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HAZARDOUS OCCURRENCE INVESTIGATORS COURSE _HOIC_ Participants Manual

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					                A-GG-040-010/PT-001




   HAZARDOUS
  OCCURRENCE
 INVESTIGATORS
    COURSE
     (HOIC)




Participants Manual
        09/10
A-GG-040-010/PT-001
Hazardous Occurrence Investigators Course




                                            D Safe G Intranet Website Address

                                            http://vcds.mil.ca/dsafeg/intro_e.asp



                                            D Safe G Internet Website Address

                                   http://www.vcds-vcemd.forces.gc.ca/dsafeg-dsg/index-
                                                        eng.asp
                                     A-GG-040-010/PT-001
                   Hazardous Occurrence Investigators Course




                            Preface


This manual has been developed in order to explain the steps
and methods required to undertake detailed Hazardous
Occurrence Investigations in your workplace.

DND/CF policy requires that all hazardous occurrences which
happen in the workplace be investigated and reported. The
tools and techniques outlined in this manual should act as a
guide to be followed when conducting hazardous occurrence
investigations.

The steps of the investigation are grouped in five phases, from
the preparation phase, gathering of evidence, interviewing,
evaluation of facts and the analysis, and finally to identifying
recommendations for prevention.

The change analysis method of investigating hazardous
occurrences presented in this manual allows for identifying
cause factors for almost all hazardous occurrences resulting in
injuries, illness, disabilities, death, or strictly material and
environmental damages occurring in organizations under
DND/CF jurisdiction.



                  Acknowledgements

   We would like to acknowledge and thank Human
   Resources and Social Development Canada – Labour
   Program and the Air Force Safety Center for allowing the
   use of their training materials and concepts in the
   development of this training program.




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     Module 1

Course Introduction
                                     A-GG-040-010/PT-001
                   Hazardous Occurrence Investigators Course




                           Introduction
   This course is provided to personnel appointed to conduct
   Hazardous Occurrence Investigations in DND/CF
   organizations.

   It outlines a detailed framework for the investigation,
   analysis and report writing requirements of Hazardous
   Occurrence Investigations and allows the participants to
   practice the learning objectives.

   General Safety Officers, Workplace Health and Safety
   Committee members, managers and other workplace
   parties will all benefit from this course. Upon completion
   personnel will be considered as “qualified” only after they
   have undertaken three HOIs in their workplace.

   This course may also be offered to more experienced
   investigators as a refresher of the principles and techniques
   of hazardous occurrence investigations and the
   establishment of effective OHS prevention programs.



Welcome
Instructor Introductions

Participant Introductions



   Course Objectives:
       Understand the duties & responsibilities to undertake
       Hazardous Occurrence Investigations (HOI) in the
       workplace

       Define the purpose of Hazardous Occurrence
       Investigations




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                                      Outline the steps in conducting effective Hazardous
                                      Occurrence Investigations

                                      Learn the Change Analysis causation process

                                      Develop professional interviewing skills

                                      Understand the importance and techniques for
                                      gathering evidence

                                      Learn HOI report writing techniques

                                      Discuss the protocols for making recommendations


                              INTRODUCTION

                              Hazardous Occurrences are investigated for various reasons:

                                  •   to determine the factors that contributed to the
                                      occurrence;
                                  •   to identify previously unknown hazards;
                                  •   to make recommendations to prevent recurrences; and
                                  •   to meet regulatory investigation and reporting
                                      requirements.

                              Within DND and the CF hazardous occurrence investigations
                              are primarily conducted to find out what happened and why, in
                              order that steps can be taken to prevent a recurrence.

                              Ideally, an investigation would be conducted by someone
                              expert in accident investigation techniques, fully
                              knowledgeable of accident causation, experienced in the work
                              processes, procedures, personnel, and industrial relations
                              environment of the environment of the particular situation.
                              Unfortunately, such people are hard to find. Especially in
                              smaller units, where both workers and supervisors with little, if
                              any, previous investigative experience may be called upon to
                              participate in an investigation or an inquiry.




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TRAINING OBJECTIVES
The Hazardous Occurrence Investigation Course was
developed in order to train personnel appointed by
Base/Wing/ASU Commanders to conduct hazardous
occurrence investigations. Once graduated and with
experience, these trained personnel will be considered as
qualified personnel to investigate accidents and incidents.

Possession of this specialty will qualify personnel to conduct a
Hazardous Occurrence Investigation and to write the required
report drawing suitable recommendations to prevent future
occurrences. This course will assist Commanders and
Managers in complying with the requirements of the Canada
Labour Code, Part II and the General Safety Program.


PERSONNEL SELECTION
REQUIREMENTS

Personnel must be tasked to conduct Hazardous Occurrence
Investigation on behalf of their Base/Wing/Unit to be selected
for this specialty.


METHOD OF QUALIFICATION
      Initial Qualification and Certification

Personnel shall be awarded the qualification and certification
upon successful completion of the HOIC and validation by the
B/WGSO after experience of conducting three hazardous
occurrence investigations.

                   Loss of Certification

Re-certification will be necessary after five years have elapsed
from the date of the trained investigator having completed
his/her last Hazardous Occurrence Investigation.



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                                                    Re-certification

                              Certification may be re-achieved after successful completion of
                              a formal course.

                                                     Prerequisites

                              Must have GSOTC or SMC


                              SPECIALTY REQUIREMENTS FOR
                              INVESTIGATORS
                              .

                              Skill

                              Must be skilled at:

                                  •   Taking charge of and securing the accident scene;

                                  •   Conducting witness interviews in a professional fact-
                                      finding manner;

                                  •   Gathering evidence and reviewing records to assist fact
                                      finding;

                                  •   Selecting correct accident causation model as
                                      framework to assist in conducting the investigation and

                                  •   Writing the Hazardous Occurrence Report with
                                      recommendations.

                              Must be semi-skilled at:

                                  •   Taking photographs, video, measurements and drawing
                                      sketches.




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Knowledge

Must have detailed knowledge of:

   •   The General Safety Program’s Hazardous Occurrence
       Investigation and Reporting Policy Procedures;

   •   Contents of the Hazardous Occurrence Data Collection
       Form

   •   The CLC Pt. II and Treasury Board requirements for
       Hazardous Occurrence Reporting.

   •   Pertinent definitions;

   •   Roles and responsibilities of Hazardous Occurrence
       investigators;

   •   Techniques of gathering and collecting physical
       evidence;

   •   Procedures to evaluate the relevancy of corrective and
       preventative action adopted by the employer;

   •   Chain of custody.

Must have basic knowledge of:

   •   The more common accident causation theories and root
       cause analysis techniques;

   •   Witness interviewing techniques;

   •   Accident investigation’s four phases;

   •   Guiding principles and basic rules in conducting a
       Hazardous Occurrence Investigation;

   •   Know where the investigation fits in with other
       investigations;

   •   Internal and external sources of technical expertise to
       assist investigators;




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                                     HAZARDOUS OCCURRENCE INVESTIGATOR COURSE SCHEDULE

                                 DAY 1                                   DAY 2                                  DAY 3                                    DAY 4
08H00/08H30                     ADM                                 REVIEW DAY 1                           REVIEW DAY 2                             REVIEW DAY 3
                           Introduction/Welcome                                                            Gathering / Recording                   Practical Learning exercise




                                                                                                                                     MODULE 10
08H30/09H15                                                          Accident causation
              MODULE 1




                                                       MODULE 5




                                                                                              MODULE 7
                              Course Overview                                                               Physical Evidence                     Introduction/ Report Format

                                                                   Learning exercise video                 Gathering / Recording                  Learning exercise continued
09H15/10H00                How did we Get Here?
                                                                   So it won’t happen again                 Physical Evidence                         Investigation Steps
                                                                         1 0 H 0 0 À 1 0 H 1 5 BREAK

                            GENERAL SAFETY                         Learning exercise video                 Gathering / Recording                  Learning exercise continued




                                                                                                                                     MODULE 10
10H15/11H00
              MODULE 2




                                                       MODULE 6




                                                                                              MODULE 7
                                 PROGRAM                                 continued                          Physical Evidence                         Interviews/Sketch
                           Hazardous Occurrence
                         investigation and reporting                Steps in the hazardous                   Learning exercise                        Learning exercise
11H00/12H00
                                requirements                       occurrence investigation                       Sketch                            Investigation/Analysis
                                                                        12H00 À 13H00 LUNCH
                          Overview of Hazardous
                                                                       Key steps in an                         Interviewing &                          Learning exercise




                                                                                                                                     MODULE 10
13H00/13H45               Occurrence investigation
              MODULE 3




                                                       MODULE 6




                                                                                              MODULE 8
                                                                        investigation                      Information Gathering                         Presentation
                                 methods
                             Learning exercise                                                               Learning exercise                         Learning exercise
13H45/14H30                                                           Preparatory phase
                            You be the witness!                                                            Interview techniques                          Presentation
                                                                         1 4 H 3 0 À 1 4 H 4 5 BREAK
                                                                                                          Analysis of the Findings
                            Concept of the work                                                                                                        Learning exercise




                                                                                                                                     MODULE 10
14H45/15H00                                                        Investigative Techniques                        Video
              MODULE 4




                                                       MODULE 6




                                                                                              MODULE 9

                            organization system                                                                                                          Presentation
                                                                                                             The Big picture
                             Learning exercise                        Learning exercise                      Learning exercise
15H00/15H45                                                                                                                                                  ADM
                                                                       Communication                            Logic Tree
15H45/16H00              CONCLUSION DAY 1                         CONCLUSION DAY 2                       CONCLUSION DAY 3                        CONCLUSION COURSE




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                              THE LAW
                              Occupational health & safety in areas of Federal jurisdiction is
                              governed by Part II of the Canada Labour Code and the
                              Canada Occupational Health and Safety Regulations.

                              The purpose of Part II of the Canada Labour Code is to prevent
                              accidents and injury to health arising out of, linked with or
                              occurring in the course of employment.

                              It is important to know what needs to be done in the event of
                              an accident or occupational disease. Once the injured or
                              endangered parties have been looked after an investigation
                              including the completion of the required paperwork for
                              reporting must be completed.

                              All accidents, occupational diseases and other hazardous
                              occurrences affecting any of the employer’s employees must
                              be investigated by a qualified person.

                              Part XV of the Canada Occupational Health and Safety
                              Regulations requires that employees report to the employer
                              every accident or hazardous occurrence in the course of work
                              that has or is likely to cause an injury. It also requires that
                              every accident, occupational disease and other hazardous
                              occurrence be investigated without delay.

                              An investigation is required for all occurrences listed in
                              Section 127 of Part II and Section 15.5 of the Canada
                              Occupational Health and Safety Regulations.

                              As soon as possible after learning of the occurrence the
                              employer must:

                                  •   Act to ensure that the occurrence does not happen
                                      again;

                                  •   Appoint a qualified person to carry out an
                                      investigation;

                                  •   Notify the Workplace Health and Safety Committee or
                                      representative of the occurrence and the name of the
                                      investigator.
                              If the hazardous occurrence was a motor vehicle accident on a
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public road, the employer will investigate by obtaining all
police reports where the police investigated the matter. If there
is no police report, the employer must still investigate.

In all cases, a copy of the investigation report must be given to
the Workplace Health and Safety Committee or the Health and
Safety representative.

Employers under Federal jurisdiction must report to a safety
officer of Human Resources and Social Development Canada
(HRSDC) Labour Program, as soon as possible, but no later
than 24 hours after learning that a hazardous occurrence has
resulted in:

   •   The death of an employee;
   •   A disabling injury to two or more employees;
   •   The loss by an employee of a body member or part
       thereof or in the complete loss of the usefulness of a
       body member;
   •   The permanent impairment of a body function of an
       employee;
   •   An explosion;
   •   Damage to a boiler or pressure vessel; or
   •   Any damage to an elevating device that renders it
       unserviceable, or a free fall of an elevating device.

Investigations may be conducted for occurrences listed in s.
15.8 of the COHSR, or the appropriate regulatory provisions of
the extended jurisdiction, and for occurrences affecting or
likely to affect employees’ health and safety.

   •   a disabling injury to an employee;

   •   an electric shock, toxic atmosphere or oxygen deficient
       atmosphere that caused an employee to lose
       consciousness;

   •   the implementation of rescue, revival or other similar
       emergency procedures; or

   •   a fire or an explosion.



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            Module 2

  General Safety Program
  Hazardous Occurrence
Investigation and Reporting
       Requirements




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                                Extract from A-GG-040-001/AG-001, General Safety Program,
                                                   Policy and Program

                                                         CHAPTER 4


                                           HAZARDOUS OCCURRENCE
                                    INVESTIGATION, REPORTING AND ANALYSIS


                                     SECTION 1- POLICY AND RESPONSIBILITIES


                              PURPOSE

                              1.     This chapter prescribes the procedures for the investigation,
                              reporting and analysis of hazardous occurrences.

                              POLICY

                              2.      It is DND/CF policy that all hazardous occurrences are
                              investigated to determine cause and recommendations made to
                              prevent recurrences.

                              AIM

                              3.      The overall aim of hazardous occurrence investigation is to
                              prevent recurrence, identify previously unknown hazards, help
                              formulate preventive measures and meet regulatory investigative and
                              reporting requirements.


                              4.      Nearly every hazardous occurrence is preventable, making a
                              formal process to determine why and how it occurred, key to
                              preventing it happening again. Every hazardous occurrence is an
                              opportunity to learn and use this knowledge to prevent future
                              occurrences with their associated human and financial costs. This is
                              accomplished by:

                                  a. determining all causes;
                                  b. determining the potential for and/or extent of
                                     injury to personnel and damage to property;
                                  c. recommending corrective action;
                                  d. communicating lessons learned; and
                                  e. assisting responsible authorities in deciding the
                                     allocation of safety resources.


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DEFINITIONS

5.     The following definitions are used within the General Safety
Program:

    a. Hazardous Occurrence. Is an undesirable event
      which results in (or has the potential to result in)
       injury or illness to personnel, material losses
       and/or property damage and includes the
       following terms:

       i. Accident. An undesired event that results in
          physical harm or occupational illness to a
          person or damage to materiel, works or
          buildings;

       ii. Incident. An undesired event that could but
           does not result in physical harm or
           occupational illness to a person, or damage to
           materiel, works or buildings;


   b. Work Injury. Any injury or occupational
      illness including work related sports injuries
      suffered by an employee in the course of
      employment;

    c. Disabling Injury. A work related illness or
       injury which prevents the employee from
       returning to work or effectively performing all
       the duties connected with his or her regular work
       on any working day subsequent to the day on
       which the injury occurred, or results in the loss of
       a body member or part thereof or in the
       permanent impairment of a body function;

    d. Non-disabling Injury. A work related illness or
       injury which results in medical attention beyond
       first aid, but involves no lost time beyond the day,
       shift or watch on which the injury occurred;

   e. First Aid. Treatments of a minor scratch, cut,
      burn, etc., which does not result in subsequent
      medical attention by a physician. It does not
      include suturing or use of specialized equipment
      or use of prescription medicines;



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                                  f. Days Lost. The number of days a person should
                                     have worked at his/her normal duties but could not
                                     because of work related illness or injury including
                                     work related sports injuries. (The day of the work
                                     injury and the day the injured person resumes
                                     normal duties are not included.) Days lost are
                                     further categorized as days off duty or off work
                                     when the individual remains absent from the
                                     workplace or days on light duties or modified
                                     duties when the individual is present at the
                                     workplace but not able to carry out all of their
                                     normal duties. Civilian personnel back to the
                                     workplace under the Return To Work Program are
                                     categorized as on modified duties; and

                                  g. DND 663. DND/CF form used for recording
                                     hazardous occurrences. Its official title is
                                     DND/CF General Safety Hazardous Occurrence
                                     Investigation Report.

                                                               NOTE

                                    I. Disabling injury is defined differently by HRSDC.
                              HRSDC’s definition does not include the words “working day”. The
                              DND/CF definition is necessitated by the Human Resource
                              Management System (HRMS) Health and Safety Module (H&S
                              Module).

                                       II. Combat casualties are not included in the definition of
                              Hazardous Occurrence for the General Safety program and are not
                              investigated by the General Safety Program nor reported by DND
                              663. However a record can be created in the HRMS H&S Module
                              for information purposes.

                              SCOPE

                              6.     While this Chapter primarily refers to the General Safety
                              Program, in the absence of specialised safety resources and
                              procedures, hazardous occurrence investigations may be required as
                              deemed necessary for occurrences normally falling under the
                              purview of specialized safety programs such as:


                                      -     Flight Safety
                                      -     Nuclear and Radiation Safety
                                      -     Fire Protection Service
                                      -     Mobile Support Equipment Safety
                                      -     Explosives Safety

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        -   Occupational Health and the Provision
            of a Healthy Work Environment
        -   Laser Safety
        -   Range and Training Area Safety
        -   Health and Safety Issues related to the
            Environment
        -   Radio Frequency Radiation Safety
        -   Diving Safety
        -   Submarine Safety

7.       Regardless of the source of the investigation, occurrences
that result in injuries or illnesses are additionally reported to the
General Safety Program. This ensures that a record of the injuries or
occupational illnesses is included in the national database for DND
and CF personnel. Also, the DND 663 General Safety Hazardous
Occurrence Investigation Report is the only form acceptable to
HRSDC-Labour to meet the Public Service reporting requirements
of the Canada Labour Code

RESPONSIBILITIES

8.      The Group Principal of a Group or Commander of each
command, area, formation, base, wing or unit shall ensure that all
workplace related hazardous occurrences are investigated and
reported. Coordination of these requirements normally falls within
the purview of the GSO.

9.      Commanding Officers shall ensure that procedures are put in
place to ensure the investigator’s report is entered into the H&S
Module of the HRMS. This system is the database for reporting
hazardous occurrences.

10.      Any individual involved in, witnessing or knowledgeable of
a hazardous occurrence shall report the circumstances that he/she is
aware of or witnessed to his/her supervisor. It is the responsibility of
the supervisor to report all injuries, including sports injuries,
occurring to his/her personnel or damage to materiel under his/her
control in accordance with Section 3.




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                                        SECTION 2 - HAZARDOUS OCCURRENCE
                                                   INVESTIGATION

                                                           GENERAL

                              11.     Every hazardous occurrence is an indication that a failure in
                              processes, practices, procedures and/or a material defect has gone
                              undetected or uncorrected. Hazardous occurrence investigation, like
                              crime detection or medical diagnosis, entails a search for these
                              unknowns. All factors must be uncovered and evaluated to correctly
                              determine what happened and why it happened. The investigation
                              need not be complicated, although the investigator should have the
                              following qualifications and exercise the following principles to
                              achieve the desired results:

                                  a. be familiar with the equipment, its operation and
                                     the procedures involved;
                                  b. understand the type of condition or situation likely
                                     to produce hazardous occurrences;
                                  c. collect the facts, weigh the value of each and reach
                                     a conclusion based on the evidence;
                                  d. explore all factors, however remote;
                                  e. consider unsafe conditions as well as personnel
                                     actions/inactions;
                                  f. recommend effective corrective measures; and
                                  g. communicate lessons learned.

                              12.      The degree of investigation and recording of hazardous
                              occurrences should be based upon the potential for damage or injury.
                              This can normally be determined by an initial examination of the
                              circumstances. A comprehensive investigation will provide a
                              number of recommendations which will assist management in
                              identifying these problem areas, determining priorities,
                              implementing corrective measures and communicating lessons
                              learned. The investigation is not limited to the prevention of
                              identical hazardous occurrences. Rarely do their components
                              reproduce themselves exactly. The investigation must ascertain what
                              action can be taken to decrease the probability of hazardous
                              occurrences of the same type recurring.

                              13.      A hazardous occurrence investigation report shall not be
                              used for disciplinary purposes. It must be emphasized that to
                              successfully determine causes and contributing factors,
                              investigations must be directed toward fact finding for prevention,
                              not fault finding for punishment. Other types of investigations, as
                              noted in para 18 and 19, fulfil these functions.


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14.     Hazardous Occurrence Investigation Reports and the
investigation data are accessible under the access to information
requirements.


        HAZARDOUS OCCURRENCE INVESTIGATIONS

15.     Detailed information on conducting a hazardous occurrence
investigation is found in A-GG-040-010/AG-010, A DND/CF
Hazardous Occurrence Investigator’s Guide and a simple accident
causation model, which may be used by investigators, is found in A-
GG-040-003/AG-001, General Safety Training Manual, Chap 6,
Annex C.

RECOMMENDATIONS

16.     Once the cause factors have been identified, the
investigator(s) recommend(s) preventive measures based on the
findings of the investigation. The basic aims when developing
preventive measures are as follows:

    a. treat the cause and not the effect;
    b. ensure preventive measures eliminate or control
       all causes; and
    c. communicate lessons learned.

PREVENTIVE ACTION

17.      Preventive action should be implemented at the lowest
appropriate level in the organization. Action must be prompt and
thorough, otherwise the investigation will be largely wasted. It is
vital that managers/supervisors:

   a. consider all recommendations and promptly
      incorporate those adopted;
   b. fully explain why recommendations are rejected;
   c. fully explain why action is delayed; and
   d. inspect other areas under their jurisdiction for
      similar unsatisfactory conditions or performance.

OTHER INVESTIGATIONS

18.     In addition to investigations conducted in accordance with
this publication, collateral investigations may be carried out for
pension, compensation or even disciplinary purposes. There could
be a Board of Inquiry or a Summary Investigation ordered by the
Commander in accordance with DAOD 7002. The hazardous

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                              occurrence investigation and associated General Safety Hazardous
                              Occurrence Investigation Report are not to be used for these
                              purposes. However, it must be remembered that the hazardous
                              occurrence reports required in Section 3 are to be completed even
                              when a Board of Inquiry or Summary Investigation has been
                              ordered.

                              19.     HRSDC-Labour, civilian and/or military police may conduct
                              separate investigations into civilian employee work related
                              hazardous occurrences.


                                SECTION 3 - HAZARDOUS OCCURRENCE REPORTING

                                                           GENERAL

                              20.     Hazardous occurrence reports focus the attention of all
                              concerned on the circumstances which could lead to or have resulted
                              in hazardous occurrence injury, death, or workplace related illness to
                              personnel or damage to materiel. By identifying these circumstances
                              or shortcomings in the system, appropriate preventive measures can
                              be implemented.

                              21.      Within DND/CF hazardous occurrences may be minor or
                              serious. Those that are minor are investigated, corrective action
                              taken, and entered into the HRMS H & S Module. Those that are
                              serious as defined by the Canada Occupational Health and Safety
                              Regulations, Part XV, Hazardous Occurrence Investigation,
                              Recording and Reporting or significant as outlined in DAOD 2008-
                              3, Issue and Crisis Management must be reported to superior
                              headquarters and/or to HRSDC- Labour as well as being entered into
                              the HRMS H & S Module.

                                  HRMS H & S MODULE REPORTING REQUIREMENTS


                              22.     The Hazardous Occurrence Investigation Report Form, DND
                              663, has been designed to provide:

                                  a. a means of dealing effectively with hazardous
                                     occurrences that adversely affect DND/CF
                                     resources;
                                  b. a means of obtaining statistical data for hazardous
                                     occurrence prevention analysis (see Annex A,
                                      Statistics and Analysis); and

                                  c. information to comply with the applicable
                                     regulatory requirements.

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23.      A form DND 663, or in certain cases an authorized
substitute (the form is also available as a MS Word template), shall
be completed for all workplace hazardous occurrences resulting in:

   a. death;
   b. disabling injury;
   c. non-disabling injury;
   d. a loss of consciousness due to exposure to any
      oxygen deficient or toxic atmosphere or an
      electric shock;
   e. the implementation of rescue, revival or other
       similar emergency procedures;
   f. an occurrence which results in a fire or explosion;
      or
   g. an occurrence which results in material or
       property damage and had the potential to kill or
      seriously injure someone.

24.     In addition to the mandatory investigation requirements as
noted in para 23, units are urged to investigate the following:

   a. hazardous occurrences that caused property
     damage but did not have the potential to kill or
     seriously injure someone;
   b. incidents that did not injure someone, but had the
       potential to do so; and
    c. incidents that did not cause material damage, but
       had the potential to do so.

