SAFETY AND HEALTH INCIDENT

INVESTIGATION AND CORRECTIVE ACTION

“THOSE THAT DO NOT LEARN FROM THEIR

MISTAKES, ARE BOUND TO REPEAT THEM”
TOPIC 4
COURSE OBJECTIVES
• To describe the Sections provision in OSHA 1994
• To describe the importance of incident investigation
• To describe principles of investigation
• To describe the steps in incident investigation
1. INVESTIGATION PROVISION IN OSHA
1994
• PART XI - ENFORCEMENT AND INVESTIGATION
• 12 SECTIONS : 39 – 48 (10 SET OF POWERS):
• SECTION 39 – 42: POWER OF ENTRY TO A PREMISE / A SITE /
LOCATION
• SECTION 45 – 45: POWER TO INVESTIGATE AND ASK WITNESS
• SECTIOIN 47: COMMON OFFENCES DURING INVESTIGATION
• SECTION 48: ISSUANCE OF NOTICES
• IMPROVEMENT NOTICE
• PROHIBITION NOTICE
PART XI - ENFORCEMENT AND
INVESTIGATION OSHA 1994
• Section 39. Powers of entry, inspection, examination, seizure, etc.
• Section 40. Entry into premises with search warrant and power of
seizure.
• Section 41. Entry into premises without search warrant and power
of seizure.
• Section 42. Power of forceful entry and service on occupier of signed
copy of list of things seized from premises.
• Section 43. Further provisions in relation to inspection.
• Section 44. Power of investigation.
• Section 45. Power to examine witnesses.
• Section 46. Employer, etc., to assist officer.
• Section 47. Offences in relation to inspection.
• Section 48. Improvement notice and prohibition notice.
10 POWERS FOR DOSH OFFICERS
• Powers of entry, inspection, examination, seizure, etc.
• To enter premises with search warrant and power of seizure.
• To enter premises without search warrant and power of
seizure.
• Forceful entry
• Taking samples.
• Power to investigate.
• Power to examine witnesses.
• Employer or employee to assist officer.
• Offences in relation to inspection.
• To issue Improvement notice and prohibition notice.
SECTION 39. POWERS OF ENTRY,
INSPECTION, EXAMINATION, SEIZURE,
ETC.
• (1) The "officer", means the DOSH officer
• To produce his certificate of authorisation
• enter,
• inspect and
• examine any place of work
• But not a place used solely for residential purposes. However, he
may enter the residential place only with the consent of the
owner!
Section 39. POWERS DURING ENTRY
• (2). Exercise the power to:
• make examination and investigation of any plant, substance,
article or other things
• direct that the place of work or any part be left undisturbed,
for the purpose of any examination or investigation
• take such measurements and photographs and recordings for
the purpose of examination or investigation
• take samples, articles or substance found in the place and the
atmosphere of the place of work;
• require any person employed in which the diseases FMA1967
which has occurred to be examined by a medical officer or a
registered medical practitioner.
Section 39. POWERS DURING ENTRY
• (3) Where a plant or substance is likely to cause a danger to safety and
health, he may –
• (a) dismantled or test
• (b) take possession and detain it for following purposes:
• (i) to examine
• (ii) to ensure it is not tampered
• (iii) to ensure it is available as evidence

