

Geographic area or division of industry or the community in which government has the power and authority to administer and apply certain laws.

SDS

A Safety Data Sheet (SDS) contains critical information about the health effects and appropriate control measures for chemicals used in workplaces.

Near miss

A situation where no one is injured or damaged, but this could have been the case.

Person Conducting a Business or Undertaking

A person conducts a business or undertaking: (a) whether the person conducts the business or undertaking alone or with others; and

(PCBU)

(b) whether or not the business or undertaking is conducted for profit or gain. Plant

Includes any machinery, equipment, appliance, implement or tool and any component, fitting or accessory.

Root Cause

The actions or deficiencies which allowed the direct cause to exist. These are usually the underlying causes of an incident.

Root Cause Analysis

A quality tool applying a multiple “why?” analysis, which is directed at identifying all causes responsible for an incident.

Worker

A person who carries out work in any capacity for a PCBU as: (a) a worker; or (b) a contractor or subcontractor; or (c) a worker of a contractor; or subcontractor; or (d) a worker of a labour hire company who has been assigned to work in the person's business or undertaking; or (e) an outworker; or (f) an apprentice or trainee; or (g) a student gaining work experience; or (h) a volunteer; or (i) a person of a prescribed class. NOTE: A PCBU can also be a worker if they carry out work in the business or undertaking

INTRODUCTION Incidents*, cases of ill health, dangerous occurrences, near misses* and property damage can have high human and financial costs. They can have a significant impact on the lives of individuals and may even threaten the viability of some organisations. It is vital that the person in charge of the business or undertaking (PCBU)* puts in place arrangements to identify, record and investigate incidents that occur. In the case of larger organisations these arrangements should be documented as procedures and policies which are integral to the organisation’s health and safety management system. Smaller organisations may need to engage the services of an experienced investigator to assist with their investigations* to ensure all the lessons are learned and corrective actions identified. The purpose of investigating workplace incidents is to ascertain both the immediate and underlying causes and to put in place measures to prevent a re-occurrence. The process of investigation involves a systematic examination of the circumstances* of the incident, the workplace, activities taking place at the time, plant* and equipment in use at the time, and any supporting materials such as existing risk assessment and control standards as well as legal obligations. Incidents need to be examined in sufficient detail so that immediate causes and the underlying failures of systems for managing health and safety have been identified. This process may result in the need for immediate remedial action as well as longer-term changes. The type and depth of any investigation that you undertake will be guided by the significance of the incident. An important consideration is not only the actual consequences of the incident but also the potential outcome. A “near miss” by way of example may not result in any injury or damage. However, if that near miss had the potential to injure people severely or damage property significantly, then a detailed investigation would be warranted. The information outlined in this learning guide is based on the need to conduct an investigation into a significant workplace incident. The principles outlined may also be applied to the investigation of more minor incidents.

Background A good understanding of laws applicable to work health and safety (OHS/WHS) is important to participate effectively in the investigation of workplace incidents.

Commonwealth, state and territory legislation Because Australia is a federation, OHS/WHS is the responsibility of the states and territories. However, Commonwealth law covers the OHS/WHS of Commonwealth workers* and certain categories of workers, such as those on Australian registered ships and on offshore drilling rigs in Commonwealth controlled areas. In some states OHS/WHS law is divided further into coverage of mining operations and mineral processing plants, petroleum facilities and other workplaces, with in some ...