25.      Hazardous occurrence investigations by a specialist safety
program need only include in the investigator’s section of the DND
663 that the hazardous occurrence is being investigated by that
program and a reference number included if available. The DND
663 will capture the information on the injuries and the associated
lost time. A separate general safety investigation may not be deemed
necessary. In addition, for a death or disabling injury to civilian
personnel, the DND 663 is used to report the occurrence to HRSDC
and therefore must be completely filled in.

26.     Integral units are to immediately inform the Base/Wing GSO
of any death or serious hazardous occurrence. Lodger units are to
inform their Command/Group Principal GSO and the Base/Wing
GSO of their host base.




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                              27.     When a hazardous occurrence occurs to a person in transit,
                              the individual involved shall report the hazardous occurrence as soon
                              as possible:

                                  a. to the unit at which they first arrive; or
                                  b. if they are unable to continue their journey, to the
                                     nearest DND establishment.

                              28.     When a person on temporary duty (including deployed
                              operations), is involved in a hazardous occurrence, a DND 663
                              Hazardous Occurrence Investigation Report Form shall be completed
                              and distributed by the host unit, and an information copy shall be
                              forwarded to the parent unit.

                              29.      A unit to which an in-transit hazardous occurrence is
                              reported shall investigate the hazardous occurrence and initiate a
                              DND 663. A copy of the report shall be forwarded to the parent unit
                              for entry into the HRMS H &S Module.

                                  HRSDC – LABOUR REPORTING REQUIREMENTS

                              30.     HRSDC–Labour will be informed of any hazardous
                              occurrence which results in:

                                  a. death to a civilian employee;
                                  b. disabling injuries to two or more civilian
                                      employees;
                                  c. the loss by an employee of a body member or part
                                      thereof or the complete loss of the usefulness of
                                      the body member or part thereof;
                                  d. the permanent impairment of a body function of a
                                      civilian employee;
                                  e. an explosion;
                                  f. damage to a boiler or pressure vessel that results
                                     in fire or the rupture of the boiler or pressure
                                     vessel; or
                                  g. any damage to an elevating device that renders it
                                     unserviceable, or a fall of an elevating device.

                              31.     The hazardous occurrences listed in para 30 will be reported
                              by the GSO as soon as possible but no later than 24 hours by
                              telephone or facsimile (Fax) to the appropriate HRSDC-Labour
                              Regional Director (see Chapter 6, Annex A for address). For DND
                              federal public servants employed on regular duties at a place of work
                              outside Canada, the report shall be made to the Capital Regional
                              Office in Ottawa.




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32.      The message outlining the date, time, location and nature of
the occurrence must not be delayed for lack of detail. If it is
incomplete, relevant information is to be submitted within three days
by a follow-up message. It should include:

    a. additional details; and
    b. the status of the investigation.

             NDHQ REPORTING REQUIREMENTS
33.   Significant Incident Reports (SIRs) will be forwarded to
NDHQ NDOC as required by DAOD 2008-3, Issue and Crisis
Management.

34.     All SIRs that were generated because of a General Safety
hazardous occurrence will be reported through the safety channel of
communication to D Safe G. Hazardous occurrences affecting
military or civilian personnel as outlined in para 29 for civilian
employees will also be reported through the General Safety channel
of communication.

RETENTION OF REPORTS

35.      A signed copy of the investigation report shall be retained by
the unit for a period of ten years, except for exposures involving
hazardous material, which shall be retained for 30 years.


                                NOTE

The investigation report for units which are disbanded or
bases/stations which close shall be boxed and forwarded to National
Archives with a notation that they are to be destroyed at the
appropriate time.

FIRST AID ATTENDANT’S TREATMENT REGISTER

36.       Labour Regulations require that a record be made of every
work related injury or illness which requires first aid treatment. All
first aid kits and first aid stations are to have a copy of either 7530-
21-921-2934 General Safety Program - First Aid Treatment Register
(8 ½” X 11”) or 7530-21-921-2933 General Safety Program - First
Aid Treatment Register (3 ¼” X 6”).

37.       The first aid treatment record shall be made in a first aid
attendant’s treatment register and signed by the person rendering
first aid. The designated person in charge of the first aid kit must
comply with C-02-040-009/AG-001, General Safety Program, Vol 2,
General Safety Standards, Chapter 11, Annex A. The designated
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                              person shall ensure that treatment records are kept for a minimum of
                              ten years following the date of the last entry.


                                  NOTE


                              First aid treatment records for disbanded units shall be handled in the
                              same manner as DND 663s (see previous Note).

                              OTHER DOCUMENTS

                              38.     Boards of Inquiry and Summary Investigations are convened
                              or ordered for any matter that a commanding officer wishes. The
                              form CF98 for military members and WCB form for civilian
                              personnel are for pension or compensation purposes. TFRs and
                              MACRs are action forms to highlight material failures or
                              deficiencies and to request changes. If these latter forms have been
                              originated because of safety implications, the word “SAFETY”
                              should be stamped or written on them, and an information copy sent
                              to NDHQ/D Safe G.

                              39.      Notwithstanding the convening of a Board of Inquiry or
                              ordering of a Summary Investigation to investigate the hazardous
                              occurrence, or the submission of any other report including a CF 98
                              for military members, a General Safety investigation is to be
                              conducted and a hazardous occurrence investigation report shall be
                              completed and distributed if required by this publication.

                              40.      The Employer’s Annual Report of Injuries, required by the
                              Occupational Health and Safety Regulations, is to be submitted on
                              behalf of all of DND by D Safe G to HRSDC-Labour no later than
                              01 March. Units are not required to complete this report.




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                      CHAPTER 4, ANNEX A

                  STATISTICS AND ANALYSIS

1.       Accidents can be prevented by wisely analyzing hazardous
occurrence data. This analysis assists commanders and managers to
eliminate defects from their systems and thereby meet their safety
responsibilities. Situations having serious consequences and a high
probability of recurrence are generally easy to analyze, as the
preventive measures are readily apparent. Individual reports of
minor and frequent hazardous occurrences may seem to supply little
preventive information. However, when collectively analysed
useful information to eliminate future similar type occurrences is
often revealed.

2. Analysis of the information recorded on hazardous occurrence
reports transforms a series of unrelated facts into coherent data on
circumstances, cause factors and trends. For instance, analysis of the
circumstances of hazardous occurrences for repetitive factors and
trends can:

   a. identify and locate the possible sources of
      hazardous occurrences by determining the
      materiel, operations and resources involved;
   b. determine the nature and size of the problem by
      section and occupation;
   c. indicate the need and priority for changes to
      equipment, shop layout, procedures, training, job
      assignments, etc; and
   d. permit objective, rather than subjective
      evaluation of the safety program.

3. The HRMS H&S Module provides current, readily available
data for statistical use. The number of injuries, days lost, the injuries
and days lost per 100 personnel per year and the dollar loss for
damages give an indication of an organization’s ability to achieve its
goals. In addition, this data helps pinpoint areas that require
attention. As the information is general in nature, comparison
between units should be done with caution due to the large variance
in conditions. However, comparisons do help in establishing safety
priorities.

4. Trends and Program effectiveness can be determined by the use
of Injury Frequency Rate (IFR) and Injury Severity Rate (ISR) for
quarterly and annual periods. In addition the Modified Duty Rate
(MDR) and the Light Duty Rate (LDR) are a ways of measuring the
effectiveness of the organization’s Return to Work Program. These
four rates are useful Performance Measurement tools.

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                              5.      Injury Frequency Rate (IFR). The number of disabling
                              and non-disabling injuries per one hundred DND/CF personnel per
                              year or quarter for any command, base, station, unit, etc. In order to
                              allow for quarterly or annual calculations, the formula assumes a
                              work year to be 2000 hours (this is a recognized Canadian and US
                              standard used in the safety field). This is multiplied by 100 people to
                              become 200,000 and is divided by the total number of hours worked.
                              Most organizations will not be able to determine the total number of
                              hours worked without great difficulty therefore an approximate value
                              can be used which is the average number of personnel multiplied by
                              the Time Factor (500 for each quarter and 2000 for the year).

                              6.       Injury Severity Rate (ISR). The number of days off duty
                              plus the number of days on "light duties or modified duties" per one
                              hundred DND/CF personnel per year or quarter for any command,
                              base, station, unit, etc.

                              7.     Modified Duty Rate (MDR). The number of days on
                              modified duties per 100 DND civilian employees per year.

                              8.      Light Duty Rate (LDR). The number of days on modified
                              duties per 100 CF members per year.


                              9.         IFR/ ISR Equations.


                              IFR = Disabling and non-disabling injuries per 100
                                    personnel/time period (annual or quarterly)

                                    A = No. of disabling injuries
                                    B = No. of non-disabling injuries
                                    C = Average number of personnel in the unit for the
                                        period multiplied by the total number of hours
                                        worked or the Time Factor.

                                                      IFR = (A+B) X 200,000
                                                                  C

                              ISR = Days off duty or days on light duty per 100 personnel/time
                              period (annual or quarterly)

                                   A = No. of Days Light duty
                                   B = No. of Days off duty
                                   C = Average number of personnel in the unit for the
                                        period multiplied by the total number of hours
                                        worked or the Time Factor.
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                      ISR = (A+B) X 200,000
                             C

                                NOTE

In the event of a fatality, the number of days lost is counted as three
years (600 days) for full time personnel.

QUERY TOOL

10.     Even after methodical investigation and careful review of
hazardous occurrences, there is still another means to obtain more
information. By analyzing certain data, trends can be seen and
problems unmasked. It can show, for instance, that large number of
incidents involve the use of certain materiel or equipment, involve
people with certain levels of experience, or occur at certain times of
the work day.

11.     More detailed information may be obtained by tabulating the
data collected by the HRMS H&S Module. The data can be
extracted as an Excel spreadsheet and manipulated to produce
meaningful charts. This can be accomplished using the Query Tool
in HRMS. By simple counting of like data elements, questions may
be answered. For example, age versus the number of hazardous
occurrences could be charted to determine which age group has the
most hazardous occurrences. Also, locations may be compared with
the type of hazardous occurrence to determine where and what
hazards exist. GSOs should review their data on a regular basis to
determine trends and problem areas that require special attention.




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      Module 3

     Overview of
Hazardous Occurrence
    Investigation
      Methods
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Overview of Hazardous Occurrence
Analysis Methods
Methods currently in use by private companies and
government authorities fall into two categories: analyses
by questionnaire and analytical approaches. Within the
General Safety Program the analytical approach is
preferred.

A) Analyses by Questionnaire
Analyses by questionnaire uses a set of questions relating
to the causes of the accident under study. These methods
are used to standardize the analytical approach by allowing
the investigator to systematically ask questions that are
considered significant and eliminate as much as possible
any subjectivity that is liable to interfere with knowledge
of the accident phenomenon.

Most questionnaires contain two parts. The first part is
descriptive and contains the basic information needed for
administrative purposes, such as the narrative history of the
accident, the victim’s actions before the accident and any
equipment involved in the accident.

The second part is interpretive and concerns the search for
possible causes of the accident, prevention methods that
would have made it possible to avoid the accident and
actions taken or that need to be taken in order to prevent a
recurrence of the accident.

One questionnaire is from France and uses the multicausal
accident model of Heinrich/Lateiner in which the
occurrence of an avoidable injury is the natural outcome of
a series of events or circumstances that invariably occur in
a fixed and logical order. One depends on the other and
comes after it, thereby creating a sequence that can be
compared to a row of stacked dominos lined up one after
another such that the first domino falling sends the entire
row toppling. This is a non-focused questionnaire based on
a linear accident model.




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                                  These errors lead directly to dangerous conditions and
                                  actions known as unsafe acts or unsafe conditions that arise
                                  from the activity (Johnson, 1975).

                                  For those conducting investigations and analyzing the
                                  results, there are several advantages to using a
                                  questionnaire. They are quick to complete and give the
                                  analysis some degree of uniformity. They make it possible
                                  to choose the questions that are relevant to the major
                                  problems previously encountered within the industry and
                                  are generally quite flexible in applying them to incidents,
                                  near accidents and material and equipment damages. For
                                  the analyst, it is easy to draw up a list of descriptors of the
                                  accident phenomenon, code them and make a statistical
                                  analysis in order to render a safety diagnosis.

                                  HRSDC – Labour Program has also developed a non-
                                  focused questionnaire for reporting accidents, without a
                                  specific accident model, in order to obtain minimal
                                  information on accident phenomena in the workplace. The
                                  LAB/TRAV 1070(10-94)B form, “Hazardous Occurrence
                                  Investigation Report” presented in Part XV of the Canada
                                  Occupational Health and Safety Regulations, as well as the
                                  document entitled “A Guide to the Investigation and
                                  Reporting of Hazardous Occurrences” are part of this
                                  group (Figure 3.1).




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Figure 3.1 – HRSDC – Labour Investigation report
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                                  The use of a questionnaire as a hazardous occurrence
                                  investigation method has several disadvantages:

                                         The narrative history of the occurrence is generally
                                     too short and lacks flexibility;

                                         The number of possible causes is restricted and
                                     often limited to already known causes;

                                         The notion of a sequence of cause factors is often, if
                                     not always, missing from the questionnaire. What’s
                                     more, the cause factors identified often focus on a
                                     specific aspect of the occurrence in order to pursue a
                                     specific field of interest the analyst has: repeaters,
                                     dangerous acts, technical factors, etc.

                                         Since the choice of responses is determined by the
                                     person preparing the questionnaire, frequently part of
                                     the questionnaire is useless or is missing points specific
                                     to the occurrence under investigation. This means that
                                     investigators check inappropriate boxes simply because
                                     they have to fill in the blank spaces or the form is
                                     rejected by the computer software.

                                  The more complex questionnaires, are often based on a
                                  standard accident model that tries to standardize accidents
                                  and deal with them all in the same way: immediate cause,
                                  sequence of causes, connection of factors, standard causal
                                  tree, etc. In this case, they contain hundreds of questions
                                  covering all possible work situations, such that in reality,
                                  they are only applicable to the analysis of simple accidents
                                  that will then be analyzed superficially.

                                  Because of these many disadvantages, D Safe G has
                                  decided not to use a questionnaire method and to adopt a
                                  much more useful and flexible analysis method called the
                                  “Change Analysis Method”.




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                  HAZARDOUS
           OCCURRENCE INVESTIGATIONS

PURPOSE

The purpose of an investigation is to:

   a. determine the potential for and/or extent of injury to
      personnel and damage to property;

   b. determine all causes;

   c. recommend corrective action; and

   d. comply with the Canada Labour Code requirements.

NOTE

   A General Safety investigation is not to be used for
   disciplinary or administrative purposes. Other types of
   investigations, as noted in Module 2, fulfil these functions.
   Hazardous Occurrence Investigation Reports and the
   investigation data are accessible under the access to
   information requirements.

GENERAL

         Every hazardous occurrence is an indication that a fault
in personal action or procedures or a defect in materials has
gone uncorrected. In spite of the efforts of everyone, they may
still occur because of the failure to detect or recognize defects
in the system, dangerous situations or behaviour. Careful
investigation assists management in identifying these problem
areas, determining priorities and implementing corrective
measures.

        Investigation is not limited to the prevention of
identical accidents. Rarely do their components reproduce
themselves exactly. The investigation must ascertain what
action can be taken to decrease the probability of
incidents/accidents of the same type occurring.



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                                     The degree of investigation and recording of hazardous
                              occurrences should be based upon the potential for damage or
                              extent of injury and the probability of recurrence. This can
                              normally be determined by an initial examination of the
                              circumstances.

                                     It is emphasized that to successfully determine causes
                              and contributing factors, investigations must be directed
                              toward fact finding, not fault finding.

                              PRINCIPLES OF INVESTIGATION

                                      Investigation, like crime detection or medical
                              diagnosis, entails a search for unknowns. All factors must be
                              uncovered and evaluated to correctly determine what happened
                              and why it happened. It need not be complicated. The
                              investigator should have the following qualifications and
                              exercise the following principles to achieve the desired results:

                                  a. be familiar with the equipment, its operation and the
                                     procedures involved;

                                  b. understand the type of condition or situation likely to
                                     produce accidents;

                                  c. collect the facts, weigh the value of each and reach a
                                     conclusion based on the evidence;

                                  d. explore all factors, however remote;

                                  e. consider unsafe conditions as well as personnel
                                     actions/inactions; and

                                  f. recommend effective corrective measures.

                              INVESTIGATION

                                      General. When an injury occurs, the first concern
                              must be for the injured. Priority should then be placed on the
                              investigation. One should only deviate from this principle
                              when an investigation would clearly interfere with the
                              immediate mission - a situation that would rarely happen
                              because the results of an investigation almost always assist
                              rather than hinder the mission accomplishment.

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        Procedure. The potential for injury or damage and
probability of recurrence dictate the extent and depth of the
investigation. In general, the investigator must:

   a. visit the accident scene;

   b. conduct interviews;

   c. gather and record evidence;

   d. evaluate the evidence and draw conclusion; and

   e. make recommendations.

        Accident Scene. It is imperative that investigators go
to the scene of the accident as soon as possible in order to:

   a. familiarize themselves with the circumstances.
      Conditions can change quickly and witnesses’
      viewpoints can be altered with the passage of time.
      This familiarization also helps decide where and with
      whom to start the investigation;

   b. prevent the removal of evidence;

   c. co-ordinate, when necessary, the taking of samples,
      quarantining of equipment and impounding of records;
      and

   d. determine and interview witnesses.

        Interviews. Whenever possible, witnesses should be
interviewed as soon as possible while the events are still clear
in their minds. The person(s) directly involved, including the
injured if practicable, should be interviewed first; interviews
with those associated in the operation, co-workers etc, follow.
The interviewer should observe the following:

   a. Put the person at ease. Do not appear condescending or
      officious, but remind the witness of the constructive
      purpose of the investigation. Reassure the witness that
      your main purpose is to find and eliminate the causes of
      the accident in order to prevent a recurrence. Make sure

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                                     the person understands that your intention is not to put
                                     blame on anyone for the cause of the accident.

                                  b. Interview at the location of the accident if possible.
                                     This allows both the interviewer and the witness to
                                     more accurately relate circumstances and details
                                     involved.

                                  c. Interview the witnesses separately so that the statement
                                     of one will not be coloured by       overhearing the
                                     statement of another.

                                  d. Ask the witness to relate his/her account of the
                                     accident. Listen closely and carefully and do not
                                     interrupt at this time. This gives the witness an
                                     opportunity to formulate the story in his or her own
                                     mind, and gives you a preview of what they know. Do
                                     not take notes or record the interview at this point; it
                                     tends to distract the witness.

                                  e. Have the witness tell the story again. Ask questions to
                                     fill in the obvious gaps. This time take notes, but not in
                                     a secretive manner. Simply write them down in such a
                                     manner that the witness is able to read what you are
                                     writing. Ask further specific questions if required.
                                     Avoid questions that lead the witness or imply answers.
                                     Rather than asking “Was there oil on the floor?”, ask
                                     “What was the condition of the floor?”.

                                  f. Encourage the witness(es) to give all information
                                     regardless of how obvious it may be or how
                                     insignificant it may seem.

                                  g. Ask the witness for suggestions as to how the accident
                                     could have been avoided.

                                  h. Do not discuss with the person being interviewed the
                                     testimony of other witness(es). This would be a
                                     violation of the confidential nature of interviews and
                                     would diminish confidence in the objectives of accident
                                     investigation.




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   i. Encourage the witness to contact you at a later date if
      he or she thinks of something else. Reinterview the
      witness to clarify points whenever necessary.

   j. Thank all witnesses for their co-operation, particularly
      those who may have contributed safety ideas.

        As you interview witnesses, ensure that you do not fall
into any of these traps: believing carelessness is a cause of
accidents; assuming contradictory evidence indicates
falsehood; conducting interviews as if in a courtroom; asking
for a signed statement from the witness; looking for only one
basic cause; forgetting about the feelings of others and failing
to keep information confidential. Any of these will limit the
effectiveness of your investigation and perhaps even prevent
you from finding the real cause of the accident.

        Evidence.    This may be any object, conditions,
event, statement etc, that may yield information about the
occurrence. It can be compromised or lost unless the utmost
care is taken. When applicable, to preserve evidence, ensure
that:

   a. the accident scene is protected and documents, orders,
      log books, personnel records, etc., are impounded;

   b. fluid (petroleum, oils, lubricants) and material (wood,
      metal, cloth, etc.) samples are taken;

   c. articulated or “working” parts are marked to identify
      settings, position or extension in which they are found;

   d. films, sketches or photographs are made before
      evidence is disturbed;

   e. disassembly of components is recorded in
      detail;

   f. parts requiring investigation are preserved in their
      original state;

   g. fractured or worn mating surfaces are not fitted
      together, otherwise significant marks may be destroyed;


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                                  h. witnesses are available until the investigation is
                                     completed;

                                  i. medical examinations are conducted immediately;

                                  j. evidence that cannot be analyzed locally is properly
                                     identified, packed and shipped for examination at
                                     another facility; and

                                  k. accurate records of the above are kept.

                                      Re-enactment. At times, in order to establish precise
                              details, it may be desirable to re-enact the circumstances of a
                              hazardous occurrence. Extreme caution must be taken to not
                              repeat the accident. Before re-enactment the participants must:

                                  a. thoroughly understand they are to go through the
                                     motions only without repeating the actual practice that
                                     caused the hazardous occurrence;

                                  b. explain what happened first before going through any
                                     motions; and

                                  c. take one step at a time - in slow motion.

                                      After examining the accident scene, interviewing the
                              victim (if possible) and interviewing witnesses (including
                              health and safety experts, if necessary), the investigator should
                              have a fairly clear idea of what happened. The objective at this
                              stage is to marshall all the evidence and testimony to discover
                              why the hazardous occurrence happened and to recommend
                              steps to prevent a recurrence.

                                      Hazardous occurrences seldom have a single cause.
                              The most apparent and immediate cause will probably be either
                              a substandard workplace condition or a substandard work
                              activity. But a probing investigation will normally reveal
                              system or procedural failures resulting in either the worker or
                              the workplace not being properly prepared. So the process of
                              analysis must consist of sifting through the evidence to
                              discover all the underlying causes. This can be achieved by
                              subjecting all the known facts and events that lead up to the
                              hazardous occurrence to a rigorous series of “what”, “when”,
                              “how”, “why”, and “if not, why not” questions. In order to

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identify areas requiring preventive measures, all causes should
be recorded in as much detail as possible. At this point it
maybe helpful to review the Accident Causation Sequence
Model in Appendix 1 to Annex A and the material in A-GG-
040-003/AG-001, General Safety Training, Chapter 4 –
Occupational Safety, and Annex C, Chapter 6 – Accident
Investigation

        Potential For Severity and Frequency. For each
hazardous occurrence investigated, the investigator and
responsible manager must ask: “What is the probability this
hazardous occurrence could recur, and what is its true potential
for severity of injury, damage or loss?” This important
question helps to determine whether the investigation has been
sufficiently complete and the extent to which corrective action
should be taken. In other words, the severity/frequency factors
control the expenditure of time, energy and other resources to
be committed to investigation and corrective action, rather than
the actual results of the hazardous occurrence.

        The severity/frequency evaluation is critical to
management to assist in planning or committing priorities and
expenditure of resources for corrective measures. Individually
or in combination, these factors provide the real magnitude of a
hazardous occurrence. In many cases the result of a hazardous
occurrence has been minor with little or no corrective action
taken and subsequently the same conditions have resulted in
serious injury, damage or loss. An evaluation that reveals a
potential for major severity coupled with a high probability for
recurrence must always assume the highest priority for
preventive action.




        The following matrix can be used to score the results of
a severity/frequency evaluation and be used as a guideline for
prioritizing the expenditure of resources for investigative and
corrective actions. It is readily apparent that an hazardous
occurrence receiving a score of “1” must be treated with
urgency, whereas one with a score of “5” does not justify such
urgency.



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                                                               Frequency
                                                                 Often            Occasional   Rare




                                  Severity
                                              Major                1                  1         2
                                              Moderate             2                  2         3
                                              Minor                3                  4         5


                              SCORE             ACTION

                              1 and 2           Immediate corrective action required. Full
                                                investigation. Activity should be discontinued until
                                                hazard is reduced.

                              3                 Urgent action required. Full investigation.
                                                Implement corrective action as soon as possible.