• (4) Where an officer is a medical officer he may-

• (a) carry out such medical examination
• (b) exercise other powers

• (5) seek assistance of the police if reasonable cause to apprehend any

obstruction in the execution of his duty.
• (6) an officer may bring with him-
• (a) any other authorised person
• (b) any equipment
Section 40. ENTRY INTO PREMISES
WITH SEARCH WARRANT AND POWER
OF SEIZURE.
• A Magistrate shall issue a warrant to an officer named or referred
• to enter the place of work or residential place
• when there is a case with information and is reasonable for
suspecting an offence commit is committed
• at any reasonable time by day or night
SECTION 41. ENTRY INTO PREMISES
WITHOUT SEARCH WARRANT AND
POWER OF SEIZURE.
• Where an officer is satisfied upon information received and
• has reasonable grounds for believing that,
• by reason of delay in obtaining a search warrant and evidence are
likely to be removed or destroyed,
• he may enter the place of work or residential place without a
warrant and seize or seal the evidence.
SECTION 42. POWER OF FORCEFUL
ENTRY AND SERVICE ON OCCUPIER OF
SIGNED COPY OF LIST OF THINGS
SEIZED FROM PREMISES.
• (1) An officer may if it is necessary;
• break open any outer or inner door of a place of work or residential
place and enter
• forcibly enter the place and every part
• remove by force any obstruction to entry, search, seizure and
removal
• detain every person found in the place until the place has been
searched.

• (2) The officer seizing any articles, things, books, documents, plants,
substances, installation shall:
• prepare a list of the things seized
• deliver a copy of the list signed by him to the occupier,
• post a list of the things seized on the premises.
SECTION 43. FURTHER PROVISIONS IN
RELATION TO INSPECTION.
• (1) Upon entering an officer shall notify the employer and the
SHCo of the entry.
• (2) Upon concluding an inspection, an officer shall give to the
employer and the SHCo information with respect to his
observations and any action proposes.
• (3) When samples taken or remove from a place of work for
the purposes of analysis, he notifies the employer and the
SHCo and where possible-
• divide the sample taken into as many parts as are necessary and
marked, sealed or and fastened
• deliver one part each to the employer or the SHCo if required
• retain one part for future comparison; and
• if an analysis of the sample is to be made, submit another part to
an analyst for analysis.
SECTION 45. POWER TO EXAMINE
WITNESSES.
• (1) May examine orally any person with the facts and circumstances
of the case.
• (2) The person is legally bound to answer all questions only if
• the officer fails or refuses on demand to produce to him the
certificate of authorisation
• there is a tendency to expose him to a criminal charge or penalty
• (3) A person making a statement is legally bound to state the truth
• (4) An officer must inform the person of the subsections (2) and (3)
above.
• (5) A statement made is reduced into writing and signed by him or
affixed with his thumb print, given an opportunity to make any
correction he may wish.
• (6) An officer may use the assistance of an interpreter.
SECTION 46. EMPLOYER, ETC., TO
ASSIST OFFICER.
• Assistance to the officer is by;
• The owner or occupier
• The employer at, any place of work
• The agent or
• Employee of the owner,
SECTION 47. OFFENCES IN RELATION
TO INSPECTION.
• A person who –
• refuses access or to assist
• obstructs, induces or attempts to induce the officer
• fails to produce any document required
• conceals the location or person or any plant or substance from
the officer;
• prevents or attempts other person from assisting the officer;
• (hinders, impedes or opposes the officer
SECTION 48. IMPROVEMENT NOTICE
AND PROHIBITION NOTICE.
• If an officer is of the opinion that a place of work, plant,
substance or process is ;
• likely to be a danger, or
• likely to cause bodily injury
• a serious risk to the health of any person,
• likely to cause damage to any property,
• The officer shall serve an improvement notice requiring the
person to
• take measures to remove the danger
• rectify any defect
• within such period after which it is not be used or operated when
the period expires.
SECTION 48. IMPROVEMENT NOTICE
AND PROHIBITION NOTICE.
• If an officer is of the opinion that the defect in subsection (1)
is;
•
• likely to cause immediate danger to life or property,
•
• The officer shall serve a prohibition notice prohibiting
•
• of the use or operation of the place of work, plant, substance or
process until danger posed is removed
• the defect made good and satisfy the officer.
• .
 WHAT IS ACCIDENT / INCIDENT
INVESTIGATION
• A management tool by which work-related injuries, ill health,
diseases and incidents are systematically studied so that
• their root causes and contributing factors can be identified
• the OSH Management System can be continually improved
• corrective actions as good OSH program and management
system be implementated
4 MAIN AIMS OF AN INVESTIGATION
• An incident investigation shall, as far as possible,
• determine the cause or causes of the incident,
• identify any unsafe conditions, unsafe acts or procedures which
contributed in any manner to the incident and
• recommend corrective action to prevent similar incidents.
• to prevent a recurrence of the same accident.
THE AIM IS NOT TO:
• Exonerate (to declare free from being blame) individuals or
management.