                              4                 Hazard should be eliminated without delay by
                                                situation not urgent. Normal investigation.

                              5                 Action as routine. Retain accident data for
                                                statistical purposes.

                                      A more elaborate matrix sometimes referred to as the
                              “Hazard Ranking Pyramid” could be used instead of this
                              matrix. The “Hazard Ranking Pyramid” includes the cost of
                              rectifying the hazard as a factor along with the severity and
                              frequency factors to generate a three-letter hazard rectification
                              priority code. Details on use of the “Hazard Ranking Pyramid”
                              are contained in A-GG-040-003/AG-001, General Safety
                              Training, Annex D, Chapter 6, Risk Assessment. This
                              technique is extremely useful to Workplace Health and Safety
                              Committees as it presents a systematic approach to setting
                              priorities and eliminates time spent in debate.



                                      Recommendations. Once the cause factors have been
                              identified, the investigator(s) recommend(s) preventive
                              measures based on the findings of the investigation. The basic
                              aims when developing preventive measures are as follows:

                                         a. treat the cause and not the effect;

                                         b. ensure that the measures will enhance and not restrict
                                            overall operational effectiveness; and

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    c. ensure preventive measures eliminate or control all
       causes.

        Simply recommending that the individual(s) involved
be briefed contributes little. It merely indicates fault finding. If
human factors (inaction or action - human error) is a cause,
revising job procedures, training of all employees doing
similar tasks and publicity of the accident, to name a few,
would be more meaningful and certainly more productive.

        If shortcomings in equipment, facilities or other
resources are causes, then modifications, substitution or
acquisition would be valid recommendations.

OTHER INVESTIGATIONS

       In addition to investigations conducted in accordance
with this publication, collateral investigations may be carried
out for pension, compensation or even disciplinary purposes.
There could be a Board of Inquiry or a Summary Investigation
ordered by the Commander in accordance with CFAO 21-9.
The General Safety hazardous occurrence investigation and
associated General Safety Hazardous Occurrence Report are
not to be used for these purposes. However, it must be
remembered that the hazardous occurrence reports required in
Section 3 are to be completed even when a Board of Inquiry or
Summary Investigation has been ordered. The description of
the hazardous occurrence can refer to the Board of Inquiry or
Summary Investigation.

       HRDC-Labour may conduct separate investigations
into civilian employee work accidents. They will also be
advised as directed in Section 3 when an accident involving a
DND civilian occurs.

PREVENTIVE ACTION

       Preventive action should be implemented at the lowest
appropriate level in the organization. Action must be prompt
and thorough, otherwise the investigation will be largely
wasted. It is vital that managers/leaders:



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                                  a. consider all recommendations and promptly incorporate
                                     those adopted;

                                  b. fully explain why recommendations are rejected;

                                  c. fully explain why action is delayed; and

                                  d. inspect other areas under their jurisdiction for similar
                                     unsatisfactory conditions or performance.


                                      When beyond local authority, recommendations for
                              changes must be forwarded to the functional offices of primary
                              interest (OPI) at command/area HQ and/or NDHQ for
                              resolution. For this purpose, established correspondence
                              channels or standard action forms such as Unsatisfactory
                              Condition Reports (UCR), Material Authorization Change
                              Requests (MACR), etc. should be used. Refer to C-02-015-
                              001/AG-000, Part 1 for guidance.




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   Module 4

Change Analysis
    Method
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   Various Analysis Methods
            There are numerous analysis methods available to a
   Hazardous Occurrence Investigator that can be used in the
   causation phase. Each method has its strengths and
   weaknesses but in the end they all allow the data collected
   during the investigation to be distilled down to one or two
   root causes that, if eliminated, would most probably have
   prevented the Hazardous Occurrence from happening in the
   first place.

         Several examples of these different analysis
   methods are listed below:

       •   Management Oversight Risk Tree (MORT)

       •   Actions and Conditions sequencing chart

       •   INRS Causal Tree

       •   NTSB Changes and Errors chart

       •   HRSDC’s Operational Analysis Approach
           (OPANAP)

       •   Change Analysis

    In this course we will deal only with the Change Analysis
Approach. Information on other methods is available in
numerous publications that your local GSOs may have access
to.




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                                  Change Analysis Method
                                  An accident is not an isolated event. It occurs in an
                                  organization through the interactions among the worker,
                                  the task, the equipment, the time of the accident and the
                                  workplace setting (Figure 4.1).

                                  Work organization includes the functions relating to
                                  workplace management, such as the company
                                  administration, managerial attitudes, philosophy of action,
                                  cultural policy, operations management and supervision, as
                                  well as more operational functions, such as work practices,
                                  production worksheets and orders. In terms of accident
                                  management, organization includes the accident prevention
                                  program, selection of personnel, their training and
                                  education, and task supervision.

                                  The working individual exists with his training,
                                  experience, habits, desires, physical and mental state,
                                  problems, etc. This is the person with all of his
                                  characteristics as they appear when he is at work in the
                                  occupational environment, meaning that he also brings
                                  with him the effect of non-work-related factors. In
                                  addition to the operator, this includes anyone whose
                                  activity is more or less directly related to him: coworkers,
                                  foreman, site manager, purchaser, maintenance mechanics,
                                  etc. Several personal factors influence accident prevention:
                                  safety attitude, physical ability, concentration, level of
                                  understanding, etc.

                                  The task reflects the work method and is part of a
                                  production process. It is the set of actions performed by
                                  persons assigned to the partial or total production of goods
                                  or services. The task includes the techniques used to
                                  execute the system operations, whether verbal or written;
                                  standards set by management, governments and
                                  professional organizations; the physical, sensory, affective
                                  and intellectual effort required for the ongoing performance
                                  of operations; and more informal tasks, for example,
                                  system preparation and access to sites and data.




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Equipment and materials refer to all technological
methods, raw materials and products made available to
persons for the performance of their tasks: land and
buildings, installations, machines and tools, constituent
materials and products, as well as by-products and
perishable items, machined parts and finished products,
rolling stock, domestic products, a truck, etc.

The time suggests notions of time, duration, period, rhythm
and frequency, for example, day or night duty, extended or
flexible work hours, work before or after a meal or break,
increased work pace or repetitive monotony.

The place encompasses the internal and external systems
environment: physical layout, physical and socioeconomic
environment, atmospheric, aquatic, terrestrial and
biological environment, and the relative location of
systems, in short, all elements of the work situation in
which individuals perform their tasks. The majority of
events related to the workplace setting are fairly easy to
identify; also, it is relatively easy to correct any faults
detected because the work is generally done with what is
tangible and palpable, things that can be seen or measured.




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                              Organ ization
                                  PLACE           INDIVIDUAL




                      TIME                                     TASK




                                     EQUIPMENT AND
                                       MATERIALS

                               Organization


                              in an Organization,
                        an Individual carries out a task
                              with Equipment and
                             Materials at a given Time,
                               in a specific Place
                                             .


                      Figure 4.1 – Basic Model of a Work System


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Accident

Let’s define work-related accident for the purposes of this
course:

    “state of a work system deviating from its
    initial objective and producing a specific
    unplanned adverse effect.”.

The accident, incident, near accident or dangerous
behaviour are merely the result and expression of a certain
operational mode of the system. By determining the
operational characteristics that are likely to give rise to
failures within a given system, it is possible to prevent
damages resulting from accidents.

It is important to note that the accident is never the result of
a single cause, but is instead the convergence of several
changes undergone by one or more components of the
system: disturbances, fluctuations, mutations, faults,
changes, failures, variations, etc. The influencing factors
that have caused these changes are collectively referred to
as malfunction factors of the technical operations of the
system.



Concept of Work

By definition, a human-machine system is a combination
of human and non-human energy intended to transform a
material or provide a service. Systems can be viewed from
different aspects. Macroscopically, a company is a system
in which each process constitutes a sub-system, in the same
way that a government is a system formed by departmental
sub-systems. With the biologist’s microscopic eye, a drop
of water is a highly complex system. The confusion
becomes evident when a mechanic views a carburetor as a
system in itself, whereas the designing engineer sees this as
simply one of the many sub-systems of the automobile.
This is why it is more useful to define systems by their
operations.




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                                                           Factory

                                                         Processes

                                                            Tasks

                                                  Technical Operations
                                  A system has a specific purpose that defines its
                                  components and their interactions. This means that a
                                  system designed for manufacturing matches using a log of
                                  wood cannot manufacture seat rails. When a system is
                                  operating normally, a continuous series of interactions is
                                  easily observed between the system’s human component
                                  and all other components.

                                  This series can be broken down into more or less lengthy
                                  sequences known as technical operations, each operation
                                  having its own purpose. The combination of several
                                  operations results in a specific product or service
                                  constituting a task.

                                  The technical operations learned and anticipated by the
                                  operator are identified as the system’s normal tasks.

                                  The tasks as a whole, whether normal or not, constitute
                                  the system’s activity or process, i.e., that portion of work
                                  in the production of goods or services (manufacture,
                                  maintenance, etc.) done by the operator in the overall
                                  production system, such as a factory, workshop or job site.

                                  The operations that make up a task are represented by a
                                  series of signals, decisions, commands and transformations.

                                  Sound complicated? There is a simpler way to go about it.
                                  In reality, describing a task means separating the
                                  operations performed by the operator in order to uncover
                                  all the “decisions” he must make.

                                  There are several work analysis techniques on the market.
                                  Any one of them can be used to describe tasks. Large
                                  firms prefer to write “standardized operational procedures”
                                  or “good work practices” rather than adopt overly
                                  complicated analysis techniques.


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In general, you don’t need these sophisticated techniques to
describe the technical operations of a normal task or an
accident phenomenon. It is only a matter of breaking down
the operations into sequences.

Let us examine a simple human-machine system. Paul and
Monica’s task is to dig a trench using a pick and shovel. In
places where the ground is packed and hard, Paul uses the
pick to break up the loose soil which Monica shovels. If in
the course of their work they discover a rock, Paul removes
it using the pick or a strong bar. If the rock is small, Paul
lifts it and sets it down on the pile of dirt. If the rock is
larger, they lift it together (Figure 4.2). Here is a simple
human-machine system in which two operators are using
tools as a machine. They operate the machine using their
own physical and mental energy.

For each shovelful, one and only one set of steps is
followed. This is how it is for all accident sequences. By
reporting the chronology of the events exactly as they
occurred, you will be able to describe accidents using
simple sequences of events, signals, decisions, commands
and transformations.

In this example we see the difference between 2 possible
circumstances. Each will have a “normal task” and an
“abnormal task”. Each time a change is made a different
action occurs. Each of these actions must be evaluated for
its potential risk.




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                                      Paul or Monica
                                 observe the soil condition                         start again
                                     by looking at it or
                                      using their tools




              Packed soil?                                       Loose soil?




            Paul breaks up the
            soil with the pick


                                                               Monica shovels
                                  No rocks
                                                                  the soil


               Paul finds
                 a rock


                                                               Monica shovels
                                  Very small rock
                                                                 the rock




                                                               Paul removes the
                                 Average-size rock
                                                              rock using the pick


                                                              Paul lifts the rock
                                                               with both hands
                                                               and sets it down
                                                                 on the pile




                                                                Paul or Monica
                                    Large rock                 removes the rock
                                                                  using a bar


                                                              Paul and Monica
                                                                 lift the rock
                                                                together and
                                                              put it on the pile




                 Figure 4.2 – Simplified diagram of pick and shovel work

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   Module 5

  Introduction
      to the
Accident Process
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Introduction to the Accident Process
A human-machine system is considered to be adapted
when it produces what it is supposed to produce. As early
as 1965, it was widely agreed that an accident occurs in a
specific system and that it is an abnormal effect of that
system. When an accident occurs, the system activity and
not only the normal tasks must be analyzed.

Note that if the accident involves several closely
interrelated activities, it may be necessary for you to
analyze numerous systems at one time. For example,
approximately 40% of accidents involve the coactivity of
several systems and occur in this sort of “no man’s land”
under the control of all operators but no one in particular.
In our case, as long as Paul and Monica dig the trench
according to the process illustrated on the operational
diagram, the system is adapted. All the technical
operations of this system have been anticipated and
everything is operating according to plan for this particular
activity.

Then the unexpected happens: the last rock that Paul has
uncovered is so big that he cannot remove it using only the
bar. He therefore asks Monica to help him, contrary to
their usual procedure.

When the system does not produce exactly what is
expected, it is poorly adapted to the purpose for which it
was created. Any deviation in a system’s activity or a
portion of its activity is referred to as a malfunction (also
called a misfunction or dysfunction).

Before the Second World War, accident models made little
reference to deviations in operations as being the source of
accidents. Analysts confused malfunction and cause. For
example, any activity or task introduced by the operator in
violation of a generally accepted safety procedure was
considered a dangerous act. They believed that the
accident occurred because the tasks introduced were not
consistent with certain “normality”, often defined after the
fact.



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                                  They were unaware that, for the most part, these “bad
                                  tasks” had been introduced precisely because there had
                                  been a previous malfunction.

                                  Kepner and Tregoe (1965) were undoubtedly the two who
                                  contributed most to spreading the idea that system
                                  processes are in a constant state of dynamic balance and
                                  that any change in their operation results in a stress leading
                                  to a series of events and/or errors causing the accident.
                                  Even though modern terminology no longer refers to
                                  changes and errors, the concept remains the same:
                                  malfunctions are at the origin of tasks introduced by
                                  operators.

                                  The Concept of Cause
                                  Contrary to popular belief, a malfunction never occurs
                                  by chance. For there to be a disturbance in the normal
                                  technical operations of a task, something or someone must
                                  act either on the system’s components or their interactions
                                  to modify them: this is the cause factor.

                                  A cause factor can take on various aspects: poor physical
                                  or environmental conditions, bad administrative decision,
                                  improper procedure invented or imposed, faulty design,
                                  mechanical failure, external catastrophic event, lack of
                                  human reliability, etc. Consequently, there are as many if
                                  not more causes as malfunctions.

                                  Every cause takes the form of an event outside the
                                  system, from a set of observable and identifiable events.
                                  Any event is considered a causal factor when it contributes
                                  to the onset of accidents or to making their consequences
                                  worse.

                                  But human-machine systems are rarely in an accident state.
                                  On the contrary, most times they operate very well.
                                  Indeed, all systems have a certain adaptation level and even
                                  if they are not perfectly adapted to the work to be done,
                                  most systems are under control.




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Since operators already have experience of their human-
machine systems, certain malfunctions are known, such
that the majority of systems are equipped with operations
to correct a deviant occurrence and bring it back on track.
These technical operations are called internal regulation
operations, which replace the normal task with a series of
control operations to correct malfunctions (Figure 5.1).

In our example, Paul and Monica had already anticipated a
type of malfunction: the presence of large rocks. They
were already equipped with a strong bar to remove these
rocks. This strong bar is therefore an internal regulation
mechanism or procedure. However, they would have liked
to have had a second one in order to remove the last rock
they uncovered, as it was bigger than all the others they
had previously encountered or imagined.

Paul left the job momentarily to go get a second bar in the
shop. Unfortunately, there were none left. He checked
with his foreman, who told them to make do with what they
had. So while Paul tried to lift the rock using the strong
bar, Monica laid her shovel on the ground on the opposite
side and used it as a lever to enable Paul to insert the bar
farther down underneath the rock.

Given that the tasks introduced by Paul and Monica (going
to the shop, asking the foreman for help, lifting the rock
using the shovel) were not part of the original scenario, i.e.,
the normal task, they introduced what we call abnormal
tasks. These tasks are intended to recover or circumvent
the normal task.

When one or several malfunctions have not been
anticipated or, if they are known, there is no internal
regulation process to return to the normal task, this leads to
an accident occurrence. The system is not yet in an
accident state, but is heading in that direction.

The system, in general the operator, may call upon an
external system in order to prevent the propagation of the
accident occurrence or mitigate the possible consequences,
thereby bringing the system back on track.




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           Areas of                        Accident             Areas of        Consequences
          prevention                        origin              control



                                             SYSTEM


          HAZARD
                                           TECHNICAL              adaptation        normal
                                           OPERATIONS                                tasks

                       initial
                       causal
                       factor

                                                                   internal         control
                                          MALFUNCTION
                                                                  regulation       operations

                    intermediate
                       causal
                        factor

         DANGER                            ACCIDENT                external         vicarious
                                          OCCURRENCE              regulation          tasks
                        final
                       causal
                       factor                                                      INCIDENT


                                                                                    fortunate
                                                                                  consequences



                                                                                     NEAR
                                                                                   ACCIDENT


                                          UNFORTUNATE           emergency and
                                         CONSEQUENCES             protection

                   Probability
                   of occurring


       HAZARD RATE

                   Probability
                   of damage

                                                                   rescue           injuries
                                            DAMAGES               survival           losses
                                                                compensation        hazards




                                   Figure 5.1 – Genesis of an accident


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Fortunately for prevention, in 75% to 95% of cases, the
operator succeeds, with a little luck and considerable
know-how, to restore balance to the system. In this case,
what occurred was only an incident.

This definition of incident was proposed by the American
aeronautics industry around 1965 and is fairly consistent
with current language: an incident is similar to an
accident, but without any injury, loss or damage.

It is important to note the difference between the
definition of incident given here and the definition from
Heinrich/Lateiner’s domino theory. They defined the
incident as a deviation in normal operations. This
definition was subsequently revisited by the event theory
that considered the accident as the result of one or more
uncorrected incidents. Since 1975, experts have rejected
this definition and use several terms to refer to a deviation
in a system’s operations, including change, error, failure,
fault, impairment, malfunction, misfunction.

In Canada, analysts also apply the term incident to
“accidents that have not caused injuries or diseases, but
which could have had the circumstances been different”
(CSA Z796, 1998 – Accident Information Standard).

Under the operational model, the incident is merely a
slowdown or temporary interruption in the system’s
“normal” operations, but the system still remains in
operation and is in no need of repair. Remember that an
incident does not cause damages. It describes an aborted
accident. However, if there is a significant halt in
production or marked drop in the quality or quantity of
products or services, these are damages.

But let us return to our example. The rock proves more
difficult to remove than they had thought. Monica right
away thinks of jumping on the shovel handle to exert
greater force on the makeshift lever. The handle breaks.
Monica falls onto the part of the shovel still stuck in the
ground and injures her thigh.




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                                  In approximately 5% to 25% of malfunctions, the operator
                                  does not succeed in recovering the normal task

                                   The system deviates from its initial objective and produces
                                  a specific unforeseen effect. This is the accident.

                                  When the consequences of an accident are fortunate, this is
                                  a near accident. If the consequences are unfortunate, as
                                  with an injury, fire, explosion, release of a toxic substance
                                  or an energy release, this results in damages:

                                            injuries (injuries, diseases and illness or
                                            impairments) are damages that directly affect
                                            systems operators.

                                            damages that occur to other system components are
                                            referred to as losses: equipment breakdowns, fire,
                                            damage to installations, decomposition, production
                                            halt, drop in quality, operations slowdown,
                                            financial loss, theft, vandalism, etc.

                                            when accidents affect the environment of
                                            neighboring systems, these are nuisances:
                                            pollution, environmental disturbance, destruction of
                                            ecosystems, threat to the survival of species, etc.

                                  Note the new definition we have given to near accidents.
                                  In most English texts, near miss and near accident are
                                  confused with the definition of incident. Here, near
                                  accidents are fortunate accidents, meaning that the
                                  damages are not considered negative. These are very
                                  rare cases, but possible.

                                  The Concept of Hazard
                                  Why did the presence of a heavy rock cause an injury?
                                  Experience shows that almost all damages are foreseeable.
                                  This means that we are able to identify situations or
                                  conditions for which there is a higher probability of
                                  damages than others.




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These characteristics are generally observable and often
measurable: the height of a scaffold, the distance between
two moving parts, the pH of an acid solution, the lower
flammability limit of a solvent, the coefficient of a floor’s
slip or adherence, the resistance of a barrier, the weight of
a container, the speed of a lift truck, etc.

We all believe that Paul and Monica could have avoided
this accident, for example, by going to get a second bar
from the shop, by asking a third person for help, by using a
tractor, by installing a mechanical winch, by going over the
rock and continuing the trench a little farther away or, as a
more drastic measure, by stopping their work. What was it
in particular about this system that led to the occurrence of
an accident?

Remember for an accident to occur there must be energy
with enough force to exert a physical demand or harmful
thermal transformation on the operator.

In its broadest sense, energy is what accompanies or
causes a change of state or a transformation. The “energy
quantity” is a scalar value, the characteristics of which are
materially identifiable within systems, observable in their
transformations, directly or indirectly measurable, and
easily described in their dimensions. We must always
measure two characteristics to calculate the energy
quantity.

Energy characteristics are known as “properties”, for
example, compression energy is measurable by volume and
pressure, electrical energy by electromotive power and the
quantity of electricity, surface energy by surface tension
and area, chemical energy by chemical potential and mass,
thermal energy by temperature, kinetic energy by speed
and mass, and potential energy by height and gravity. In
terms of occupational health and safety, we are
concerned only with those energies that our senses can
perceive.

For an accident to occur, energy must be part of the system
and must pose a threat, thus becoming a danger capable of
modifying operations. Physically, a system is a
combination of people and materials confined within
certain limits, real or imaginary, mobile or stationary.

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                                  Whatever is not included in the system constitutes the
                                  external environment. Generally speaking, only the
                                  internal environment acts on work systems, whether in the
                                  form of heat or in the form of work. Apart from energy of
                                  position (potential) and energy of movement (kinetic), all
                                  other forms of energy are internal.

                                  Any form of energy that threatens or compromises the
                                  safety or existence of a system or one of its components
                                  constitutes a hazard. For example, everyone knows that
                                  lifting weights that exceed the physical capabilities of
                                  humans and machines is in itself dangerous. Here is the
                                  first hazard in Paul and Monica’s system. Everyone also
                                  knows that using a piece of wood that is too fragile as a
                                  lever can cause it to break. Here is the second hazard of
                                  Paul and Monica’s system. Note that the first hazard was
                                  present in the system from the start of operations or the
                                  work, even though both operators did not see the rock
                                  buried in the ground, whereas the second hazard was also
                                  present but introduced into the system during a vicarious
                                  task.

                                  Energy is considered dangerous and may produce an
                                  injury or illness when:

                                  1.    the quantity that may be released exceeds the
                                        physiological structures of the person affected by it;

                                  2.    it interferes with the normal exchange of energy
                                        between a living organism and its environment (e.g.
                                        asphyxiation by drowning).

                                  Several theories maintain that the accident itself occurs in
                                  five phases (Table 5.1). At the outset, the hazard is present
                                  in the system and presents a more or less controlled risk:
                                  this is the passive phase. The release of energy and threat
                                  of contact with one or more components of the system are
                                  the direct causes of damages, which is the final phase.
                                  Injuries and damages represent the conclusive phase. This
                                  phase begins as soon as there is contact between the energy
                                  and components, and ends when the components absorb the
                                  energy or when the energy flow ceases. These phases are
                                  preceded by a preparatory phase that initiates the causal
                                  factors and a factual phase beginning with the first
                                  malfunction and ending with the release of energy.

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                              Table 5.1

                     The Five Accident Phases

             Phase   State and transformation                       Results

Passive                hazard                              danger

Preparatory            causal factors                      changes

Factual                malfunctions                        vicariances

Final                  energy transfer                     accident

Conclusive             contact                            damages


                        We can therefore often prevent injuries by controlling the
                        energy source, or the vehicles or carriers it borrows to
                        impair a system component or the operator’s organism.
                        Although the various energies that cause injuries are few,
                        the forms they take are many and the vehicles or carriers
                        are countless.

                        The “barrier” concept developed by Gibson (1961) and
                        later by Haddon (1966 and earlier) helps considerably in
                        understanding the energy content of the hazard. All human
                        beings and all objects have tolerance levels for all forms of
                        energy. According to these authors, we can establish dose-
                        response curves for most of these, calculate minimal injury
                        threshold levels and thus determine the level of control
                        required to protect ourselves.

                        The US Commission on Product Safety attempted to
                        establish these thresholds for several forms of energy. By
                        following the path of energy deployed during an accident,
                        it is possible to place barriers at various points to interrupt
                        or decrease the accumulation, release and contact of
                        energy.




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                                  DANGER : energy source




                               Barrier to energy source




                                 Unwanted release of energy




                     Barrier between energy source and target




                                   Unwanted energy flow




                                    Barrier to target




                         Unwanted contact between energy and target:
                                  INJURY OR DAMAGE




                      Figure 5.2 – Energy Transfers and Barriers

                                  All preventionists are aware that hazards do not cause
                                  malfunctions. They are activated only when the internal
                                  and external regulation mechanisms prove ineffective in
                                  counteracting the possible consequences of malfunctions
                                  and accident occurrences.



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Consequently, it is not the weight of the stone that tore the
muscles in Monica’s leg. What is necessary then is a
principle that creates, modifies or destroys an operation of
the system for the danger to become activated. As we have
seen, this principle is the cause or combination of causal
factors.

Risk Assessment
If the rock had been smaller, there would certainly not have
been an injury since Paul and Monica knew the operations
that would have enabled them to remove it together. If the
rock had been larger, there would not have been an injury
because a bulldozer would have been needed to remove it.
In order for the accident to occur, it was necessary for the
rock to be a particular size, not too large and not too light
or too heavy, so that the operators believed they could lift it
out together.

The system designer could have anticipated that one day a
rock would be heavy enough that its removal would result
in excessive exertion. He had considered this situation for
simple cases, as he had supplied a strong bar to replace the
pick as needed. He had not anticipated any “normal”
operation for heavier stones.

The risk is defined as the possibility that an accident
occurrence can cause damage to the system in the presence
of a hazard that is more or less foreseeable by the designer
and system operators. Any situation or action that
increases the probability of the hazard being activated and
resulting in damages contributes to increasing the risk.

In this sense, all causal factors are “risk factors”. For each
causal factor and for all technical operations of the system
in general, it is possible to quantify this risk by calculating
a risk rate or a hazard rate. This requires having enough
data on the systems and their past operations to estimate
the probability of accident occurrences.



For example, the fatality risk in a tractor trailer truck
is X per million hours driven.

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                                  The concept of risk is not always one that investigators
                                  wish to consider. Some deny it; others do not want to deal
                                  with it. The concept of risk is just like the concepts of
                                  accident, cause or prevention. Rejecting the concept of
                                  risk is the same as rejecting the concept of prevention,
                                  because without risk, there is no prevention.

                                  Some risks are “normal” and we are willing to take them.
                                  For example, a company risks financial loss when making
                                  a new investment, launching a new product, determining
                                  market opportunities or handling the competition. No one,
                                  not even the economist hired by this company, wants to put
                                  an end to this risk, since there would be no more financial
                                  speculation, and consequently no economy.

                                  We refer to these risks as normal because we agree to be
                                  exposed to danger in the hope of obtaining certain
                                  advantages: in this case, monetary gain. In the context of
                                  occupational health and safety, we are not prepared to take
                                  this kind of risk. It would be crazy to expose a worker to
                                  the danger of injury or disease in return for a particular
                                  advantage, such as a higher salary.

                                  Prevention deals with risks that are “abnormal”, i.e., those
                                  relating to occurrences that cause damages. To deny these
                                  risks is to deny that there could be damages. Any activity
                                  involves a certain risk. Any activity can deviate from its
                                  predetermined (normal) path and lead to an undesirable
                                  (abnormal) outcome.

                                  For example, a car is a machine designed to get us from
                                  one place to another. As long as it performs this function,
                                  the system is normal. When it can no longer carry out this
                                  function (mechanical failure, flat tire, collision, wear and
                                  tear, etc.), the system is abnormal. By drawing a
                                  comparison between the number of times the automobile
                                  did not get us where we wanted to go and the number of
                                  times we used it, we can calculate the abnormality rate, i.e.,
                                  the risk of being stuck on the side of the road!

                                  Conversely, the lottery system was designed so that we
                                  lose our money. If this happens, it is normal. If we win, it
                                  is abnormal. By comparing the number of times we win
                                  with the number of times we play, we can measure the

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abnormality rate, i.e., the risk of winning the lottery.

The same applies for damages resulting from industrial
accidents. To estimate the abnormality rate, i.e., the risk
of damages or accident potential, the preventionist first
estimates the frequency of danger being present during
malfunctions, then the severity of possible damages.

These two parameters are measured in terms of probability
and by multiplying these two probabilities, we can
calculate the risk rate, generally expressed by a percentage
or the number of times the damage can occur (X times in
1000, Y times in 1,000,000).

Rarely is there enough data to calculate the risk rate of a
particular industrial system, but it is possible to calculate
the risk rates for unit operations, simple procedures or
specific trades. For example, in 1994, a Canadian dock-
worker had a 53% probability of having an occupational
injury reported to the compensation board during the year,
a 15.7% probability of having a disabling injury and a
0.10% probability of dying (HRDC-Labour, 1995).

Summary
The accident investigation and analysis techniques of this
approach are closely tied to the more modern concept of
work operations. The accident phenomenon is itself a work
operation and, in this sense, is part of the work system that
created it.

The accident phenomenon is itself a “work task”. It is the
consequence of system activities that did not follow
“normal” operations and, more than that, of inefficient
vicarious tasks. In other words, by uncovering the
malfunctions that disrupt normal operations, we can
identify the cause factors at the root of these task
deviations.

In conclusion, we must specifically determine the hazard
that becomes a danger and harms an accident victim and
the risk inherent in a specific task.



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      Module 6

          Steps
          in the
Hazardous Occurrence

    Investigation
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  Objectives of the Module:

      Introduce general investigation principles for
      Hazardous Occurrences.

      Show the necessary steps in performing an
      investigation.

      Know what to do when informed of an accident.



  Content of the Module:

  Statement of the guiding principles and basic rules in
  conducting an accident investigation

  The key steps in an investigation

  Preparing for the investigation

  Summary




Investigation
  Definition of an Investigation
  Just as an individual takes risks, so does a company. An
  individual may take risks that could cause damage to his
  organs (such as alcoholics to their liver, smokers to their
  lungs), his personal property (a fireplace in the living
  room, an unlocked door) or his loved ones (a child not
  properly buckled in his car seat, a guard dog). A company
  may also takes risks involving its employees, property,
  third parties, management and the environment.

  For the purpose of this course, the topics of investigation
  will be tasks and situations that have caused, could have
  caused or might cause an occupational injury, i.e.,
  accidents, near accidents, incidents and poisonings:

  •   accidents that result in a fatality or compensable injury;


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                                  •   accidents that only require first aid or emergency
                                      treatment;

                                  •   accidents that result in equipment shutdowns and
                                      breakdowns and property losses;

                                  •   accidents that result in environmental disturbances;

                                  •   near accidents that result in production loss only,
                                      without any apparent damages;

                                  •   incidents that result in lost time only, without any
                                      major production loss; and

                                  •   malfunctions that were controlled by efficient vicarious
                                      tasks.



                                  The investigation techniques described in this course are
                                  difficult to apply to occupational diseases and chronic
                                  poisonings, which require specific methods of analysis, like
                                  the toxicological study and the industrial hygiene sampling.
                                  If these potential conditions exist, you should contact your
                                  W/BGSO, who will determine whether or not to seek
                                  assistance from the specialists.

                                  An investigation may be defined as follows:

                                      A series of steps and activities carried out to
                                      gather the facts and evidence needed to
                                      identify the causal factors and analyze the
                                      accident sequence in order to specifically
                                      determine preventive actions.



                                  Basic Rules


                                  Here are some basic rules to help you with your
                                  investigation.

                                      Always ensure your own health and safety.

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    Always identify yourself to all persons you meet during
    the investigation.

    Always record in a bound and numbered notebook
    all activities related to an investigation. If the
    investigation could lead to legal action, it is better to
    use the notebook for that investigation only.

    Except for situations involving danger, limit the
    investigation to the occurrence at hand and advise
    management of all other situations requiring action.

    Gather the maximum of information and statements in
    order to obtain a general view of the occurrence and
    then gradually proceed to obtain the specifics of the
    situation.

    Develop an action plan relevant to the occurrence
    under investigation.



Goals of Investigations


The goals of an investigation are to:

•   identify the causes or contributing factors;

•   determine the corrective measures that will prevent
    a similar accident from recurring;

•   determine if the General Safety Program or standards
    need to be modified or amended; and

•   determine whether new procedures or standards
    should be developed.




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                                  In a unit’s operations, a combination of at least six key
                                  elements can cause malfunctions that may result in an
                                  accident. They are:

                                     personnel;

                                     equipment;

                                     materiel;

                                     environment;

                                     work organization; and

                                     work procedures.



                                  Personnel

                                  Employees must be aware of potential work-related
                                  dangers. The employer is responsible for ensuring that his
                                  employees adequately follow instructions. The immediate
                                  supervisor must be a role model in terms of safety. Here
                                  are a few factors that can influence this aspect: lack of job
                                  knowledge, lack of job skills, failure to follow instructions,
                                  misunderstood or ignored instructions.




                                  Equipment

                                  Machines and tools used to carry out the work must be in
                                  perfect working condition, well-maintained and equipped
                                  with protective guards to avoid any direct contact with
                                  moving parts. Tools must only be used to do the tasks
                                  for which they are intended.




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Material

Storage areas must be suited to the use for which they are
intended. Access points must be free of any obstacles. The
use of hazardous materials as well as dangerous procedures
(storage of incompatible materials) may be contributing
factors.




Environment

The site must be adequately maintained and buildings must
be tidy, properly heated, lighted and ventilated. Noise
is also a factor as well as the general layout of the site
(corridors, staircases, exits, etc.)




Work Organization and Work Procedures

Have employees received the necessary training in order to
perform their work in a safe and adequate manner? Are
work procedures clear and specific? Procedures for
manual handling of materials must be developed and
applied. Here is a list to help guide you: inadequate health
and safety program, misunderstood safety practices, lack of
supervision, lack of occupational training, lack of safety
instructions when assigning work, inadequate safety
inspection program, lack of safety standards in design
and construction.

Responsibility for the Investigation
Within DND/CF General Safety Program, the assignment
of investigators to conduct hazardous occurrence
investigations is normally the responsibility of the General
Safety Officer(GSO). The following approach is offered as
an example and may assist the GSO in this task, hazardous
occurrences may be categorized into four separate classes.


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                                  Class A. A Class A hazardous occurrence is defined as any
                                           serious accident resulting in the following to
                                           members of the CF or civilian employees of
                                           DND:

                                             a. death;
                                             b. disabling injuries to two or more persons;
                                             c. the loss, by a person, of a body member or
                                                part thereof, or the complete loss of the
                                                usefulness of the body member or part
                                                thereof;
                                             d. the permanent impairment of a body
                                                function of a person;
                                             e. an unplanned explosion that put at risk or
                                                caused injury to a person;
                                             f. loss of consciousness to civilian employee
                                                or CF member through an electric shock,
                                                toxic atmosphere, or oxygen deficient
                                                atmosphere; or
                                             g. the implementation of rescue, revival, or
                                                other similar emergency procedures, but not
                                                including ambulance transportation.

                                  Class B. A Class B hazardous occurrence is one where an
                                           individual suffers a disabling injury not included
                                           in the Class A list.

                                  Class C. A Class C hazardous occurrence is an accident,
                                           which caused a non-disabling injury or an
                                           incident (near-miss), which could have caused
                                           injury to a person.

                                  Class D. A Class D hazardous occurrence is an accident
                                           which caused damage and/or loss to material,
                                           works, or buildings, or an incident which could
                                           have caused damage to material, works, or
                                           buildings. Class D hazardous occurrences are sub-
                                           divided into groups by commands/groups to
                                           further define them and to assist in determining
                                           who should be assigned to do the investigation.
                                           For example, Group 1 could be defined as an
                                           accident which caused damage, or an incident that
                                           had the potential to cause damage amounting to
                                           more than $100K; Group 2, between $100K and

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           $10K; Group 3, between $10K and $1K; Group 4,
           all others.

In assigning investigators to conduct hazardous occurrence
investigations, B/WGSO may follow these guidelines:

   a. Class A. An investigation team headed by the
      B/WGSO.
   b. Class B. A team headed by the UGSO for units
      comprised mainly of CF personnel and a team
      consisting of at least one management
      representative, and one union representative from
      the Occupational Health and Safety Committee for
      units comprised mainly of civilian personnel.
   c. Class C. Class C hazardous occurrences may
      continue to be investigated by supervisors.
   d. Class D.
        i. Group 1. B/WGSO
        ii. Group 2. UGSO or OHS Committee Team
        iii. Group 3&4. Supervisors


As suggested above, depending on the nature and severity
of the accident, the investigation may be conducted by:

Employer

The employer is responsible for determining the main
causes of hazardous occurrence and taking the proper
corrective measures prior to reactivating the system.

The employer must investigate and submit a report to
HRDC-Labour on any accident that caused bodily injury or
illness (Part XV of the Regulations). The employer must
understand the nature of the work performed and the
circumstances surrounding the accident. Also, the
employer is in the best position to understand and apply
corrective measures to prevent the recurrence of an
accident.




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                                  Work Place Health and Safety Committee

                                  The committee must be notified of any hazardous
                                  occurrences, including accidents and occupational diseases.
                                  Committees participate in the investigations.

                                  When to Conduct an Investigation?
                                  The investigation must be conducted as soon as possible
                                  after the accident, while witnesses still have an accurate
                                  recollection of what occurred. In the case of serious
                                  accident, some witnesses may need time to calm down
                                  prior to giving an accurate and objective account of the
                                  accident.

                                   The Key Steps in an Investigation
                                  In chronological order, the key steps in an investigation
                                  are:

                                  A) Receiving notice of a hazardous occurrence.

                                  B) Planning the investigation:

                                      • location of the hazardous occurrence;

                                      • establishing investigation level;

                                      • reporting to outside agencies (if required);

                                      • verification of the Investigation Kit.

                                  C) Arriving on the scene:

                                      • introduction as investigator;

                                      • securing the site;

                                      • simultaneous investigation by other agencies (if
                                         required);

                                      • creating a list of witnesses.




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D) Gathering physical data:

     • note-taking;

     • photos;

     • physical evidence;

     • sketches.

E) Gathering witnesses’ accounts and statements.

F) Assessing the facts, searching for causes and
   identifying the corrective measures taken.

G) Drawing the preliminary conclusions.

H) Preparing the investigation report.

I)   Analyzing the accident sequence.

J)   Drawing final conclusions and drafting
     the recommendations.

K) Preparing the final report.

The first three steps, A, B and C, constitute the preparatory
phase of the investigation. These will be covered in this
module. At this stage, the actual investigation has not yet
begun.

Steps D and E constitute the evidence gathering phase.
These steps will be dealt with in later Modules.

Steps F, G and H make up the facts assessment phase.

A report may or may not be prepared at this point.

Steps I and J represent the accident analysis phase. This
phase is a separate part of the investigation because more
often than not, the event analysis and search for cause
factors can be done in your office, whereas the assessment
of facts phase is done in the field.




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                                  Step K, the last step, can be called the follow-up phase.

                                   An investigation must normally result in changes to the
                                  work system in order to 1) prevent a similar accident from
                                  recurring and 2) identify the failures in the internal
                                  responsibility system supported by the General Safety
                                  program.

                                  It is very important to understand that these phases are not
                                  distinctly separate from one another. They overlap and
                                  extend often well beyond our expectations. If the
                                  preparatory phase is over quickly, the facts phase starts
                                  with the initial data collection and often extends right to the
                                  end of the investigation.



                               The Preparatory Phase


                                  The preparatory phase of a work-related accident
                                  investigation includes the following steps:

                                      receiving notice of a hazardous occurrence from the
                                      employer;

                                      planning the investigation;

                                      arriving on the scene.



                                  Receiving Notice of a Hazardous
                                  Occurrence
                                  Once you receive notice of the hazardous occurrence, you
                                  must attempt to obtain as much information as possible
                                  on the following:

                                  •   the nature of the occurrence and the extent of damages;

                                  •   the date and time of the occurrence;



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•   the accident sequence as a whole: who, what, when,
    where, why, how, etc.

•   the name of the caller, their address, phone numbers
    where they may be reached, their occupation, etc.

Immediately remind individuals on the site not to disturb or
remove any piece of equipment, machinery or material,
unless it is necessary in order to control a fire or a
hazardous situation, move an injured person or restore
essential services.



    Notify HRSDC – Labour Program in case of a
    serious injury

    Within 24 hours HRSDC must be notified. This is
    normally done by the GSO.



Planning the Investigation


1) Information on the Workplace

In order to prepare for a hazardous occurrence
investigation, you must, if there is time, review the
following items in the unit’s file:

•   previous safety inspection reports;

•   accident statistics and previous accident investigation
    reports;

•   minutes from Health and Safety Committee meetings, if
    available;

•   brief description of the equipment involved, if
    applicable.




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                                  This information will enable you to determine:

                                  •   the type of personal protective equipment you need
                                      (check the contents of the investigation kit);

                                  •   the type of specialized testing and sampling equipment
                                      required;

                                  •   the type of technical services required: police, CE, fire
                                      department, environmental or hazmat services,
                                      radiation safety etc.

                                  2) Establishing Location

                                  It is important to check with your GSO as to whether the
                                  unit is under the base/wing or a lodger unit.

                                  3) Investigation

                                  Only qualified personnel must investigate
                                  Hazardous Occurrences. (see Module 2)



                                  4) Verification of the Investigation Kit

                                  Make sure you bring all of the required materials and
                                  notebooks.

                                  Also check the content of your investigator’s kit (an
                                  example of what it may contain):

                                  •   a polyvinyl chloride Tychem 7500 Fabric coverall
                                      (check the compatibility with chemical products before
                                      use; if in doubt, consult local GSO)

                                  •   rubber gloves (check compatibility with chemical
                                      products before use);

                                  •   safety glasses/ goggles;

                                  •   earmuffs or plugs;

                                  •   camera & extra film;


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•   flashlight;

•   plastic 100 feet tape;

•   bulk sampling containers;


•   yellow “danger/caution” tape;

•   high visibility vest;

•   safety hat.




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Table 1       Checklist for use upon notification of a hazardous occurrence



     Obtain from the caller:
        a brief description of the accident
        the number of people injured, their names and the types of injuries
        the date and time of the accident
        the unit name
        the location of the accident
        the caller’s name, occupation and phone number
     Verify the employer’s jurisdiction(contractor)
     Ask whether the scene of the accident has been disturbed
     Tell the caller not to disturb the scene until an investigator has arrived
     Consult the unit’s record’s
     Determine who will be conducting the investigation
     Check the contents of the investigation kit
     Verify the availability of protective equipment
     Check that you have:
         notebooks
         a camera
         the forms
         measuring instruments
     Determine whether you need:
        the police
        the fire dept.
        the gas company
        the firefighters
        the environmental emergency team
        a specialist from the other safety organizations on Base




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Arriving on the Scene

When you arrive on the scene, you must:

   first, introduce yourself and explain, if necessary, your
   role;

   secure the site if necessary;

   identify investigators from other agencies;

   create a list of victims and witnesses.


1) Introduction of the Investigators

You should begin by introducing yourself to the managers
present or any persons designated by the union.

You must then explain the purpose of your investigation.
By providing a clear explanation you will obtain better
cooperation to help you uncover the facts surrounding the
hazardous occurrence.

2) Securing the Site

You must not interfere with emergency and rescue teams:
fire extinction, first aid, clean-up efforts following an
accidental spill, etc. You must not access the site unless
specialists have already secured it.

Before accessing the site, you must immediately inquire
about any protective equipment that must be worn:
respirator, earplugs, clothing, safety boots, etc. If you do
not have the equipment, the employer must provide it.

When access to the site is clear and safe, you must
ascertain that the accident scene has not been disturbed.
If it has, you must check if the scene was disturbed and
why. Take measures to ensure the scene is not further
disturbed.

Upon arriving on the scene, note the time, weather
conditions (wind direction and speed, temperature, rain,

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                                  snow, fog, etc.) and the first sensations you feel: heat,
                                  humidity, chemical odour, housekeeping etc.

                                  Then, as quickly as possible, and certainly before
                                  questioning witnesses, you must familiarize yourself with
                                  the circumstances surrounding the hazardous occurrence
                                  and gather as many technical details as you can on the
                                  operation of the equipment involved. At this point, you
                                  can decide whether or not to secure the site.

                                  As soon as the site is secured, make sure you inform the
                                  employer and any other person not to disturb the wreckage
                                  or things related to the situation unless authorized by the
                                  investigator.

                              CLC Part II

                                  127.(1) Subject to subsection (2), if an employee is killed
                                  or seriously injured in a work place, no person shall, unless
                                  authorized to do so by a health and safety officer, remove
                                  or in any way interfere with or disturb any wreckage,
                                  article or thing related to the incident except to the extent
                                  necessary to:

                                      (a) save a life, prevent injury or relieve human
                                          suffering in the vicinity;

                                      (b) maintain an essential public service; or

                                      (c) prevent unnecessary damage to or loss of
                                          property.

                                      127.(2) No authorization referred to in subsection (1)
                                      is required where an employee is killed or seriously
                                      injured by an accident or incident involving

                                      (a) an aircraft, a ship, rolling stock or a commodity
                                          pipeline, where the accident or incident is being
                                          investigated under the Aeronautics Act, the
                                          Canada Shipping Act or the Canadian
                                          Transportation Accident Investigation and Safety
                                          Board Act; or

                                      (b) a motor vehicle on a public highway.


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4) Creating a List of Witnesses

Before gathering physical data, you should make a list of
witnesses and other persons who may be useful in your
investigation, e.g. the name of an electrician familiar with
the machine, the name of an engineer, or the name of the
first aider.

You must also note where they may be reached, phone
numbers, e-mail address and work addresses.




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Table 2          Checklist for arrival at scene of a Hazardous Occurrence

     Advise the employer of your arrival
     Immediately note the date and time
     Identify yourself to the people present: name, department
     Identify the committee representatives: name, position, phone number,
     Identify the employer representatives: name, position, phone number,
     Explain why you are at the scene
     Ensure that first aid has been administered
     Identify the victim(s):
        name
        address
        occupation
        seniority in unit and at work station
        age and sex
     Immediately make note of:
        environmental conditions
        first impressions
     Ask whether any PPE is compulsory and wear it
     Establish a safety perimeter with tape
     Advise everyones not to disturb the scene:
     Record the names, phone numbers and organizations of other interveners:
        police
        firefighter
        ambulance
        first aid
        coroner
     Familiarize yourself with the facts surrounding the accident
     Identify the people who will be joining you during the investigation
     Establish a list of probable witnesses:
        name
        occupation and company
        phone number
        arrange a place to meet with them
     Proceed with the gathering of physical data:
        photographs
        sketches
        evidence




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Summary


The investigation process is a series of steps and activities
designed to gather the necessary facts and evidence in the
search for cause factors and the analysis of accident
phenomena for the purpose of how to prevent a
reoccurrence.

A standard investigation involves roughly ten steps, which
are grouped into five phases: the preparatory phase, the
gathering of evidence, the assessment of facts, the analysis
and the follow-up. These phases overlap and are not really
over until the follow-up phase has ended.




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     Module 7

Gathering/Recording
 Physical Evidence
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Objectives of the Module:

   Know what preliminary information to collect.

   Know the procedures of an accident investigation and
   the techniques of gathering/recording physical
   evidence.

   Know when to make use of internal or external
   expertise.



Content of the Module:

Gathering preliminary data

Note-taking

Photographs and videotapes

Measurements and sketches

Physical evidence

Requesting internal/external expertise (police, coroner,
etc.)




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                                  Gathering Preliminary Data


                                  Data gathering is the starting point of any Hazardous
                                  Occurrence analysis. The information required for a
                                  complete accident description includes the identifying
                                  characteristics of the accident event as well as the technical
                                  operations relating to the normal task and those that
                                  resulted in damages. The preliminary investigation is only
                                  concerned with identifying the accident event.