• Satisfy insurance requirements.

• Defend a position for legal argument.

• Or, to assign blame.

INVESTIGATION CONCEPTS
• Why do we investigate accidents?
• Prevent future incidents
• To identify and correct/eliminate unsafe conditions, acts or
procedures
• Reduce costs and down time
• Regulatory requirements
• Process WCB claims
2. FIVE BASIC PRINCIPLES OF
EFFECTIVE ACCIDENT INVESTIGATION
• Accidents are generally rooted in management system flaws
or failures
• All accidents (or at least their outcomes) are preventable
• Investigations must be aimed at identifying root causes
• Proper investigative techniques & tools
• Proper investigative training
WHO SHOULD DO THE INVESTIGATION
• Expert in accident causation: Investigations shall be carried
out by persons knowledgeable about the type of work
involved
• Experienced in investigative techniques and full
knowledgeable of
• work processes
• procedures
• persons and industrial relations environment
• Unbiased/impartial
• Safety Committee member or other investigating bodies
WHOSE ROLES & RESPONSIBILITIES?
• Management / Managers
• Safety Director / Executive
• Safety and Health Committee
• Supervisors
• Task Force
INFORMING DOSH OFFICE (NADOOPOD
2004)
• Every employer shall inform DOSH Office immediately of the
occurrence of any accident which:
• resulted in serious injury to or the death of a worker, or
• involved a major structural failure or collapse of a building,
bridge, tower, crane, hoist, temporary construction support
system, or excavation, or
• involved the major release of a hazardous substance, or
• was an incident required by regulation to be reported.
WHAT TO INVESTIGATE?
• Serious and Major accidents
• usually investigated automatically.
• Minor and Near-Miss
• indicators that point to a condition or practice that, if allowed to
continue, could cause injury or equipment damage.
• Investigations of serious accidents often reveal earlier
incidents of a similar nature that have been dismissed as
insignificant.
WHAT TO DETERMINE DURING
ACCIDENT INVESTIGATION?
• Who - was involved/injured? Witnesses
• Where- did accident happen? exactly
• When - did accident occur? Time, date, activities,
• What - were immediate & basic causes
• Why - was unsafe act/condition permitted
• How - can similar accidents be prevented
ACCIDENT TIME PHASES
• Look at accident in three time phases.

Events leading up to accident. The accident. Immediately afterwards.

3. INVESTIGATION PLANNING &
STRATEGY : SIX STEPS
• STEP 1: Collect Information: Search and gather for establish
facts: On-Site and Off-Site
• STEP 2: Analyze/Determine All Causes: Immediate and Root
causes
• STEP 3: Assess Future Accident Potential
• STEP 4: Develop Corrective Action
• STEP 5: Report data ,review findings and make
recommendations
• STEP 6: Implement/Take Corrective Actions and Monitor
INVESTIGATION STEPS STEP 1

• STEP 1: Collect Information: On-Site and Off-Site

• On-site:
• Securing the scene
• Investigating at the scene
• Recording key information
• Equipment is needed...
• Off-site:
• Interview key people
• Assess past accident history
• Review pertinent records
SECURING THE SCENE STEP 1

• Identify of the individual/person who is in charge and assigns

responsibilities
• Determine the authority to conduct investigation;
• Securing the accident site for the duration of the investigation,
after rescue and damage control are complete
• Gather photographic support or capability
• Follow procedures to ensure observation and recording of
fragile, perishable or transient evidence (instrument readings,
control panel settings, weather & other environmental
conditions, chemical spills, stains, skid marks)
MAKING SCENE OBSERVATION STEP 1