                                  The purpose of this data gathering exercise is to label
                                  accident events in order to situate them in time, space and
                                  environment. Data are used to “recognize” the accident
                                  once the facts and circumstances leading to damages have
                                  been corrected or eliminated. The main data focus on
                                  identifying:

                                  •   the victim: name, rank, occupation, qualification, age,
                                      date of birth;

                                  •   the physical injury sustained: medical diagnosis,
                                      anticipated disablement, type of injury, affected
                                      body part;

                                  •   the property damages: hazardous material spill,
                                      machine breakdown, destruction of buildings and
                                      structures, machine shutdown, production loss;

                                  •   the workstation involved: company, business place,
                                      department, service, workshop, floor, machine, tool,
                                      material, position title, accident location;

                                  •   the timeframe relating to the key actions surrounding
                                      the accident: date and time of the accident, statement
                                      and analysis, length of shutdowns;

                                  •   the actual working conditions when the accident
                                      occurred: team, schedule, physical environment, and
                                      psychological and social atmosphere;

                                  •   the witnesses and the first individuals notified;



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•   the first aid attendants; and

•   the investigators and their report.

Most of this data is logged by the employer using a work
related injury or illness record (Figure 7.1).

Almost all companies have developed this type of record or
have adopted the record required by legislation or the
workplace compensation agency.

This record is critical to all administrative personnel who
are responsible for compensation files when an injured
worker requests reimbursement for salary loss, medical
treatment, loss of limb, deterioration of a body function,
psychological effects or rehabilitation.




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                                                        Sample

   Plant:                                                      Department:
   Immediate Supervisor:
   Who was injured?
   ID #:
   Last name:                                                  First name:
   Age:                 Sex:   M          F      Occupation:
   Job seniority:                                                                        Days        Months        Years


   Job training:                                 No        Yes        Date:
   Previous injuries:
   When did the accident occur?
   Date:                                                       Time of accident:
   Job start time:
   Date of last day off:
   Work schedule:              Normal         Stationed            Steady            Rotation            Condensed
   Where did the accident occur?
   Exact location of accident: room #:
   Name of room:
   Machine —Charging station #:
   Designation:
   Portable machine:
   Instructions on workplace safety:       No                   Yes             #:
   What are the alleged facts of the accident?
   Technique #:
   Who witnessed the accident?
   Last name:                            First name:                               Department:
   What are the damages?
   Part of body:
      Head                         L. Arms. R.                    L. Legs. R.                    Trunk
      L. Eyes. R.                  L. Hands. R.                   L. Feet. R.                    Internal injury




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   What are the damages? (cont’d)
   Details:
   Nature of injury:
      Fracture                     Contusion                 Asphyxia                   Visual problem
      Burn                         Dislocation               Poisoning                  Hearing problem
      Bite                         Shock                     Amputation                 Muscle tear
      Wound                        Lumbago                   Foreign body               Neurological injury
      Sprain                       Cut                       Other
   Lost Time — No Lost Time:             stopped work on:                   return to work on:
   Temporary disability:                 total days:                        days worked:
   Partial permanent disability:    %
   Fatality: death occurred on:
   Physician’s or nurse’s signature:


Figure 7.1 - Report of Injury/Illness/Damage


                                             These records are generally kept by the employer, the first
                                             aids attendants and the physician or nurse in the health
                                             service department, where this service is available.

                                             In the case of accident events requiring first aid only,
                                             records completed by first aid workers are less detailed.

                                             For incidents and minor near misses, the analyst often
                                             gathers this information on site, since records of these
                                             events are few or non-existent.

                                             Always keep in mind that the purpose of gathering
                                             preliminary data is to facilitate the analytical understanding
                                             of the complex series of components of human-machine
                                             systems involved in accident events. This data will be used
                                             to clearly define and identify the following:

                                             •   the system input: what is transformed by the work
                                                 involved;

                                             •   the output: what is produced by the work involved;

                                             •   the machine: tool, material, equipment, robot or
                                                 installation used to carry out the work;


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                                  •   the control system: all devices that activate the
                                      machine or transform the work field;

                                  •   the signal system: all devices that provide the operator
                                      with information on the status of the work field or the
                                      transformations carried out;

                                  •   the regulation system: all devices that regulate
                                      a machine in response to the difference between the
                                      output and the actual status of the work field;

                                  •   the work field: the temporal, spatial and biological
                                      setting in which the work is carried out;

                                  •   the operator: the individual that receives the signals or
                                      sends the orders;

                                  •   the instructions: information that tells the operator
                                      what to do;

                                  •   the work aids: information that establishes the
                                      system’s operating rules.



                                  The main tools available to you are:

                                      your notebook;

                                      a still camera and video camera;

                                      a sketching kit: measuring tape, flashlight, drawing
                                      pad, markers, angle protractor, graph paper, etc.;

                                      the physical evidence; and

                                      advice from an external expert.




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Note-Taking


Notebooks originated as a management tool in London,
England, when police forces were first established. The
advantages of well-maintained notebook are:

•   Since nobody has total recall of all the minute details of
    an accident, it is helpful to record these.

•   The notebook eliminates the need to memorize small
    but important details.

•   Notebooks are used to keep track of evidence.

•   Extensive notes facilitate the preparation of complete
    and accurate reports.

•   Notes serve as an aid to recalling information and
    events.

•   Notes help to establish your credibility as a witness in
    court. They can attest to one’s professional
    competence when they are complete, accurate and
    legible.




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Figure 7.2 - Example of Safety Officer’s Notebook


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Rules and Standards of Well-Maintained
Notebooks


•   Notes are any written information.

•   Notebooks are never, ever thrown away.

•   Original notes must be kept.

•   Notebooks are used for business purposes only.

•   The notebook must be a bound notebook. Never loose
    leaf.

•   The dates of the first and last entries are recorded on
    the inside front cover.

•   Only one notebook is used at a time.

•   Notes are chronological.

•   Pages are never torn out. All pages are numbered.

•   Notes are always written or printed in ink.

•   Errors are stroked out with a single line, with the
    correct entry following immediately. Corrections are
    initialed. The incorrect, deleted information must be
    legible. Errors are never erased or scored out
    completely.

•   Each entry includes the date, time and place writing by
    hand and is signed or initialed by the author.

•   Write on each line. Do not leave blank spaces between
    entries. Enter an X in unused spaces.



TAKE NOTES OF ONLY FACTS, NO OPINIONS




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                                  •   Record arrival time, telephone report, date, and weather
                                      conditions.

                                  •   Record the names, addresses, telephone numbers and
                                      title of persons interviewed. Also, note details of
                                      conversations and comments if formal statements are
                                      taken.

                                  •   Notes must be legible. You must be able to read your
                                      own notes, even after a long time has passed.

                                  •   You may use any language, abbreviations or shorthand
                                      as long as you are consistent.

                                  •   Letters and/or numbers may be used instead of names
                                      to identify key witnesses after they have been
                                      previously identified. For example:



                                            O         Owner

                                            S         Supervisor

                                            V         Victim

                                            W1        First Witness

                                            STMT      Statement

                                            LOC       Location



                                  Important Information

                                      If more than one person is working on
                                      an investigation, one person will be appointed
                                      in command and will delegate tasks and record
                                      who performed what task.

                                  Each time a witness is interviewed, the same biographical
                                  information should be recorded:

                                  •   exact name, correctly spelled;


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   •   business address including postal code (i.e., where the
       person can be reached during the day);

   •   home address including postal code; and

   •   business and home telephone numbers.



   For every person interviewed, record the following basic
   information to jog your memory:

   •   sex (“M” or “F”);

   •   race (“B”, “W”, or “O”);

   •   approximate height, weight and build;

   •   eye glasses;

   •   beard; and

   •   eye color, distinguishing marks, tattoos or scars.

NOTE: Personal information not to be reproduced in the
investigation report.

   Record the answers to all questions, using “Q” for
   questions and “A” for answers.

   Notes may be filed as evidence in court. They must be
   neat, accurate and understandable.

   Some rules and suggestions on note-taking are:

   •   Plan your note taking.

   •   Never write a lie or “fudge” information in a notebook.

   •   Notes must be made as soon as possible while the
       event is still fresh in your memory. “As soon as
       possible” means immediately. Notes made the next
       day can be challenged.




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                                  •   Notes must be brief but complete. Understanding
                                      should not be sacrificed for brevity.

                                  Your notes must be legible not only to you but to anyone
                                  else who may need to refer to them. This can be achieved
                                  by:

                                  • using short sentences or phrases;

                                  • working chronologically;

                                  • using only commonly known and accepted
                                    abbreviations;

                                  • showing direct quotes within noticeable quotation marks
                                    to distinguish them from paraphrased statements.

                                  Notes must always be accurate. This includes:

                                  • correct, full names of all persons involved;

                                  • correct addresses and telephone numbers of all persons
                                    involved;

                                  • correct date and time of occurrence and investigation;

                                  • exact description and location of scene, machinery,
                                    accident, victim, etc.;

                                  • sketches of scene; and

                                  • description of evidence obtained or required.



                                  The time to make proper notes is when information is
                                  obtained. In a crisis, when there is confusion and you are
                                  rushed, you must adapt your note-taking to the situation.

                                  When it is time for note-taking, you will have to deal with
                                  several difficulties: frightened witnesses, many people
                                  talking at once and no real privacy for interviews. In such
                                  situations you must rely on your own resources based on
                                  training, experience, common sense, and sound judgment.


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You must take notes primarily for accuracy and
completeness of information; there will be no time to think
about form.

Be sure your notes are complete and clear enough so that
you can read and understand them later.



Control List


The EFFECTIVENESS of your notebooks is based on:
Accuracy, Completeness, Conciseness and Clarity.

Accuracy and clarity include writing/printing legibly and
correct spelling of names, places and addresses. Accuracy,
completeness, conciseness and clarity depend-upon a
thorough, accurate and objective investigation. Keep a
checklist of the information that must be obtained and
recorded in your notebook during an investigation.

This information includes all facts and details necessary to
answer the questions Who? What? When? Where?
How? and sometimes Why? in relation to the occurrence
and investigation. This information will make up the
content of written reports and will serve as a reference.

      Who           did what to whom and where, when,
                    why and how was it done, information
                    about the accident, victim, witness,
                    complainant, owner, etc.

      What          information about the accident,
                    machinery, procedures, worker
                    training, etc.

      Where         information about the location of
                    machinery, the accident, problem,
                    evidence, etc.




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                                        When           information about date and time
                                                       of accident, actions taken and
                                                       investigation activities, etc.

                                        Why            information about reasons for the
                                                       accident to have occurred.

                                        How            information about the manner in which
                                                       the accident occurred.

                                  Example:

                                  To answer the question Who? in relation to the victim, you
                                  must record all details including name, sex, age, rank,
                                  occupation, address and telephone number, as well as any
                                  other relevant information.

                                  Information on each witness who gives a statement,
                                  including name, occupation, employer, address and
                                  telephone number must be recorded.

                                  You must also record the information necessary to answer
                                  the question Who? in relation to all health and safety
                                  officers and investigators participating in the investigation.

                                  For example, who responded to the call, who conducted the
                                  investigation, who preserved the scene, who labeled each
                                  piece of evidence and who took custody of the evidence.

                                  Likewise, you must record all facts and details necessary to
                                  answer the other five basic questions.

                                  Photographs
                                  The camera is one of the investigator’s most versatile
                                  and useful tools. As with any tool, however, when used
                                  improperly it can destroy or distort the very evidence it
                                  seeks to preserve. Photographs can record what the eye
                                  misses at the scene. They can also record a great deal of
                                  detail thereby saving the investigator time and tedious
                                  work. The camera also has an infallible memory and can
                                  remember, for the investigator, minute details he may need
                                  later in his analysis. A well-taken photograph can be of
                                  immeasurable value to a disciplined investigator.


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But the camera can also be detrimental to a disorganized
investigator. Poor shots can be misinterpreted and the end
result is the same as if the camera had lied as a witness.

Possibly the most serious drawback to photography is the
tendency to let the camera think and see for the
investigator, i.e., to take large numbers of photographs at
random hoping that the key to the accident will suddenly
jump out from one of them. This approach not only
undermines the credibility of the accident analysis, but also
wastes the investigator’s time by having to examine a pile
of unusable photographs.

General uses of photographs during an investigation
include:

•   To determine the coordinates of the accident scene.

•   To record the details of injuries and damages.

•   To record relative positions of several object or
    damaged items.

•   To depict witnesses’ views of the scene.

•   To show evidence of improper assembly or use of
    equipment, materials and structures.

•   To record detail of marks, spills, signs, etc.

•   To show evidence of deterioration, abuse and lack of
    proper maintenance.

•   To locate parts or other evidence overlooked during
    early stages of investigation.

•   To demonstrate sequence machine failures.

Take a series of photos and, if possible, make a videotape.
Start by taking an overall picture of the workplace, then
progressively photograph or film up to the exact site of the
hazardous occurrence, in order to obtain a general view of
the scene and record the maximum number of details.



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                                  If you are taking a picture of an object outside of its
                                  original environment, place it on a table covered with a
                                  pale blue cloth. Avoid white which reflects light, and
                                  green and red which are difficult to reproduce with color
                                  photography.

                                  Identify each photograph and film by noting the date, time,
                                  location, item or person photographed and the name of the
                                  person taking the picture or film (Figure 7.3).

                                  Draw a sketch indicating where photos were taken in order
                                  to clearly indicate the subject or item and the location.




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                                 Photo Log

Film Index : _________________________________________________________
Accident : ___________________________________________________________
Date : ________________________ Investigator : _____________________________


       Subject           Lens   Orientation                 Notes                No

                                                                                 1
                                                                                 2
                                                                                 3
                                                                                 4
                                                                                 5
                                                                                 6
                                                                                 7
                                                                                 8
                                                                                 9
                                                                                 10
                                                                                 11
                                                                                 12
                                                                                 13
                                                                                 14
                                                                                 15
                                                                                 16
                                                                                 17
                                                                                 18
                                                                                 19
                                                                                 20
                                                                                 21
                                                                                 22
                                                                                 23
                                                                                 24


Figure 7.3 - Sample Photo log




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                                  Sketches and Measurements
                                  Sketches are very useful for understanding the order of the
                                  various elements of the accident system. They also help in
                                  locating where pictures were taken.

                                  •   Use graph paper (Figure 7.4).

                                  •   Indicate the scale used : one square representing one
                                      foot, one metre, etc.

                                  •   Indicate directions: N.S.E.W.

                                  •   Use a sheet of paper to measure diagonally.

                                  •   Proceed as with photographs: start far away and close
                                      in.

                                  •   Identify objects, materials, etc., by their perimeter.

                                  •   Identify the accident, the victim and witnesses inside
                                      the perimeter and use an arrow outside the perimeter
                                      for pointing at specific objects.

                                  •   Identify photos taken and cross-references to other
                                      pictures.

                                  •   Identify all sketches as with photographs: labels,
                                      captions or writing on the reverse side.




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                                Sketch

Accident:                                                    No:
Date:                      Investigator:




                                                          Scale:

Figure 7.4 - Graph paper



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                                  The relative position of persons, equipment, materials and
                                  objects on the scene is an important source of information
                                  and evidence. To record this “positional evidence”, the
                                  investigator makes use of sketches and measurement tables
                                  that will be useful later when analyzing the accident
                                  phenomenon. Sketches and tables can be used to draw up
                                  plans supporting the analysis and conclusions of the
                                  accident report.

                                  The first problem confronting you at the accident scene is
                                  that of identifying what is relevant to the accident. To
                                  solve this problem, you must look at the kind of
                                  information that is likely to provide you with positional
                                  evidence, for example:

                                  1. Impact points will inform you of the trajectory of
                                     moving parts and objects and their on impact;

                                  2. The way objects are positioned will inform you of any
                                     differences in actual operating positions compared with
                                     the normally correct and anticipated operating
                                     positions, the movement of objects within a given area
                                     and the storage of materials;

                                  3. The position of witnesses will enable you to determine
                                     whether these witnesses could have seen what they
                                     reported having seen, whether they were able to reach
                                     the control mechanisms that were supposed to have
                                     been activated and their ability to work comfortably
                                     without undue physical stress;

                                  4. The relative position of heavy equipment and structural
                                     elements will enable you to identify any interfering
                                     factors that could have led to decreased visibility,
                                     restricted movements because of obstructions,
                                     congestion, etc.




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Items to Record and Measure

Since your role is to mentally reconstruct what happened,
and how and why it happened, you must attempt to do this
from the many elements at the accident scene and the
respective positions of objects and people. Your first task
is therefore to determine which elements at the scene will
help you answer these questions, that is, which elements
are positioned in such a way as to give you at least part of
the answer. You will find it almost impossible, however,
from your first glance around the area to identify these
elements and their exact locations before and after the
accident. Consequently, nothing should be considered
unrelated to the accident until proven so. Using a grid, you
must position all elements present on the scene, including
injured persons, damaged equipment, marks or gouges in
structures, etc.

You must record the position of the following:

(1)   The dead and injured;
(2)   The key witnesses;
(3)   Machines, vehicles and other types of equipment
      involved in or affected by the accident;
(4)   Parts broken off or detached from equipment,
      vehicle, and materials;
(5)   Objects broken, damaged or struck during or as a
      result of the accident;
(6)   Gouges, scratches, dents, paint smears, stains, marks,
      etc., on surfaces;
(7)   Tracks or skid marks or other similar signs of
      movement;
(8)   Defects or irregularities in surfaces;
(9)   Pools or stains from fluids, whether existing before
      the accident or spilled as a result of the accident;
(10) Spilled or contaminated materials;
(11) Areas containing debris;
(12) Sources of distraction or adverse environmental
     conditions; and


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                                  (13) Safety devices and equipment. Although not
                                       necessarily actual pieces of evidence, these are very
                                       useful in terms of evidence.

                                  Be on the lookout for things that are missing. What is not
                                  found at the accident scene can often be essential to the
                                  analysis. For example, a vital part of a machine or vehicle
                                  may have loosened and fallen off some time before the
                                  accident or landed some distance away from the accident
                                  site. Or, this missing part may not have been replaced
                                  during maintenance or may not have been installed at the
                                  time of manufacture.

                                  Failure to record the positional evidence in a detailed and
                                  orderly manner means that during your analysis, your
                                  conclusions will lack a firm basis regarding the role this
                                  vital part played in the accident.



                                  Triangulation is the most commonly used method for
                                  measuring and recording positions (Figure 7.5).

                                  Essentially, this method involves connecting each element
                                  of the sketch to at least two other fixed elements by
                                  measuring the distances between them. At the end of the
                                  exercise, you will have at least two measurements for each
                                  element in the sketch. Greater accuracy is achieved when
                                  each element is part of at least two triangles and when the
                                  angles are near 60 degrees. In this case, each element will
                                  have three measurements.




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                                                              C




                                                         D

                                    E




Figure 7.5 - Accident site sketch

                                    To avoid confusing recorded positions, we recommend the
                                    following:

                                    1) Identify elements to be recorded on your sketch (Figure
                                       7.5).

                                    2) Identify each element using letters to avoid mixing
                                       them up and causing confusion with measurements.
                                       Use double letters (AA, BB, etc.) to represent fixed
                                       points and single letters to represent pieces of evidence.
                                       This will facilitate recording and identification.
                                       Position the elements on your sketch.

                                    3) Record the relative position of all elements in a table
                                       format (Figure 7.6).

                                    To obtain an accurate sketch, several measurements must
                                    generally be taken for each element. As you can see, each
                                    measurement is composed of two distances or one distance
                                    and one angle. A single measurement is sufficient only in
                                    the case of small elements or specific points.


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                                  All other elements, such as the orientation of bodies,
                                  machinery, vehicles, marks and areas where debris is
                                  found, in short, for anything than may constitute important
                                  evidence for subsequent analysis, more than one
                                  measurement will be necessary.

                                  Position and orientation must be established by measuring
                                  specific body parts, objects and areas because the way in
                                  which a body, machine or object fell or moved after the
                                  initial contact may play an important role in reconstructing
                                  and analyzing the accident phenomenon. Therefore their
                                  position must include all the necessary measurements in
                                  order to establish their orientation.




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                               Record of positions

Hazardous Occurrence: __________________________________________________
Date:________________________ Investigator:_______________________________

Key               Item             Reference      Distance           Direction
                                     Point




Figure 7.6 – Record of positions




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                                  Positional evidence must be established by two or more
                                  measurements in the following cases:

                                      Victim’s body: head, feet and body length in situ.

                                      Machines and vehicles: two opposite corners, plus
                                     length, width and height.

                                      Gouges or marks: both ends, plus length, radius of
                                     curvature, if curved, or distance between several points
                                     on the curve and a straight reference line. Include a
                                     photo if curve is complicated.

                                      Areas of debris: outer points, center and diameter, as
                                     appropriate, and the key or specific pieces of debris.



                                  Accuracy of measurements
                                  Although these two alternative methods to triangulation
                                  allow you to establish the AB distance on the sketch, they
                                  are better suited to a general analysis. You must remember
                                  that the positioning is not exact and that triangulation is
                                  more precise.

                                  You will not obtain greater accuracy with tenths of inches
                                  or too many decimals. The same is true for angles: no
                                  need to measure to the exact minute, nor is it necessary to
                                  use a square for 90-degree angles.

                                  A 100-ft. tape should accommodate virtually all your
                                  needs. You may use nails, magnetic hooks or weights, and
                                  even a briefcase can be used to hold down the end of the
                                  tape.

                                  Measure each distance and angle twice for accuracy. If at
                                  all possible, lay your measuring tape on the ground to
                                  avoid stretching and vertical deflection of the tape.




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                                 Physical Evidence

                                 Gather as much material evidence as possible. Ensure you
                                 record all evidence gathered and removed from the scene.
                                 (Figure 7.7). Return the evidence when no longer needed.



                           Record of Evidence (Sample)

I, the undersigned, acknowledge to have taken or removed from
_________________________,
In the workplace situated at
_____________________________________________________,
the following objects or documents: _______________________________________________




_______________________________
Investigator

_______________________
Date



Figure 7.7 – Receipt of Physical Evidence


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                                               A) Labeling of Evidence
                                               Label each piece of material evidence with an Evidence
                                               Tag (Figure 7.8) or insert the evidence in an evidence
                                               envelope or bag with the details attached.



Figure 7.8       Evidence tag (Sample)
                            o                                                                                         o
  Evidence No. / Preuve n       Assignment No. / No d’assignation   Evidence Report No. / Rapport sur les preuves n


  Investigator                                                      Date


  Description




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                          GUIDE TO COLLECTION AND PRESERVATION
                                    OF REAL EVIDENCE

    The role of forensic science in investigations is almost impossible to assess with any
    accuracy. In many investigations its role can be relatively minor. As the body of
    knowledge and techniques increases, scientific evidence becomes even more important
    in a greater proportion of cases. For forensic science to properly impact the outcome of
    the investigative process, it is essential that the investigator have a basic understanding
    of what the forensic laboratory can or cannot do. Investigators must also have an
    appreciation of what they can do to best use the laboratory services available.

          The following is information provided as a guide for the collection of evidence
    that may be encountered in a Hazardous Occurrence Investigation. Local laboratories
    should be consulted when time permits or there is doubt as to correct procedures.

           Each item or container must indicate:

           a)   what the item is,
           b)   where it was found,
           c)   when it was found, and
           d)   who found it.

Item                         Investigative Value          Precautions In Handling
Blood

On objects which can be      Blood grouping and the       Dry stain in air. Note if the stain is
removed for examination      nature (human or animal)     wet or dry when discovered. Protect
                             of blood can be              the dry stain with clean paper. DO
                             determined.                  NOT use a fan to hasten drying and
                                                          avoid excessive heat or intense
                                                          sunlight.

On floors, rugs, walls,                                   Protect the stain on the floor by
etc.                         Splatters and drops from     placing a clean pan or box over the
                             wound can indicated          stain. Label the pan or box with
                             distance, direction and      information as to who found it and
                             speed of travel.             the date and time of discovery.
                                                          When the stain is dry, remove the
                                                          crust without breaking by scraping
                                                          and preserving in a paper using the
                                                          Druggist’s fold. Photograph before
                                                          collecting.



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Buttons and Fasteners     The significance lies in      Package each item separately. The
                          their absence from their      working ends of tools should be
                          normal place on a             wrapped in paper to form a sheath.
                          garment and in the            Saws with wood particles in the teeth
                          manner in which they          should be packaged to prevent
                          were removed, i.e. cut or     dislodging and material loss. Where
                          torn. Torn buttons will       practical, the damaged section of the
                          often retain threads or       wood should be submitted. Attention
                          small pieces of fabric.       should be given to the possibility of a
                          Fragments of wood,            physical match between fragments
                          silver, sawdust etc, may      of the questioned material at the
                          provide useful                scene. The samples should be
                          information in some           collected with a minimum alteration.
                          cases.
Fibers

Wood, Cotton, Nylon       An examination by             Paper is the preferred packing
                          microscope can                material. DO NOT remove any
                          determine:                    surface markings. String, rope or
                             a. the source,             torn clothing should be handled
                                weather the fibers      carefully and preserved in the same
                                are animal,             state in which it was found. The
                                vegetable or            possible matching of either may be
                                synthetic;              handicapped if the frayed ends or
                             b. the colouring of        edges have been carelessly handled.
                                the fibers;             Knots should not be untied as it may
                             c. comparison with         deprive the laboratory of the chance
                                standards; and          to compare the knot with known
                             d. the nature of the       samples. All exhibits forwarded for
                                separation.             comparison by a laboratory must be
                                                        accompanied by a reasonable
                                                        amount or a known source.
Glass                     All glass can be identified   Photograph fragments before
                          and classified. It is         collecting them. All glass fragments
                          possible to determine         from both the known and questioned
                          whether a window was          sources should be forwarded. The
                          broken from inside or         two should be kept in separate
                          outside if a radial crack     containers and properly marked for
                          (one radiating outward        identification. RCMP laboratory
                          from the impact point)        indicate samples must not be
                          can be identified and if it   marked by scratches, ink, crayon,
                          is known which side of        etc as such markings may interfere
                          the glass was inside as it    with the examinations being
                          was installed.                conducted. The thin edges of glass

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                                               fragments are important in physical
                                               matching. To protect them, pack
                                               firmly between layers of absorbent
                                               cotton or some similar protective
                                               material.
Flammable Liquids   Where liquid is recovered Containers found at the scene
                    from the debris,           should be closed with a screw cap or
                    accelerants can normally tightly fitting stopper. Submit as soon
                    be identified even when    as possible. Where large quantities
                    badly evaporated. When of liquid remain in a container,
                    no liquid can be           remove and submit only a small
                    recovered the accelerant sample (10mL), retain the rest in the
                    may often be identified    event further testing is required.
                    from the vapor. It is NOT Supply information from any labels
                    usually possible to relate when the original container is not
                    accelerant from debris to submitted. Flammable liquids should
                    liquid from a specific     NOT be sent in jars with rubber
                    container or other source. sealers since the rubber may
                                               dissolve.
Gases               The gas or vapour can be One of the simplest ways of
                    identified as natural gas, collecting gas or vapour samples is
                    propane, acetylene,        to take a jar or bottle full of water into
                    gasoline, etc.             the area where gas is suspected,
                                               pour the water from the container
                                               and immediately seal securely.
                                               Vacuum gas sampling bottles may
                                               be used if they are available.
Leather and Suede                              Use paper. DO NOT package in
                                               plastic.
Paint               The value is dependant     Avoid shaking clothing. Employ
                    on the amount of paint     same precautions as with other
                    and layers of paint.       stains. Package small chips in paper
                    Significance may vary      using the druggists fold. Never place
                    from diving direction to   them directly in an envelope or
                    providing conclusive       plastic bag. DO NOT use tape for
                    evidence. Physical         lifting paint. Large chips which may
                    matching of the chips      physically fit in a damaged area
                    may provide leads and      should be placed in rigid containers
                    evidence.                  to prevent fragmentation.. When
                                               possible, submit the object rather
                                               than trying to remove paint.




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Plaster, Concrete, Mortar   Wall plaster or concrete     Package small loose particles in
                            with several layers of       small containers having tightly fitting
                            paint may provide useful     lids. DO NOT crush these materials
                            evidence. This evidence      and thus destroy the physical detail.
                            may be of value because      Comparison sample should be a
                            of the circumstances         representative sample from the
                            under which it was found     damaged area. (approx 50 grams).
                            rather than its
                            composition.
Plastics and Resins         Pieces of plastic can be    Where chemical analysis only is
                            physically matched. It is   required, the material should be
                            possible to determine the   placed in a clean box, bag or vial.
                            type of plastic by          Where a physical match of broken
                            chemical analysis. The      pieces of plastic is possible, protect
                            size and shape may          the broken edge and place in a rigid
                            indicate origin.            box. DO NOT use adhesive tape to
                                                        collect particles of plastic as the
                                                        adhesive will interfere with the
                                                        analysis.
                                                        Comparison samples should be
                                                        taken from the remaining portions
                                                        and submitted. Where the
                                                        questioned sample is intact, submit a
                                                        similar item if available.
Wire and Cables             Wires and cables that are When submitting wires for
                            certified by CSA have       examination, remove 45 cm from all
                            codings which assist in     cut ends. Identify and protect the
                            identifying their type      questioned ends.
                            (use) and manufacturer.     Comparison samples should also be
                            Several ends of wires       about 45 cm in length and
                            and cables can be           appropriately identified.
                            compared with other
                            remaining ends and with
                            tools that may have been
                            used to sever them.
Metals                      Analysis of trace           Collect and package metal particles
                            elements can show           in a small plastic box or bottle or fold
                            similarities in composition in a sheet of paper (druggist fold). If
                            to comparison samples       the metal particles are adhering to a
                            and differences from the    surface such as a tool, package to
                            metal of similar items.     avoid loss or contamination and
                            The type of metal can be submit the entire item. Submit metal
                            determined.                 pieces in any appropriate paper or
                                                        container.

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                                                     Comparison samples from the
                                                     suspected source of the particles
                                                     should be submitted packaged as
                                                     above. If the type of metal is
                                                     significant, supply any pertinent
                                                     information as to its chemical
                                                     specifications, usage, etc.
Mechanical Failures   Broken mechanical parts        Fracture components should be kept
                      may be submitted for           dry to prevent rusting. Under moist
                      chemical, metallurgical or     or wet conditions, a fresh steel
                      mechanical analysis.           fracture may become covered with
                      Generally it can be            brown rust within one hour. Fracture
                      determined whether a           surfaces may be protected from rust
                      fracture is the result of an   by coating with motor oil. If chains,
                      impact, overload or pre-       cables or ropes have broken, it is
                      existing crack or defect.      important to submit information
                      Broken chains, cables          about the configuration of the rigging
                      and ropes can be tested        involved including lengths, ands
                      for tensile strength. It       appropriate angles, block sizes, etc.
                      may be possible to relate      The weight of the load is also
                      two pieces of broken           required.
                      metal even though a
                      physical match is not
                      obvious. In cases where
                      there is structural failure
                      or collapse, eg in hoisting
                      operations, explosions,
                      etc, it may be possible to
                      provide technical or
                      engineering assistance in
                      establishing the cause of
                      such occurrences.
Vehicle Lights        Determination of whether       Disconnect one of the leads from the
                      lights were on or off at       battery. Observe the light switch to
                      the impact is usually          determine if it is on or off.
                      possible only when a           Photograph the light before
                      portion of the filament is     removing. Disconnect from its wiring
                      still present.                 and carefully package the broken
                                                     light. When the light is completely
                                                     smashed, collect the debris from the
                                                     headlight pot.




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Tires                      When a tire is to be             Submit the damaged tire still
                           examined for the cause           mounted on the rim. The condition of
                           of a failure, all the tires of   the rim is often of significance in
                           the vehicle should be            assessing tire damage. Severe
                           examined and their               vehicle instability may be caused by
                           condition and location on        incipient tread separation of which
                           the vehicle noted. The           there may be no visible external
                           make , type, size and            evidence. Where such a condition is
                           state of wear of the tires       suspected, all four tires should be
                           not submitted should be          submitted. Identify the position of the
                           included in the                  tire on the vehicle. If available,
                           accompanying                     submit photographs of any skid
                           documentation set to the         marks and close-ups of the damaged
                           laboratory. Examination          tire taken before the vehicle was
                           can usually determine            towed or the wheel removed. Submit
                           whether the damage to a          a sketch of the scene, showing the
                           tire is the result of the        point of collision, skid marks, final
                           collision or whether a           position of the vehicle(s) involved
                           puncture or other defect         and the vehicle speed if known.
                           caused a sudden                  Submit information on the vehicle(s)
                           deflation. Incompatibility       (make, model, year), road (type,
                           of tire types and sizes          number of lanes) and weather.
                           can be hazardous and
                           may contribute to vehicle
                           instability.

    Source Documents:

    Laboratory Aids For The Investigator, Fourth Addition, The Centre Of Forensic Sciences
    Public Safety Division, Ministry Of The Solicitor General (Ontario)

    A-SJ-100-004-/AG-000 Volume 4, Military Police Procedures




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      Module 8

      Interviewing
                &
Information Gathering
                                 A-GG-040-010/PT-001
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Objectives of the Module:



      Establish the order of interviews.
      Learn how to conduct an interview and the
      principles of good listening.

      Learn how to take written statements.




Content of the Module:



The interview process

The written statement

Re-enacting the accident



Exercise:




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                                  The Interview Process
                                  One of the most important sources of information comes
                                  from interviewing witnesses.

                                  Listening and interviewing skills are very important. The
                                  way an interview is conducted can make a difference in the
                                  number of facts that are discovered.

                                  It is up to you to obtain that information and the manner in
                                  which you conduct the interview will help in obtaining the
                                  information.

                                  When an accident occurs, people are nervous and fearful.

                                            Who is at fault?

                                            Will compensation benefits be lost if someone has
                                            broken a rule?

                                            Could charges result?

                                            Will disciplinary       action   result   from   the
                                            investigation?

                                            Are details of what happened embarrassing, such as
                                            running a red light?

                                            Were drugs or alcohol contributing factors?

                                            What about peer pressure?

                                  Investigators should be aware that concerns/fears might be
                                  present.




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    Interview Methods
    There are essentially two interview methods:                the
    “Directed” and the “Non-Directed”.



    Directed interviewing is designed to get specific
    information in the form of short answers.

    Non-Directed interviewing encourages the respondent to
    talk freely.

    Some non-directiveness is advisable for exploratory
    purposes.

    Since we are looking for true responses rather than
    screened responses, we want to encourage some degree of
    spontaneity.

    Such responses are more genuine and often provide
    relevant information that may not have been disclosed if
    the interviewee had not been encouraged to talk freely on a
    given topic.

    There are other important reasons for using the non-
    directed method.

•   It helps to establish a stronger rapport.

•   It is useful when the witness is angry, nervous or has
    trouble expressing himself/herself.
•   It allows the witness to be recognized as an individual.

•   The directed interview should not be overlooked, however.
    Remember that your dual purpose is to find out what
    happened and to identify the causal factors leading to the
    accident. Let witnesses have their say and if by the end of
    it you still need further clarification, ask directed questions.




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                                  The interview can be described as a seven-step process.


                              1. First, choose a place to hold the interview. Every one
                                 should be at ease and be comfortable.

                              2. Start off by introducing yourselves and explaining the
                                 interview objectives.

                              3. Listen the initial testimony without making judgments and
                                 apply the principles of active listening.

                              4. Ask questions on points you wish to clarify or that
                                 specifically concern the accident phenomenon.

                              5. Evaluate the credibility of a witness in relation to his/her
                                 own testimony and especially that of other witnesses, and
                                 your preliminary observations of the accident site.

                              6. Analyze the testimonies to detect any contradictions, look
                                 for information needed to “fill in the gaps” and shed light
                                 on critical elements.

                              7. Ask the witness to make a written statement. Since
                                 memory sometimes fails, a written statement allows the
                                 witness to leave nothing out and to recall details in a
                                 subsequent interview.


                                  Types Of Questions
                                  There are six types of questions:

                                     •      Open-ended questions;

                                     •      Closed questions;

                                     •      Clarification questions;

                                     •      Exploratory questions;

                                     •      Probing questions; and

                                     •      Leading questions.

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Open-ended Questions

Definition

Questions which require more than just a few words for an
adequate response.

Characteristics/Applications

•   The open-ended question is people oriented rather than
    fact oriented.

•   It tends to put the witness at ease.

•   It is used when you want the witness to elaborate on a
    point.

•   It is useful as a method of initiating an interview.

•   The response is more likely to be detailed and
    informative.

•   It encourages less structured responses.

•   It encourages spontaneity.

•   It gives the witness more room for self-exploration and
    self-expression.

•   It is an effective technique if the witness is secretive or
    evasive or has difficulty understanding closed questions.

Open-ended questions that begin with the word “HOW” are
often used to encourage witnesses to give their personal or
subjective view of the situation.

Open-ended questions that begin with the words “COULD”,
“COULD YOU” or “CAN YOU” often elicit detailed
responses.

The word “WHY” may make the witness feel defensive.



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                                  Limitations

                                  •   It is more difficult to clearly communicate the meaning
                                      and intent of an open-ended question.

                                  •   An open-ended question is more likely to be
                                      misunderstood.

                                  •   There is more freedom to deviate from the desired
                                      response.

                                  •   Response time is greater.

                                  •   Interviews are less directed.

                                  •   Some witnesses may find it difficult to tolerate a number
                                      of open-ended questions because they are not used to
                                      talking at length spontaneously and expressing
                                      themselves coherently or because they are uncomfortable
                                      in a structured situation.



                                  Closed Questions

                                  Definition

                                  Questions which can be answered in a few words.

                                  Characteristics/Applications

                                            The closed question is useful in obtaining specific
                                            information.

                                            It helps a witness focus on a specific point.

                                            Since responses are more relevant and specific,
                                            issues may be covered more quickly.

                                            It tends to focus on information that is of interest to
                                            you.

                                            It allows for a continuous train of thought with a
                                            series of questions.



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       It can be used to redirect the interview and bring the
       focus more in line with what you want to know.

       It is easier to formulate.

       It gives you more control.



Questions that begin with “WHAT” are frequently used to
elicit factual data.



Limitations

   •   Predominant use of closed questions may give the
       impression that you are not really interested in the
       witness’ viewpoint or in him/her as a person, and that
       you merely want brief responses to questions that
       have been prepared in advance for use with all
       respondents.

   •   There is some evidence to suggest that respondents
       with less education tend to give a “yes” answer
       irrespective of the question being asked. Closed
       questions also allow them to answer a question they
       do not really understand without revealing their lack
       of understanding.

   •   Closed questions tend to discourage spontaneity.



Clarification Questions

Definition

Questions that are direct request for information on a vague
or ambiguous point made earlier in the interview.




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                                  Characteristics/Applications

                                     •      It is used to clarify, further specify or render more
                                            coherent a response.

                                     •      It always relates to prior information.

                                  Limitations

                                     •      Clarification questions may be time-consuming if the
                                            witness strays off topic.



                                  Exploratory Questions

                                  Definition

                                  Questions which encourage the witness to volunteer new
                                  information that is not directly related to prior knowledge.



                                  Characteristics/Applications

                                     •      The exploratory question is particularly valuable
                                            when trying to identify issues that will be productive.

                                     •      Witnesses are given considerable leeway in making
                                            and developing their responses. You then analyze
                                            and clarify the information you receive. As the
                                            exploratory process unfolds, however, you should
                                            rely less and less on the witness to develop the topic
                                            and provide new information. At this point you
                                            need to adopt a more directed approach in order to
                                            obtain the most relevant responses and cover all
                                            aspects.

                                     •      Specific issues to be covered in more detail are
                                            derived from the information provided voluntarily by
                                            the witness.




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Limitations

    •   Witnesses may introduce topics that are not relevant.

    •   It can be time-consuming, since the witness is
        encouraged to talk freely.



Probing Questions

Definition

Questions that are a request for new information related to
prior knowledge.



Characteristics/Applications

•   Prior knowledge helps you formulate a hypothesis. You
    then probe for facts to support your hypothesis.

•   The probing question is used to encourage the witness to
    elaborate on a specific issue.

•   It usually lends itself to a more complete account of the
    facts.



Limitations

•   Witnesses may resist this line of questioning.

•   A lack of information or interest on the part of the
    witness, or feelings of anxiety and insecurity, or of being
    threatened, can all have an effect on the quality or
    validity of the response.




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                                  Leading Questions

                                  Definition

                                  Questions that either explicitly or implicitly include the
                                  answer the interviewer expects to receive.



                                  Characteristics/Applications

                                  •   A leading question calls for a brief response and
                                      indicates whether you expected it to be affirmative or
                                      negative.

                                  •   It is structured so that the response is strongly suggested.



                                  Limitations

                                  •   There is some evidence to suggest that leading questions
                                      are not likely to elicit a true response.

                                  •   The witness may afraid to give a response that does not
                                      conform to the one you are suggesting.

                                  •   The witness may be eager to please you and therefore
                                      may give you the response that you indicate is expected,
                                      even if it is incorrect.

                                  •   Leading questions may make it easier for the witness to
                                      conceal important information.

                                  The interview process is generally completed once you
                                  have identified the normal tasks, you understand the
                                  sequence of events leading to the accident and have a good
                                  idea of the malfunctions and probable causes.




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The Ten Commandments for Active
Listening
1. Stop talking

   You cannot listen if you are talking.

2. Put the witness at ease

   Help the witness feel free to talk. This is often called a
   “permissive environment”.

3. Show that you want to listen

   Look and act interested. Do not read while the witness
   talks. Listen to understand rather than to reply.

4. Remove distractions

   Don't doodle, tap your fingers, or shuffle papers.

5. Put yourself in the witness’ place

   Try to see the witness’ point of view.

6. Be patient

   Allow plenty of time. Do not interrupt. Don't start for
   the door or walk away.

7. Hold your temper

   Becoming angry only leads to missing the meaning of
   what is being said.

8. Avoid arguments and criticism

   Witnesses are put on the defensive, causing them to become
   angry and “clam up”.




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                                  9. Ask questions

                                      This encourages witnesses and shows you are
                                      listening. It helps to develop points further.

                                  10. Stop talking

                                      This is the first and last commandment, because all
                                      others depend on it.

                                  You simply cannot listen carefully if you are talking. We
                                  have all been given two ears but only one tongue to show
                                  us that we should listen twice as much as we talk.

                                  Hints
                                  Basic hints

                                  The interview phase of your investigation may serve as
                                  your principal source of information and it is important that
                                  it be conducted in a professional manner.

                                  •   Determine who will be interviewed and why.

                                  •   Determine where the interview will take place.

                                  •   Interview people one at a time.

                                  •   Introduce yourself and explain the purpose of the
                                      interview.

                                  •   Know how to listen (see the Ten Commandments for
                                      active listening).

                                  •   Do not let your emotions show.

                                  •   Do not threaten.

                                  •   Avoid sarcasm.

                                  •   Respect the witness’ pauses and periods of silence.

                                  •   Allow the witness to describe the facts; ask questions
                                      afterwards.



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•   Make sure that you do not distract the witness when
    you take notes: do not try to write what he or she is
    trying to tell you.

•   Verify your understanding of the witness' account.

•   Invite witnesses to contact you if they recall or learn
    more facts. (Provide your telephone number and
    address.)

•   Ask witnesses if they know anyone else who could
    possibly help to shed light on the events surrounding
    the accident.



Concerning the accident

•   Find out about the technology in question. Your
    questions and remarks will be more pertinent and you
    will gain credibility.

•   Choose the appropriate time.

•   Begin by putting the witness at ease from the time you
    introduce yourself.

•   It is sometimes useful for the interview to take place at
    the accident site.      The witness may remember
    additional details.

•   Do not interrupt the witness, except to bring him or her
    back on track.

•   Be prepared to deal with certain constraints, e.g. fear of
    talking, fear of reprisals, shyness, and prejudices.

•   Do not consider it useless to question persons who did
    not see the accident. They may be able to provide
    information concerning operations, equipment and
    attitudes.



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                                  It is not always possible to get all the information on an
                                  accident because sometimes the only witness is the victim.
                                  It is almost impossible to reconstruct the accident when
                                  there is only one witness, and that witness is deceased.

                                  Because the conclusive phase unfolds rapidly, witnesses
                                  are not mentally prepared to take in what is happening:

                                  •   They may remember only partially what they saw.

                                  •   They may state that they saw what they thought they
                                      saw.

                                  •   They may state that they saw what others claim to have
                                      seen.

                                  In fact, they become increasingly convinced of having seen
                                  it themselves.



                                  Written Statements
                                  Obtaining a written statement from a witness is part and
                                  parcel of any investigation. (Figure 8.1)

                                  It is preferable that witnesses write down their own
                                  statement. However, if you are doing the writing, the
                                  following rules apply:

                                  •   Write the statement as the witness tells it, in the “I”
                                      forms, using his/her own words and vocabulary.

                                  •   After the witness has finished, read the statement back
                                      to make sure it is accurate.

                                  •   Ask questions to obtain any necessary clarification,
                                      writing down each question and answer.

                                  •   Make any corrections the witness requires, initial them
                                      and have them initialed by the witness.

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•   When the statement is completed and verified, initial
    each page and have the witness do the same. Then sign
    and date the last page of the statement and have the
    witness sign it.

If for whatever reason, the witness refuses to sign the
statement, make a note of the refusal on the last page of the
statement.

Give a copy of the statement to the witness.

Where a third party is present while a witness is being
interviewed, ask the person to write his/her name and
signature in the appropriate section of the statement form.




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Sample
                                             DÉCLARATION DU TÉMOIN
                                               WITNESS STATEMENT
                                                                                                         Page      de/of

 N° d’assignation/Assignment no.                          Genre et date de la situation/Type and date of event


 Date de la déclaration/Date of statement                 Lieu de la déclaration/Location of statement




 Déclaration commencée à                                  Statement started at
 Nom du témoin/Name of witness                                    Nom de l’employeur/Name of employer


 Adresse du domicile/Home address                                 Adresse du lieu de travail/Workplace address


 N° de téléphone personnel/Private phone no.                      N° de téléphone au travail/Workplace phone no.


 DÉCLARATION/STATEMENT




Continuer sur le formulaire Suite de la déclaration/To follow on the Continued Statement form


 Déclaration terminée à                                  Statement finished at
 Signature du témoin/Signature of witness                                    Date


 Signature des personnes présentes/Signature of persons present              Date


 Signature de l’agent/Signature of Officer                                   Date



 Figure 8.1 – Front side of witness statement



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                                            SUITE DE LA DÉCLARATION DE
                                             CONTINUED STATEMENT OF
                                                                                          Page    de/of

N° d’assignation/Assignment no.




Signature du témoin/Signature of witness                                        Date


Signature des personnes présentes/Signature of persons present                  Date


Signature de l’agent/Signature of Officer                                       Date



Figure 8.2 – Back side of witness statement



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                                  Re-enacting the Hazardous Occurrence
                                  The first question asked by management, emergency teams,
                                  medical personnel and curious bystanders upon arriving at
                                  the scene of an accident is “What happened?” Many times
                                  each year this simple question prompts the person involved
                                  to show what he/she was doing and repeat the accident.
                                  While accident re-enactment can provide valuable insight
                                  and information, the process must be tightly controlled.

                                  Re-enactment of an accident or near-accident should be
                                  well planned and supervised to prevent the accident or
                                  near-accident from happening again. A re-enactment
                                  should be done only :

                                  •   when information about the actions or sequence of
                                      events cannot be obtained any other way;

                                  •   when precise step by step observations are needed to
                                      develop preventive or remedial actions;

                                  •   when key facts from witnesses are contradictory and
                                      need to be verified for analysis.

                                  If for one reason or another you do decide to re-enact the
                                  accident, here are some guidelines.

                                  At least two investigators should participate in the re-
                                  enactment. One will observe and take notes, photographs
                                  or a video while the other will direct the operations. If you
                                  are alone, act as the observer and assign the direction of
                                  operations to someone else in authority.


                                  Ask each witness to go back to where they were at the time
                                  of the accident and to retrace their steps by proceeding
                                  backwards, telling you what was seen and observed.


                                  As an observer, you must try to establish a clear picture of
                                  what happened. Witnesses’ testimony will reveal what
                                  happened.



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Make sure not to introduce surprise elements that could
lead to further accidents. Make sure all sources of energy
are shut down and locked out as per the employer’s
procedures. If there are no written procedures, ask
operators or professionals on site to proceed with the
lockout.

Carefully perform the technical operations of the accident
phenomenon. Before each operation, ask witnesses to
describe precisely what happened as if they were giving a
verbal statement. When everybody agrees on the technical
operations to be performed, ask the employer for
authorization to proceed with the re-enactment. For
obvious reasons, the re-enactment must end before the last
malfunction that caused the accident.