• Visit all accident scenes/locations

• Take/collect samples
• Visual records: for evidence proving
• Preserve accident items: labelled / barracade
• Identify people involved: worker /supervisor /manager /
visitors/vendors
• Interview witnesses: within /outside the scene
• Review information: counter check between observations
/locations
RECORDING KEY INFORMATION STEP 1

• What was the exact/nature of injury or damage ?

• What was the damaging source of energy?
• What event before and immediately preceded the damaging
event ?
• What happened in between ?
• What else was going on at the time of the accident ?
• Was anyone else involved ?
• Interview witnesses
 STEP 1
EQUIPEMENTS & INVESTIGATION KITS
• specimen containers
• camera, film, flash
• magnifying glass
• tape measure
• compass
• clipboard, pad of paper
• danger tags
• pens, pencils • yellow crayon
• A.I. forms • orange flouro spray paint
• Checklist • Torch/flash light
• cassette recorder & spare tapes • with batteries
• Highly vissible barrier tape for scene preservation
• Highly vissible orange vest
• first aid kit • hearing & eye protection
• identification tags for parts • plastic containers for
• gloves (industrial & medical) samples
• safety helmet • roll of paper towelling
INTERVIEWING KEY PEOPLE /
WITNESS STEP 1

• Availability of witnesses: The employer must:

• make every reasonable effort to have available for interview
by the person conducting the investigation, or by an officer of
the SHCo: all witnesses to the incident and any other persons
whose presence might be required for a proper investigation
of the incident.
• Record the names, addresses and telephone numbers of
witnesses and other persons with information
WHO TO INTERVIEW?
STEP 1

• Injured worker
• supervisor
• eye witnesses
• workers on another shift
• new or transferred workers to area
• anyone with information!
MANNER OF CONDUCTING
STEP 1
INTERVIEWS
• Put the person a ease
• they may not see the bigger picture and feel personally
responsible.
• Reassure each person of the investigation’s main purpose.
• Ask person/witness to relate their account of the accident (in
their own words).
• Listen but do not interrupt.
• Do not take notes?
• Do not use a tape recorder?
MANNER OF CONDUCTING
INTERVIEWS (CONTINUED) STEP 1

• Have person relate account again.

• Take notes.
• Ask questions.
• Go over notes with person to ensure accuracy.
• Ask for suggestions to prevent recurrence.
• Thank person for their help.
STEP 2: DETERMINING CAUSES; STEP 2

• The root cause is the most fundamental and direct cause of an

accident or incident
• There may be one or more contributory causes, in addition to
the root cause
• Accident Investigation is ineffective unless all causes are
determined and corrected
ACCIDENT CAUSATION: STEP 2
MUST REMEMBER 3 BASIC FACTS:
• Accidents are caused.
• Unsafe Acts or
• Unsafe Conditions?
• Most accidents have at four or five root causes or factors that
contribute. Often there are more.
• Your task is to identify as many as possible
• Accidents can be prevented by eliminating the causes.
• Unless the causes are eliminated, the same accidents will happen
again.
ACCIDENT CAUSATION STEP 2

• 3 questions to ask, when considering the contributing factors

of an accident.
• What can management do to prevent the incident from
recurring?
• What can the supervisor do to prevent recurrence?
• What can the worker do?
A. ACCIDENT CAUSES –
IMMEDIATE CAUSE ANALYSIS STEP 2

• Human behaviour
• Design of equipment and plant
• Systems & procedures including use of materials
• Environmental Surroundings
B. ACCIDENT CAUSES –
ROOT CAUSE ANALYSIS STEP 2

• Task
• Material/Equipment
• Environment
• Human Factors
• Management (cultural factors)
1. Task STEP 2

• Was a safe work procedure used?

• Had conditions changed to make the normal procedure
unsafe?
• Were the appropriate tools and materials available and used?
• Were safety devices working properly?
2. Materials / Equipment STEP 2

• Was there an equipment failure?

• What caused it to fail?
• Poor design? …. Poor Maintenance?
• Were hazardous materials involved?
• Were they clearly identified?
• Was a less hazardous material possible/available?
• Should PPE has been used?
3. Environment STEP 2

• Weather conditions?
• Housekeeping?
• Temperature?
• Lighting?
• Noise?
• Air contaminants?
4. Human Factors
STEP 2
• Age
• Experience
• Attitude
• Physical condition
• Health status
• Emotional status
C. Accident Causes - Management /
Organizational ANALYSIS STEP 2

• Had hazards been previously identified?

• Were hazards eliminated or adequately controlled?
• Had procedures been developed to address them?
• Were work procedures available/followed?
ANALSYSE THE Core Management STEP 2
Responsibilities:
• Task Structure
• Work organization
• Workplace design/layout
• Equipment availability
• Policies/procedures
• Training program-new & transferred
• Supervision
• New employee screening program
• Management’s example
WHY INSPECTION FAIL?
• Inspection was done by incompetent person
• Inspection did not identify the hazard which could lead to the
accident
• Inspection must have done using outdated checklist
• The result of the inspection was not communicated to the
management
• Lack of management commitment to take necessary action to
implement the control measures identified in the inspection
• Poor employees health and safety culture toward identified
control measures
• The control measures recommended are not enough to
eliminate the hazard
• Poor health and safety culture within the organization
 STEP 3
STEP 3: ASSESS FUTURE POTENTIAL
• Assess Severity:
• Class A Hazard (Major):
• A condition or practice likely to cause permanent disability, loss of life, body part
and/or extensive property loss or damage
• Class B Hazard (Serious):
• A condition or practice likely to cause serious injury or illness
(resulting in temporary disability) or property damage that is
disruptive, but less severe than Class A
• Class C Hazard (Minor):
• A condition or practice likely to cause minor (non-disabling)
injury or illness or non-disruptive property damage
Analyze for Remedies STEP 3

• Identify factors which if modified would eliminate the unsafe

behavior
• Example - in this instance it may be discovered that:
• worker had not been trained in lockout procedures,
• unsafe behavior not corrected in past as supervisors not
adequately trained to correct
• workload means that if lockout device is not readily available,
then it will not be used
ANALYSE Impact and effect of accidents
STEP 3
• On the Victim
• Death
• Pain & suffering
• Permanent disability
• Effects on family & dependents
• Loss of earnings
• Extra expenditure
• Inability to resume occupation
• Psychological effects
• Feeling of uselessness
• Fear of further injury
• Social effects
• Loss of sports or hobby
ANALYSISE Impact and effect of
accidents STEP 3

• 1. On the Victim
• 2. On the Supervisor
• loss of trained worker
• loss of production
• extra work
• investigations & reports
• training new employee
• loss of prestige by:
• management
• other workers
• effects on promotion
• worry (could I have prevented it ?)
• Stress
ANALYSE Impact and effect of accidents
STEP 3
• 1. On the Victim
• 2. On the Supervisor
• 3. On the Company
• loss of trained worker
• loss of production
• damage to machinery
• damage to equipment
• wasted materials
• increased insurance premiums
• prosecutions
• fines
• civil actions
• legal costs
• loss of prestige - customers
ANALYSE Impact and effect of accidents
STEP 3

• 1. On the Victim
• 2. On the Supervisor
• 3. On the Company
• 4. On the Nation
• loss of section of workforce
• loss of production
• increased cost of production
• effects on imports
• effects on exports
• effects on balance of trade
• the community pays !
Evaluating / Analyzing Information STEP 3

• Be objective - don’t start with a fixed opinion.