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       Module 9

Analysis of the Findings
                                A-GG-040-010/PT-001
              Hazardous Occurrence Investigators Course

Objectives of the module:

   Understand the concepts of cause factor and logic
   sequencel tree.

   Learn how to draw a logic tree.

   Learn how to interrupt the analysis




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                                  Concept of Cause Factor

                                  The Sequence Logic Tree
                                  The logic tree of cause factors consists of the logical chain
                                  of events        and conditions leading to various
                                  malfunctions, incidents or changes.

                                  While the description of the hazardous occurrence is very
                                  important in terms of the system, information organization
                                  is the most important step from a prevention point of view,
                                  since this will determine the solutions required in order to
                                  reduce the frequency and severity of accident occurrences.

                                  The logic tree of cause factors must potentially contain all
                                  information suggesting prevention measures. It becomes a
                                  kind of source document from which a number of
                                  important solutions may be drawn, including identifying
                                  recommendations.

                                  With a hazardous occurrence, there are as many causes as
                                  there are malfunctions and often more because some
                                  malfunctions can be brought about by more than one cause
                                  at any given time.

                                  Searching for Cause Factors
                                  A cause factor is considered to be any event that leads
                                  either to the origin of an accident or an aggravation of
                                  its consequences. Each malfunction, change or incident
                                  can be explained by a group of more or less interconnected
                                  events. Each event leading to malfunctions is considered a
                                  cause factor, since the discontinuation of this event would
                                  put a stop to the hazardous occurrence and, consequently,
                                  there would be no damages.

                                  Cause factors essentially introduce variations in the
                                  components of the system. A variation can be rather
                                  sudden, or it can have occurred long before the hazardous
                                  occurrence. The variation in a component is an objective
                                  event and not an interpretation of this event.




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Cause factors essentially introduce variations in the
components of the system. A variation can be rather
sudden, or it can have occurred long before the hazardous
occurrence. The variation in a component is an objective
event and not an interpretation of this event.

For example, if we find in the course of the
investigation that an instruction was not followed,
this is not a component variation but an
interpretation of certain events and actions. The
following table sums up the main variations found
in organizations under federal jurisdiction (Table
9.1).




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Table 9.1 – Examples of variances in work system components


Class      Part of                         Definition of causal factors
           System

1        Input         Variations in components, characteristics, concentrations, properties, shape
                       and content of the product, activity or item that will be transformed by the
                       system.

2        Work field    Variations in characteristics, products released, ventilation, energy sources,
                       reactions, transformations in time, place and biological environment in which
                       the product, activity or item is transformed.

3        Machine       Faulty design, unreliability of a tool, machine, material, piece of equipment,
                       device or installation leading to variations in signaling, command or self-
                       regulating mechanisms. New machine given to the operator.

4        Operator      Variations in behavior, work practices, hygiene, physical and mental health,
                       poor posture, effects of fatigue, inabilities, factors outside of work, poor
                       communication among individuals, conflicts between work groups or teams,
                       replacing an operator with another.

5        Aids          Ignorance of the proper use and handling of tools, the sequence of technical
                       operations, the consequences of actions taken, the control mechanisms and
                       the emergency procedures. Misinterpretation of charts, notes, diagrams and
                       programs. Omission of basic operations during execution of tasks.

6        Instruction   Ignorance of signals and commands, poor planning, organization or
                       supervision of work. Ignorance of health and safety rules. Poor
                       understanding of rules, practices and programs. Conflicts among several
                       coactive systems. Unusual or unexpected tasks.

7        Output        Variations in components, characteristics, concentrations, properties, shape
                       and content of the product, service or item manufactured by the system.

8        Environment   Poor organization among several systems, dangerous situations, hazardous
                       environments, high energy potential systems, inadequate individual or group
                       protection, technical, economic or sociological constraints, nuisances from
                       outside the system. Operator in an unfamiliar workshop, congested traffic
                       area. Poor atmospheric conditions.




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Drawing the Sequence Logic Tree



Relationships between Events



To explain the logical relationships between two events or
cause factors, specify whether the action is a sequence of
events follow each other in succession or whether there are
time lags between events.

To establish the logical relationship, here are specific
questions to help determine the type of relationship that
exists between the causal factors and a malfunction.

•   What caused or introduced this malfunction?

•   Was it necessary in order to produce this malfunction?

•   Was it sufficient or were other factors also necessary
    for this malfunction to occur?

•   Did another event have to take place in order for the
    factor to cause this malfunction?

•   Did the malfunction occur immediately once the factor
    was activated?

Here is a simple example. A truck is transporting material
on a construction site. Going down a steep incline, the
driver wants to brake. The driver puts on the brakes; they
do not respond. The truck is overloaded and crashes into a
wall. The driver suffers a minor head injury.




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                                     The only facts you have are the following:

                                     1- steep incline,

                                     2- brakes not responding,

                                     3- overloaded truck,

                                     4- crash into a wall, and

                                     5- head injury.

                                     The logic tree will look like this:




                                                                  Slope is
                                                                   steep

                      Brakes do
                     not respond

                                                                  Truck is
                                                                 overloaded




                      Truck hits
                        a wall




                    Driver suffers
                     head injury


Figure 9.1 – A simple logic sequence tree

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                                   Evidently, this logic tree is incomplete. It is difficult to
                                   draw a tree with incomplete information. However, the tree
                                   may serve to raise new questions. For instance, if you add
                                   the following facts to the ones you already have, the
                                   diagram would have a different appearance:

                                   6- brakes in poor condition,

                                   7- this was a spare truck,

                                   8- regular truck was not working,

                                   9- road with steep incline not part of regular route, and

                                   10- no maintenance program for spare trucks.




                                    Regular truck not
                   Space truck
                                      in operation




                                      Brakes are in               No maintenance
                                     poor condition                program for
                                                                   spare trucks


                    Brakes do
                   not respond
                                                           Slope is           Not regular
                                                            steep               route

                                      High
                                    momentun

                                                            Truck is
                                                           overloaded




                   Truck hits
                     a wall




                  Driver suffers
                   head injury


Figure 9.2 – A detailed logic sequence tree

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                                  Note that the addition of a new fact (“high momentum”) to
                                  explain the logic of the tree. An object’s momentum is the
                                  product of its mass by its speed. The more information you
                                  gain from the investigation, the more complex and logical
                                  the tree.



                                  Validating the Tree


                                  The victims, witnesses and their immediate supervisors are
                                  generally those in the best position to identify the probable
                                  causes of malfunctions that have occurred. You should
                                  therefore not hesitate to ask them these questions, taking
                                  care to concentrate on the technical aspects of the
                                  malfunctions rather than their justification. They may be
                                  inclined to justify the existence of the variations introduced
                                  into the operations of the system, to exonerate themselves if
                                  they were directly involved or responsible for their
                                  execution, or to blame others.

                                  All cause factors identified must be consistent. In order to
                                  verify this, you must be able to answer the following
                                  questions for each malfunction:

                                  •   If cause factor X did not exist, would the malfunction Y
                                      have occurred?
                                  •   In order for the malfunction Y to disappear, would
                                      cause factor X and only factor X be necessary?

                                  A positive answer to the first question indicates that factor
                                  X is not the cause of Y (there is no arrow between them).

                                  A negative answer to the first question and a positive
                                  answer to the second indicate a sequence.

                                  Negative answers to both questions indicate an absolute or
                                  connection of several factors.




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This cross-checking can seem tedious to the novice, but it is
crucial. You are often required to go back in time and look
for additional information to clarify points that are vague.
When this happens, you must remember to correct the
description of the accident occurrence accordingly.
Constructing the logic tree is useful in carrying out and
completing the process of gathering information. It is your
only way of uncovering the true causes of accidents. If a
factor is improperly identified or incorrect, those involved
will apply solutions that are not likely to reduce the number
of accidents.

When a logic tree is well constructed, all those involved
agree on what the risk factors are. If there is ongoing
disagreement between the witnesses or parties involved,
this means that the information gathering was inadequate in
some respects. You must above all avoid “negotiating” a
factor. You are not constructing your tree to please this
person or that person. Your task is to record the facts and
only the facts. You will avoid many problems by
concentrating on the technical and organizational causal
factors and avoiding interpretations and comments.

All those involved directly or indirectly in an accident have
their own version of the turn of events and the most
probable cause. Sorting through the information should be
done carefully in order to keep subjective content to a
minimum if not, the final tree will always be subject to
interpretation.

Here are a few examples of selected at random from trees
previously constructed:

•   Workstations and equipment that are not designed for
    human beings play a significant role as causal factors of
    malfunctions.     Non-ergonomic workstations exert
    physical and mental loads that exceed the normal
    capacities of many individuals.

•   Environmental factors, such as noise and poor lighting,
    have a disruptive effect in the case of most accidents.

•   Poor working conditions often prevent an operator from
    functioning normally.

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                                  •   Wearing protective equipment can distract a worker:
                                      gloves that are too large or too small, uncomfortable
                                      masks, goggles that interfere with peripheral vision, etc.

                                  Organizational factors include:

                                  •   Management errors by team leaders and foremen.
                                      These are often former salaried workers who received
                                      little or no management training and hence are unable
                                      to explain to others how to work in a safe and sound
                                      manner, unskilled at giving clear regulatory guidelines
                                      or instructions, or simply unable to explain a technical
                                      services aid.

                                  •   A prevention program that is inadequately implemented
                                      or not followed can also cause an accident, e.g. undue
                                      delay in taking corrective action, lack of preventive
                                      maintenance, inadequate or non-functional workplace
                                      quality control.

                                  •   Work structure, rotating shifts, excessive night work,
                                      overtime, lack of supervision.         These are all
                                      organizational factors that contribute to the
                                      multiplication of accident phenomena.

                                  •   A worker who is too young and lacks adequate training,
                                      a worker who is too old assigned to tasks requiring
                                      sustained attention or excessive effort, or an improperly
                                      trained worker can all affect the rate of incidents and
                                      accidents.

                                  These are only a few types of causal factors. Certain
                                  psychosocial factors, such as a lack of motivation on the
                                  part of company management, can often lead to a lack of
                                  self-discipline and concentration at work. On a personal
                                  level, a divorce, death in the family or drug addiction are
                                  also factors that trigger malfunctions. You must closely
                                  examine all factors and record everything that led to the
                                  malfunctions or contributed to them either directly or
                                  indirectly.




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   Sometimes you may be led to record assumptions in the
   tree regarding a set of facts due to a lack of information,
   e.g. the victim is deceased, or the equipment is destroyed.
   In this case, you indicate clearly in your description of the
   accident occurrence that this is an assumption and record
   the causal factor inside a diamond shape with a question
   mark. In the process of identifying solutions or directions,
   you will know whether these potential causal factors are
   worth considering or not.

   Presentation of the Logic Tree


   All logic trees are presented the same way.

    1. The first column is reserved for the normal task only.

    2. Make a new column each time you discover a
       malfunction, change or incident in order to construct a
       staircase.

    3. Each malfunction, change or incident is reported at the
       top of a different page.

    4. On each of the pages, construct mini causal tree for
       each malfunction, change or incident.

    5. Justify each mini causal tree at the bottom of the page
       by indicating your sources and the facts you collected
       during your investigation.

   When the accident phenomenon is simple, you can
   illustrate the entire event logic tree on one page.

   However, for easier reading and to allow room for sources
   and comments, it is preferable to start a new page for each
   malfunction, change or incident.

An example of a complete logic tree for an accident involving a
fall from heights and the subsequent death of the worker is
provided below:




            9-11
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  Radar taken out of
service prior to start of
   maintenance of
       radome


 Skilled climbers with
    proper training
  permitted to work
 above ground level


  Panel replacement Work started around
 work proceeds when midnight in gusting
                     wind conditions                       1
 winds below 24km/hr

                            Scaffolding erected,
 Scaffolding erected,         positioned and
   positioned and                 secured
       secured

                        Workers climb onto Deceased climbs on
  Workers climb onto scaffolding and attach  scaffolding and
 scaffolding and attach  fall restraint PPE doesn't attach fall                      2
   fall restraint PPE                         restraint PPE


                                                   Panel connecting bolts
Panel connecting bolts                              removed to free one
 removed to free one                               side for installation of
side for installation of                                 safety line
      safety line

                                                    Safety line installed      Safety line not
  Safety line installed                                                                                3
                                                       and secured               installed
     and secured

                                                                              Remaining panel     Problem removing
   Remaining panel                                                            connecting bolts    panel bolts creates
   connecting bolts                                                              removed            further delays           4
      removed
                                                                                                    Line or lines for
                                                                                                    lowering panels
    Line or lines for                                                                                  installed
    lowering panels
       installed
                                                                                                 Panel brought through
                                                                                                 opening and lowered
Panel brought through                                                                              to the floor inside
opening and lowered                                                                                     radome
  to the floor inside
       radome
                                                                                                  Replacement panel Workers have problem
  Replacement panel                                                                               raised into position aligning replacement              5
  raised into position                                                                           and aligned with help         panel
 and aligned with help                                                                                of guide pin
      of guide pin                                                                                                                                  Deceased leans
                                                                                                                           Deceased leans
                                                                                                                                                  forward, grips panel,
                                                                                                                         forward, grips panel,
                                                                                                                                                  gust of wind catches     6
                                                                                                                          manhandles it into
                                                                                                                                                  panel like a sail and
                                                                                                                               position
                                                                                                                                                     pulls him off of
Panel connecting bolts                                                                                                                                 scaffolding
       installed

                                                                                                                                                   Deceased falls to
  Procedure repeated                                                                                                                             ground 75 feet below
  until all panels have
    been replaced
                                                                                                                                                   Deceased receives
                                                                                                                                                 First Aid treatment and
                                                                                                                                                           CPR


                                                                                                                                                   Deceased dies of
                                                                                                                                                   injuries 1 hr later




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Normal Task: Replacement of radome panels

        The radome panels were to be replaced as per the instructions detailed in the company
technical manual. Work started at about midnight on July 27, 2004 due to adverse wind
conditions prior to this and was to be completed “normally”. We considered only the technical
operations relevant to the accident and purposely omitted those that reveal nothing about causal
factors, such as routine material handling tasks, use of hand tools and sealing operations.



                     Radar taken out of
                   service prior to start of
                      maintenance of
                          radome


                    Skilled climbers with
                       proper training
                     permitted to work
                    above ground level



                     Panel replacement Work started around
                    work proceeds when midnight in gusting
                    winds below 24km/hr wind conditions




                                                       1




                                               9-13
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First Malfunction: Work started around midnight in gusting wind conditions

         The first malfunction is that the workers were working in gusting wind conditions. The
initial causal factor of the accident occurrence as a whole is the pressure placed on the workers
to work in the gusting wind conditions. The reason behind the pressure from the supervisor is
based on the fact that numerous delays had been incurred due to bad weather at the site and they
had reached the date of the original deadline for completion and still had most of the work to
complete. This may have created a perceived time constraint in the minds of the workers (as
alluded to in the interview of Witness 1) which in turn led them to overlook or ignore the explicit
warning in the company technical manual not to work in winds over 24 km/h. The workers
decided to work on the side of the radome that is opposite to the gusting winds and hence they
install the scaffolding and move it around to accommodate this decision. In so doing, they
believed that they were working within safe limits.


           1



                                 Warning on
  Work started around                                                  Pressure      Initial deadline for
                                 page 7-2 of           Perceived
  midnight in gusting                                                    from         completion was
                                  company                 time
   wind conditions                                                    supervisor      day of accident
                                tech manual            constraint?
                                                                     to start work
                                not followed



                                Postion based on
  Scaffolding erected,
                               decision to work on
    positioned and
                              side opposite gusting
        secured
                                      winds




  Workers climb onto Deceased climbs on
 scaffolding and attach  scaffolding and
   fall restraint PPE   doesn't attach fall
                          restraint PPE




                                2




                                                      9-14
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Second Malfunction: Deceased climbs on scaffolding and doesn’t attach fall restraint PPE

        Based on the statements provided by the other workers at the scene it is clear that the
deceased did not attach his fall restraint PPE to the scaffolding or other anchor point. Even after
being asked directly by Witness 2 if he was tied off the deceased answered something to the
effect of “I Guess not” but still didn’t take any action to comply with the well established fall
restraint policies of his employer. The reasons for this will never be known due to the fact that
the deceased never regained consciousness after his fall. It is known and documented that the
deceased did have the appropriate fall restraint equipment available to him for use and that he
had been adequately trained on his employer’s fall protection program and the equipment.
(company’s signed training document)

                             2



                                                                  Perceived time
                   Deceased climbs on                              constraint?
                     scaffolding and
                    doesn't attach fall
                      restraint PPE
                                                                   Restriction of
                                                                   movement?
                  Panel connecting bolts
                   removed to free one
                  side for installation of
                        safety line


                   Safety line installed     Safety line not
                      and secured              installed




                                                   3




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Third Malfunction: Safety line not installed

        It is clearly indicated in the company technical manual, to “connect a safety line as
shown in figure 7-1, view A or B. Secure the line on the inside to an adjacent panel or to
scaffolding.” It is unclear at this point whether there was indeed a safety line connected to the
panel being removed as no mention of this was made in any of the statements or discussions with
the workers. There is also no information relating to the reasons why the safety line was not
used if that is indeed the case. It may have simply been a short cut used by the workers to
expedite the repair procedures. Once again, the idea of a perceived time constraint may be at the
root of this decision. Further investigation into this malfunction may reveal new information
that would help nail down the causes, however, it is felt that this malfunction does not have a
significant enough contribution to the final phase of the accident to warrant the efforts nor the
possible emotional consequences on the witnesses.


          3


                               W arning on
                                                                      Pressure
                               page 7-2 of     Perceived                                Initial deadline for
    Safety line not                                                     from
                                company           time                                   completion was
      installed                                                      supervisor
                              tech manual      constraint?                               day of accident
                                                                    to start work
                              not followed




   Remaining panel    Problem removing
   connecting bolts   panel bolts creates
      removed           further delays




                              4




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Fourth Malfunction: Problem removing panel bolts creates further delays

        During Witness 1’s interview, it was mentioned that they had a hard time removing some
of the panel bolts, possibly due to some of them being cross threaded or having some foreign
matter caught in the threads. This information seems to be supported by the physical evidence at
the scene of the accident. This can’t be totally confirmed due to the state of disarray that was
found during the investigation visit. The investigation team did find several broken bolts on the
floor but it was impossible to determine if they were the ones taken from the panel being
replaced at the time of the accident. It was not possible to determine with certainty during the
investigation visit which panel was the one they had troubles removing. This was due to the
disturbance of the accident scene in order to secure the Radome against further damage. A
cursory visual inspection of several panels that could have been the one in question showed that
some thread inserts did contain foreign matter in the threads. However, this evidence is
inconclusive and is only seen as a potential cause of the difficulties encountered. It is doubtful
that further investigation into this malfunction will reveal any conclusive proof.


                     4



                                                                         Cross-threaded bolts?

            Problem removing                 Possible
            panel bolts creates              stripped
              further delays                  bolts?
                                                                           Foreign matter in
                                                                               threads?
              Line or lines for
              lowering panels
                 installed



           Panel brought through
           opening and lowered
             to the floor inside
                  radome



            Replacement panel Workers have problem
            raised into position aligning replacement
           and aligned with help         panel
                of guide pin



                                         5




                                                        9-17
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Fifth Malfunction: Workers have problem aligning replacement panel

         Witness 1 explained in his interview that once the replacement panel was raised into
position they had a hard time trying to align it even though the guide pin was being used. In
order to insert the guide pin into the proper hole for alignment the panel must physically be
pushed outside of the Radome about 6 inches. The technician then grips the guide pin and aligns
it with the appropriate hole on the mating Radome panel. Once aligned, the panel is pulled into
place and bolts are installed to keep the panel from falling out. It is thought that it was during
the process of aligning the guide pin with the hole in the mating Radome panel that the accident
occurred. Witness 1 stated that there was increase in the speed and frequency of the wind gusts
and that they were trying to get the two removed panels back in place in order to secure the
Radome structure. Once a panel is removed, the workers are somewhat locked into completing
the sequence for replacement, except in exceptional circumstances, due to the fact that the
Radome is not structurally sound unless complete. The witnesses tend to think that the panel
being installed may have been caught by an impromptu gust of wind that came over the top of
the Radome structure from the opposite side. The panel in the wind would have acted like a sail
on a windsurfer’s sailboard, being buffeted back and forth as it tried to tear itself from the
technician’s grip. This buffeting would have made alignment of the panel that much more
difficult. Another possible cause is also attributable to the windy conditions. The Radome itself
may have been affected by the winds due to the fact that it loses some of its structure integrity
once an opening is made in the surface. The winds may have caused the Radome to flex thus
deforming its shape slightly and making alignment of the replacement panel difficult, even with
the guide pin. It’s not possible to confirm this theory since the exact conditions at the time of the
accident are not known, making any attempt at a re-creation less than an optimal solution. A
third possible cause is related to the replacement panel and adjacent panels themselves.
Although unlikely, there may have been a defect in one of these panels that made mating them
together difficult. Things such as misaligned holes, misaligned thread inserts and misshapen
portions of the panels may have hindered the alignment process. A cursory observation of the
panels didn’t turn up any signs that these three possible conditions existed. Due to the
unlikelihood that there was indeed a defect in the Radome panels or structure this possible line of
causation was not pursued any further. It is also deemed that the contribution of these possible
causes to the overall cause of the accident would have been minor in nature. Rather, it is felt that
the existence of such conditions would be inherent to the performance of the work and as such
need not be considered at this stage.




                                              9-18
                                                                                                  Warning on
                                                                           Postion based on                                     Pressure
                                                        Wind buffets                              page 7-2 of   Perceived                     Initial deadline for
                                                                          decision to work on                                     from
                                                           panel                                   company         time                        completion was
                                                                         side opposite gusting                                 supervisor
                 5                                                                               tech manual    constraint?                    day of accident
                                                                                 winds                                        to start work
                                                                                                 not followed


                                                                                                  Warning on
       Workers have problem                                                                                                     Pressure
                                                             Possible                             page 7-2 of   Perceived
       aligning replacement                                                    Wind buffets                                       from        Initial deadline for
                                                           deformation                             company         time
               panel                                                              panel                                        supervisor      completion was
                                                           of Radome?                            tech manual    constraint?
                                                                                                                              to start work    day of accident
                                                                                                 not followed




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                                                            Possible
                                                            defects in
                                                             panel?
                                  Deceased leans
                                forward, grips panel,
          Deceased leans
                                gust of wind catches
        forward, grips panel,
                                panel like a sail and
         manhandles it into
                                   pulls him off of
              position
                                     scaffolding




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Sixth Malfunction: Deceased leans forward, grips panel, gust of wind catches panel like a
sail and pulls him off of the scaffolding

         The witnesses were not able to confirm if it was a possible loss of balance caused by the
buffeting of the panel in the wind that lead directly to the fall since the event happened so
quickly before any of the adjacent workers could react. The statements from several of the
witnesses indicated that the deceased was leaning forward towards the opening in the Radome
and had gripped the replacement panel with both hands, one holding the guide pin and the other
holding the right edge of the panel, and was trying to align the panel for installation. They put
forth the idea that his gloved hand, which was holding onto the guide pin, may have gotten
caught when the panel was buffeted by the gusting winds thus causing him to lose his balance
and be pulled off of the scaffolding. Witness 2 was in the best position (on top of the radar
array, above and behind the workers on the scaffold) to observe what happened but was still
unsure of the exact sequence of events immediately before the fall. The site owner’s
representative, has offered another plausible contributing factor. He explained that the natural
curved shape of the Radome structure acts like an aerofoil (wing) in windy conditions. The laws
of aerodynamics stipulate that when air moves over and under a curved surface, the air above
must accelerate in order to arrive at the same point at the same time as the air flowing
underneath. This acceleration of the air creates a low-pressure area above the curved surface and
gives rise to what is known as lift, or a vacuum. Tests performed on these Radomes have shown
that in high wind conditions several hundred tons of lift can be generated. Another physical
phenomenon associated with air flowing over surfaces is that of the venturi effect. This effect
deals with fast moving air flowing over an opening or aperture and consequently creating a low-
pressure cell over the aperture leading to a vacuum effect. These two physical phenomena may
help explain the quickness with which Tim Coffey was pulled off of the scaffolding and out of
the Radome resulting in his fall to the ground and subsequent death. Not only would he have
been pulled off balance by the panel in his grip but the vacuum effect of the winds coming over
the top of the Radome would have effectively sucked him completely out of the Radome before
anyone knew what was happening. This hypothesis could be verified through extensive testing
of a similar Radome structure in the conditions thought to exist at the time of the accident or by
complicated computer modeling. However, it is not deemed necessary to do so as part of this
investigation due to the fact that considerations have already been made in the recommended and
documented work procedures to deal with this potential threat in the form of a warning to not
work in wind speeds over 24 km/h. The decision to work in windy conditions by staying on the
opposite side of the Radome from where the winds were blowing created a false sense of
security at the same time as it created a potential physical hazard otherwise unknown to the
workers at that time. No matter which of the above possible causes actually contributed to the
accident, one fact remains. The deceased was not wearing appropriate fall protection PPE nor
was he tied into any fall restraint system at the time of the accident. Had he been, the incident
would in all likelihood still have occurred but at least his fall would have been arrested resulting
in all probability only in minor injuries and not his death.