• Consider all contributing factors.
• Consider what information is direct, circumstantial or hearsay.
• Do not draw conclusion on the first basic cause found.
Key questions:
• why did unsafe behavior occur?
• why did unsafe condition exist?
STEP 4: Correcting the causes STEP 4

• Control(s) must directly address each cause identified

• Consider short term controls if permanent controls are not
readily available
• More than one control may be needed
• Use the “Control Hit List” to make sure that the “best” control
has been found
The Control hit list STEP 4

• 1. Eliminate the Hazard

• 2. Substitute a less hazardous material
• 3. Use Engineering Controls
• 4. Use Administrative Controls
• 5. Personal Protective Equipment (PPE)
• 6. Training of Employees
STEP 5: Report data &
recommendations STEP 5
• Document facts only
• Determine if the corrective action applies to more than one
employee, more than one job function, more than one shift,
etc.
• Prioritize corrective actions based on future accident potential
• Submit both short term and long term solutions, if necessary
 STEP 5
Element of a good report
• Accuracy & completeness of information
• Clarity & completeness of the description of the sequence of
events leading up to the accident
• Correct identification of all causal factors
• Clarity & completeness of all causal factors
• Recommendations made for corrective actions to reduce or
eliminate the probability of recurrence of a similar accident
• Recommendations for corrective actions to improve
management system
• Timelines - specific time periods, monitoring and
responsibilities
• Proper review and sign off
 STEP 5
Incident investigation reports
• The employer shall ensure that an incident investigation
report is prepared containing:
• a) the place, date and time of the incident
• (b) the names and job titles of persons injured
• (c) the names of witnesses
• (d) a brief description of the incident
• (e) a statement of the sequence of events which preceded the
incident,
• (f) identification of any unsafe conditions, acts or procedures
which contributed in any manner to the incident,
• (g) recommended corrective actions to prevent similar
incidents,
• (h) the names of the persons who investigated the incident.
Distribution of reports Follow-up action
and report STEP 5

• Copies of incident investigation reports shall be forwarded

without undue delay to the OH&S Committee and to the
nearest DOSH office.
• Every employer shall initiate corrective action without undue
delay to prevent recurrence of similar incidents
• Prepare a report of the action taken to the Health & Safety
Committee
STEP 6: Take action & monitor
STEP 6

• Ensure that long term solutions don’t get “lost in the shuffle”

• Evaluate the effectiveness of implemented controls:

- Interview Employees
- Job Safety Analysis
- Accident / Incident Experience
Determining Corrective Action STEP 6

• Review training program-analyze to determine flaws

• Review training for supervisors-look at motivation
• Purchase additional lockout devices and issue one set to each
electrician

• GOAL IS TO PREVENT FUTURE INCIDENTS

• often necessitates making fundamental changes
 STEP 6
Investigation Follow Up
• Delegate recommendations for corrective action.
• Publicize the investigation results.
• Copies of reports through usual routings.
• Post action taken as well as any
non-action and reasons.
• Confirm that action has corrected the problem.
Investigation Procedure-Summary
• Visit the scene - secure to minimize risk of further
injury/damage
• Keep scene as undisturbed as possible
• Make accurate record of scene (photos, drawings,
measurements)
• Conduct interviews
• Evaluate evidence, draw conclusions
• Write report with recommendations.
• Follow-up.
Why Accident Investigations fail...
• Lack of time to complete
• Lack of motivation to complete
• Lack of accountability
• Lack of skills & knowledge
• Investigation stopped short and didn’t reveal all causes of the
accident
REMEMBER…..
• Focus on causes NOT on to blame
• This allows management and supervisors to consider failures
in the management system (company’s basic operating
procedures and management/supervisors attitudes), as the
real cause of the accident, rather to simply blame the
“defective worker”.
• Murphy’s Law - “If it can go wrong, it will”
• goal is to minimize consequences of mistakes or unsafe acts