                                             9-20
                                                                         Warning on
                                                                                                       Pressure
                                  Gloved hand                            page 7-2 of   Perceived
                                                Wind buffets                                             from        Initial deadline for
                                   caught on                              company         time
                                                   panel                                              supervisor      completion was
                                   guide pin?                           tech manual    constraint?
                                                                                                     to start work    day of accident
                                                                        not followed

                 6

                                                  Postion based on
                                     Aerofoil    decision to work on
                                     Effect ?   side opposite gusting
          Deceased leans                                winds
        forward, grips panel,
        gust of wind catches
        panel like a sail and
           pulls him off of
             scaffolding                          Postion based on
                                     Venturi




9-21
                                                 decision to work on
                                     Effect?
                                                side opposite gusting
                                                        winds
         Deceased falls to
       ground 75 feet below



         Deceased receives
       First Aid treatment and
                 CPR              No fall
                                 Protection
                                 PPE used
         Deceased dies of
         injuries 1 hr later                             Restriction of
                                                         movement?
                                                                                                                                            Hazardous Occurrence Investigators Course
                                                                                                                                                              A-GG-040-010/PT-001
                       A-GG-040-010/PT-001
     Hazardous Occurrence Investigators Course




     Module 10

     Report Writing
           &
Making Recommendations
                                  A-GG-040-010/PT-001
                Hazardous Occurrence Investigators Course

Objectives of the module:

   Become familiar with the table of contents and the
   investigation report (excluding the accident analysis).

   Learn to describe the Hazardous Occurrence using the
   accidental model.

   Determine the appropriateness of corrective and
   preventive actions required.



Content of the Investigation Report


The Hazardous Occurrence Investigation Report is an
integral part of the internal and external reporting
requirements for all work related injuries and/or illnesses.
Consequently, it should contain the following items, when
applicable:

1. Cover page.

2. Table of contents.

3. Summary of the accident sequence.

4. General information about the occurrence.

5. Detailed description of the accident sequence.

6. Action and follow-up

7. Attachments to the report (as required).




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                                   Cover Page


                                  The cover page is what identifies the report and
                                  distinguishes it from other reports.

                                  The heading is located at the top of the page. This
                                  information identifies the GSO handling the investigation
                                  and/or producing the report. The content must be fairly
                                  complete so that anyone wishing to can locate where the
                                  report is kept.

                                  •   Branch /Headquarters name

                                  •   Unit name:

                                  •   Provincial location:

                                  •   administrative unit where the report is kept, for
                                      example, Base C.E.

                                  The title specifies the investigation dealt with in the
                                  report. It generally consists of one sentence in large print,
                                  indicating the hazardous occurrence that has occurred. It
                                  must contain:

                                  the location of the hazardous occurrence site;

                                  the names of employees involved;

                                  the date of the hazardous occurrence.



                                  Below the title, it is advisable to specify the type of report,
                                  if applicable:

                                  •   Preliminary report: a report that precedes another and
                                      leads one to assume that there will be a second more
                                      extensive report.

                                  •   Final report: a complete report, generally including
                                      the investigation and analysis reports.


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•   Summary report: a report that summarizes a more
    lengthy report.

•   Investigation report: when only the investigation is
    considered in the report.

•   Analysis report: when only the accident analysis is
    considered in the report.

•   Investigation and analysis report: when both the
    investigation and analysis are covered in the report.

•   Addendum to report “X”: to add further information to
    an already published report.



The information field at the bottom of the page identifies
the:

•   Date on which the author finished the report (normally
    the date of printing or publishing).

•   HRMS assigned number.

•   employer’s establishment number.

•   Name(s) of investigator(s) who drafted the report and
    their identification number.

In an investigation report, page numbering begins with the
cover page, which shows number 1 at the bottom. All
pages are numbered, even blank pages and appendices. For
example, if a report contains 49 pages, all numbers from 1
to 49 must appear in sequence.

If you photocopy a report, all pages must be copied, even
blank pages. This will show that there have been no
omissions.




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                                  Table of Contents
                                  The table of contents is a list of headings and subheadings
                                  allowing readers to quickly locate the section and pages of
                                  the document they are interested in.

                                  In an investigation report, all headings are important
                                  and therefore all of them must be listed. This is why
                                  we recommend having no more than three subdivisions
                                  in order to make the table of contents and ultimately the
                                  entire report more reader-friendly.

                                  The table of contents must also include the list of
                                  attachments or appendices.

                                  Attached is a standardized table of contents (Figure 10.1).




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                                  Table of Contents

    1.0 General Information
        1.1 Summary of the accident sequence
        1.2 Date and time of the hazardous occurrence
        1.3 Date and time GSO was notified
        1.4 Date and time investigator began investigation
        1.5 Investigating personnel
        1.6 Identification of the unit
        1.7 Location of the hazardous occurrence
        1.8 Identification of employee’s representative(s) (WHSC)
        1.9 Identification of victim(s)
        1.10 Description of damages
        1.11 Description of the final phase of the hazardous occurrence
        1.12 People who accompanied investigators
        1.13 Other interveners
        1.14 Witnesses and third parties involved

    2.0 Detailed Description of the Accident Sequence
        2.1 Terminology
        2.2 Summary of statements, documents and evidence
        2.3 Facts noted
        2.4 Description of tasks being performed at time of hazardous occurrence
        2.5 Description of the accident sequence
        2.6 Analysis of causal factors
        2.7 Corrective and preventive measures

    3.0 Action and Follow-up
        3.1 Conclusion
        3.2 Corrective and preventive actions taken
        3.3 Recommendations

    Signature

    List of Attachments
         Appendix 1: (title)
         Appendix 2: (title)
         Appendix 3: (title)

Figure 10.1 – Standard Table of Contents for Hazardous Occurrence Investigation
              Report


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                                  General Information
                                  Sections of the first part of the report cover:

                                  •   all the information relating to the conclusive, final and
                                      passive phases of the accident phenomenon;

                                  •   a brief summary of the hazardous occurrence;

                                  •   the undertaking of the investigation by the
                                      investigators;

                                  •   the necessary information for the administrative
                                      management of the file;

                                  Section 1.1: Summary of the Accident
                                  Phenomenon

                                  The purpose of section 1.1 of the report is to briefly
                                  describe the accident phenomenon. It is an executive
                                  summary, in the generally accepted sense.

                                  Careful writing of this summary is very important.
                                  Remember that more people will read this section than the
                                  report as a whole. The section should be short but
                                  complete, although not so short that all useful data on the
                                  accident is lost. A good summary should not be more than
                                  twenty lines.

                                  For practical purposes, we have divided accident
                                  phenomena into seven descriptive phases (Table 10.2):

                                  •   passive phase: provides information on the system,
                                      the hazard(s) present and the threat level, according to a
                                      fairly specific level of probability (risk rate);

                                  •   preparatory phase: groups together the causal factors
                                      preceding the occurrence that are likely to increase the
                                      risk rate and trigger the accident phenomenon;



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•   factual phase: describes the events that occurred, in the
    order in which they occurred, and identifies the
    malfunctions of the normal task and vicarious tasks
    introduced;

•   final phase: indicates the accident that occurred, i.e.,
    the contact between the energy source and the victim
    or, where applicable, other components;

•   resultant phase: reports the damages in the form
    of injuries, losses and environmental disturbances;

•   legal phase: identifies the sections of standards, rules,
    regulations and acts that have been violated, in order
    to determine responsibility for cause factors; and

•   preventive phase: focuses on reducing the risk and
    implementing mitigation and control measures.

A good summary should answer the following questions:

•   In which system did the accident occur? At what
    location? At what time? Who is the victim?

•   What type of accident occurred?

•   What are the resulting damages? Injuries? Losses?
    Environmental disturbances?

•   What hazard or danger was involved?

•   What sequence of events led up to the accident?

•   What are the main cause factors and what corrective
    measures did the employer adopt?

•   What recommendations were issued?




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Table 10.1    The seven phases of the accident phenomenon
  Accident
phenomenon
   phase                       Content                           Description

Passive           Specific hazard rate             system involved and coactive systems
                                                   danger (energy source)
                                                   foreseeable damages
                                                   hazard and risk rate

Preparatory       Factors modifying tasks          causal or risk factors
                                                   root causes

Factual           Events and interactions among    normal tasks
                  components                       malfunctions
                                                   vicarious tasks

Final             Accident                         energy flow
                                                   type of contact

Resultant         Damages                          injuries
                                                   losses
                                                   environmental disturbances

Legal             Legal liability                  legislative sections violated
                                                   standards and rules

Preventive        Mitigation                       actions on the hazard (elimination,
                                                   substitution, transfer)
                                                   adaptation
                                                   internal or external regulation
                                                   protection and emergency
                                                   rescue, survival, compensation




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Use a narrative style and follow the sequence of events that
led up to the damages/injuries. Here are two examples
from HRSDC – Labour Branch investigations:

“On November 2, 1999, the refinery’s mechanic, Frank S.,
went into a tank car with a nitrogen-rich atmosphere to
remove a broken downspout. When a second employee,
Tom. F., noticed that Mr. Frank S. was unconscious, he
also went in and fell unconscious himself. When Paul F. at
the scene and found out that his brother Tom was inside the
tank car, he attempted to go down wearing a SCBA, but he
was not able to fit through the manhole. He removed his
SCBA, intending to put it back on once inside, but also lost
consciousness and fell to the bottom of the ladder. The
three employees were rescued by local firefighters. Frank
and Tom died from asphyxia, whereas Paul was taken to
the Waterloo hospital suffering from hypoxia and multiple
head and shoulder contusions. He was able to fully
recover. Following analysis of the causes, three directions
were issued: the first requires the employer to develop
procedures regarding entering confined spaces, the second
requires the employer to develop a system for identifying
tank cars containing hazardous materials, and the third
involves finding a technical solution to prevent downspouts
from breaking off.”

“On May 23, 2002, P. Burner, an electrician, was on the
bridge of Transtainer 210 changing the forward hoist
motor. Without locking the electrical input, he removed
the motor cover and the brake cage, and cleared the debris
that was blocking the gears. Then, with two coworkers, he
began to lower the load. For unknown reasons, he had left
a ratchet wrench on one of the rotor-head bolts on the
motor. When the barrel of the hoist descended, the motor
mechanically restarted and the ratchet wrench was sent
flying off, mortally hitting Mr. Burner in the head and
subsequently causing him to fall 16.5 meters. The
investigation found an absence of readily available written
safety procedures. Two directions were issued: the first to
repair the bridge that was damaged during the fall and the
other to develop safe work procedures for tasks involving
the upkeep and repair of heavy machinery.”



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                                    For quick reference, sections 1.2 to 1.14 are not narrative.
                                    Data are presented with descriptors or short sentences. We
                                    prepared the following checklist as a guide (Figure 10.2)




    1.1    Summary of the accident phenomenon: brief description of the seven phases.

    1.2    Date and time of the accident: time descriptors and variables.

    1.3    Date and time GSO was notified by the employer or how GSO learned of the
           accident.

    1.4    Date and time an investigator began the investigation at the workplace, and
           explanation of the delay, if any.

    1.5    Identification of investigating personnel and other experts :
              full name;
              identification number;
              office address;
              E-mail, phone and fax numbers (at work).

    1.6    Identification of the unit :
              name and unit’s number;
              address.

    1.7    Location of the accident :
              city, site, mile, etc.;
              building address if different from the one in section 1.6;
              department, workshop or room;
              work station number;
              name and serial number of equipment, vehicle, etc.;

    1.8    Identification of employee’s representative(s): name, title and phone number.

    1.9    Identification of victim(s) :
              name, age, date of birth, sex;
              occupation or profession;
              years of experience in the plant;
              years of experience at the work station.




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    1.10   Description of damages :
              injuries;
              poisonings or illnesses;
              fatalities;
              asset losses and production losses;
              environmental disturbances.

    1.11   Description of the final phase of the accident :
              final cause agent (injury source);
              form of energy;
              secondary cause agent;
              type of accident;
              nature of injury;
              part of the body affected.

    1.12   Name(s) and title(s) of people who accompanied officers in their investigation
           or helped them during the analysis: employer, Workplace Health and Safety
           Committee member, union representative, etc.

    1.13   Identification of other interveners (name and phone number) :
              ambulance attendant;
              police officer;
              coroner;
              firefighter;
              provincial inspector.

    1.14   Identification of witnesses and third parties involved: name, title, employer,
           phone number.



Figure 10.2    General information checklist




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                                  Section 1.2: Date and time of the accident
                                  Time descriptors situate the accident in time:

                                  •   month;

                                  •   day;

                                  •   hour;

                                  •   time lapse between accident and investigation;

                                  •   work after regular work hours.

                                  We have long been aware that time variables have an
                                  influence on accidents without being able to explain why.
                                  For example, more accidents occur at the start and end of
                                  the work week, in the few minutes before health breaks,
                                  during full moons, during overtime periods, etc. These
                                  descriptors can provide indicators of work organization
                                  errors.

                                  Clearly indicate the date and time of the accident. If final
                                  damages result some time after the accident occurred,
                                  indicate this as well, for example:

                                  •   “As a result of this accident, Mr. Jackson died six days
                                      later, (date), (hour)”.

                                  •   “Fire burned for two days and firefighters left the site
                                      on…”

                                  •   “Signs and symptoms appeared about eight days after
                                      overexposure”.


                                  Section 1.3: Date and time GSO was
                                  notified
                                  If you were informed of the accident by other means, you
                                  must specify: newspaper article, radio or TV news bulletin,
                                  letter or phone call from a provincial officer, fax from an
                                  officer of an extended jurisdiction, etc.



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Section 1.4: Date and time Investigator
began its investigation

It has been shown that the more time lost between the
accident and the start of the investigation, the more likely it
is that victims and witnesses will obscure certain causes or
interpret them differently.

Specify the date and time you first arrived at the site to start
your investigation.

If for one reason or another, you do not have immediate
access to the site, mention it and explain why:
jurisdictional conflict, incorrect address, delay in securing
the site due to rescuers present (firefighters, police officers,
ambulance attendants…), discussion among those
mandated by different agencies, etc.



Section 1.5: Identification of the
   Investigating Personnel


This section is for your identification. Write your full
name, preferably in CAPITALS, your identification
number, office address and telecommunication numbers.
For obvious reasons of security, never mention your home
address and personal communication numbers.

When more than one person takes part in the
investigation/analysis, write all the names specifying the
role and responsibilities of each individual. The name of
the person in charge that appears on the cover page must be
indicated at the beginning of the section.

If during the course of your investigation/analysis you
called for an expertise from specialists, describe this here:
industrial hygienist, Technical Services engineer, lawyer
from Legal Services, Air Transport safety officer, etc.




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                                  The name of external private experts can be mentioned here
                                  but we prefer that you mention their contribution in
                                  sections 1.12 or 1.13.



                                  Section 1.6: Identification of the unit

                                  The name, address and identification number of the unit.



                                  Section 1.7: Location of the accident

                                  One of the most frequent errors we encounter in
                                  investigation and analysis reporting is the failure to
                                  accurately identify the location of the accident.
                                  Investigators forget to locate the organization where the
                                  accident occurred, or to identify the work system involved
                                  in the accident sequence. This section is very important for
                                  a good understanding of your report; we ask you to give it
                                  special attention.

                                  Description of the Accident Site

                                  Site descriptors situate accidents within the environmental
                                  framework in which they occur. The most common ones
                                  are:

                                  •   natural space: city, country, forest, mountain, etc.;

                                  •   constructed space: dwelling, factory, parking lot, road,
                                      mile, kilometric marks, etc.;

                                  •   residential area: industrial park, suburb, community,
                                      shanty town, etc.;

                                  •   industrial space: owner’s premises, business place,
                                      department, workshop, section, etc.;

                                  •   atmospheric conditions: sun, rain, wind, snow, etc.



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These descriptors are used only if, for the unit being
studied, you believe that these variables could have
influenced the occurrence of accidents. For example, it is
appropriate to include the descriptor of atmospheric
conditions for an accident analysis on postal workers,
fishermen, police officers and truck drivers. This choice
would be misguided if all accidents occurred inside
buildings.

These descriptors may be further tailored to meet the needs
of a particular analysis. There could be a descriptor for the
outdoor temperature (from -40 °C to 40 °C in Canada), one
for humidity level, one for road conditions, one for
snowfall amounts, one for shower activity and so on.

Description of the Work System

System descriptors identify accidents according to the
type of human-machine system in which they occur.
The primary descriptors seen in work-related accident
analyses are:

•   type of system: manual, tool, machine-tool, machine,
    machine-transfer, robot;

•   type of installation: height, small space, confined
    space, entire floor, etc.;

•   victim’s occupation: welder, office worker, carpenter,
    engineer, postal worker, etc.;

•   type of equipment: name and serial number of
    equipment, instruments, vehicles, tools, etc., with a
    brief description of the process, e.g. lead burning, MIG,
    TAG, laser welding;

•   parceling of work: continuous operation, batch
    production, assembly line, etc.;

•   workstation occupancy: regular, occasional, new, etc.;

•   presence of standardized controls: alarm, flashers,
    guards, gates, etc.;



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                                  •   use of personal protective equipment.



                                  Section 1.8: Employee’s representative(s)


                                  This section is reserved for the identification of the
                                  employee’s representative on the Workplace Health and
                                  Safety Committee.

                                  Include, name, address and phone numbers.



                                  Section 1.9: Identification of victim(s)
                                  Descriptors of persons are individual variables and
                                  psychosocial traits that can have an impact on accidents.
                                  They include descriptors of demographic features, family
                                  traits, hereditary endogenous traits, ontogenetic defects,
                                  as well as lifestyle habits such as drug abuse, food habits,
                                  smoking, hobbies and relaxation. Most of these descriptors
                                  are useful in medical epidemiology, but few appear in
                                  accident injury analyses.

                                  The most common personal descriptors are:

                                  •   victim’s age or date of birth

                                  •   victim’s address;

                                  •   victim’s sex;

                                  •   seniority in the factory;

                                  •   seniority in the department;

                                  •   turnover of workers.

                                  There has been considerable criticism as to whether
                                  all of these personal descriptors are necessary. The
                                  victim’s age when the accident occurred could help
                                  identify inexperience or lack of training and information

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for young injured workers or, conversely, a significant
physical stress for older workers. Management would
henceforth gear its education activities towards the most
affected groups.

Never include personal information in the investigation
report, e.g. home address, home phone number. Record
this information in your notebook.

The victim’s sex can also be a determining factor
depending on the system: weight to be lifted, work pace,
women who are pregnant or of childbearing age exposed
to a mutagenic, teratogenic or carcinogenic contaminant
crossing the placenta, etc.

The descriptor of seniority in the factory helps identify
inexperience or, conversely, fatigue, wear and tear and
monotony, while the descriptor of seniority in the
department identifies the risks relating to mobility without
task preparedness.



Section 1.10: Description of damages


The descriptors of damages are, as a general rule, easy to
determine. They vary depending on the type:

    wound or injury;

    poisoning or occupational disease;

    asset loss; and

    environmental disturbances.



Description of Injuries
With any causal analysis, it is important to relate the cause
to the effect. Normally, three descriptors are needed to
adequately describe a wound, injury, or condition resulting
from an occurrence, exposure or chain of events occurring
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                                  in the work environment (CSA, 1993):

                                      Type of injury: cut, sprain, burns, fatality, etc.

                                      Extent of injury: minor, superficial, serious, grave,
                                      deep, etc.

                                      Part of body affected: head, eyes, hands, arms, knees,
                                      feet, etc.

                                  Since the extent of injuries is a matter of medical diagnosis,
                                  it is rare to find this descriptor in investigation reports
                                  because of issues of confidentiality of files. Where
                                  relevant, mention the autopsy report, coroner’s report or
                                  hospital report.



                                  Description of Occupational Diseases

                                  Occupational diseases are diseases linked to exposure to
                                  chemical, physical, biological, ergonomic or psychological
                                  stressors in the work environment. They are often
                                  described as:

                                  •   prevalence of disease, signs and symptoms;

                                  •   incidence of physiologic injuries;

                                  •   number of days lost;

                                  •   lethality;

                                  •   severity.


                                  Description of Asset Losses

                                  Asset losses involve damage to property and production
                                  and business disruptions. They affect the site, layout,
                                  structures, procedures, equipment, boilers and machines,
                                  and electricity, water and gas supplies. They are dealt with
                                  in the same manner as other damages in terms of type and
                                  extent:


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•   type of damages: break, deflection, burst, destruction,
    fire, etc.;

•   extent of damages: repair costs, production losses, etc.

Description of Environmental Disturbances

Environmental disturbances require a longer description
given the numerous and varied ecological systems
involved. They have not yet been officially standardized.
Here are a few criteria that must be considered:

•   toxicity of substances released: LD50, LC50, NOEL,
    TLV, etc.;

•   ecotoxicity of substances released: LC50 fish,
    IC50 algae, etc.;

•   persistence in the environment: air, water, soil,
    biological, global, etc.;

•   physical state: gas, vapor, liquid, fumes, or solid;

•   chemical strength: inflammability, explosivity,
    corrosivity, reactivity, oxidizing power, etc.;

•   effects on DNA: carcinogenicity, mutagenicity,
    genotoxicity, etc.;

•   teratogenicity;

•   immunotoxicity;

•   emission type: local or diffuse source;

•   emission rate;

•   extent of contamination: local, regional, general;

•   emission duration;

•   bioaccumulation.




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                                  Section 1.11: Description of the final
                                  phase of the accident


                                  Accident descriptors are undoubtedly the most universally
                                  widespread. They describe the final events leading up to
                                  the accident. They are a kind of synthesis or snapshot of
                                  the final action: the sudden and unforeseeable event that
                                  produces the injury. The most common descriptors are:

                                  •   source of injury or disease;

                                  •   secondary source of injury;

                                  •   event or exposure;

                                  •   form of energy.



                                  Description of Final Source of Injury

                                  The term “injury source” means the object, substance,
                                  exposure or body movement that directly caused the
                                  injury or disease indicated by the type of injury, for
                                  example, methane gas, noise, a container, a pallet, a
                                  forklift truck (CSA Z795, 1996).

                                  Many use the United States coding system (BLS, 1992),
                                  but others use the CSA standard which is much more
                                  detailed and takes into account repetitive movements
                                  responsible for repetitive strain injuries.

                                  Description of Secondary Source of Injury

                                  The secondary injury source denotes the machine,
                                  equipment, object, substance, circumstances or person
                                  having directly generated the source of the injury or
                                  disease or having contributed to the event or exposure
                                  (CSA Z795, 1996).



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For example, if the accident results in noise exposure, the
primary injury source is the noise and the secondary injury
source is the machine emitting the noise. If an operator
dies as a result of exposure to hydrogen sulfide in a sewer,
the injury source is the hydrogen sulfide and the secondary
injury source is the inhalation in a confined space.

Description of Event or Exposure

The event or exposure describes the way in which the
injury or the disease was produced or inflicted by the
injury source (CSA Z795, 1996).

For example, contact with objects or equipment, striking an
object, being hit by an object, being caught or compressed
by an object or equipment, being caught or crushed by
loose materials, abrasion by friction or pressure, being
subjected to vibrations, performing a repetitive movement,
assuming a stationary position, an act of violence or
assault, transportation accident, fire and explosion,
exposure without impact, etc.

Description of the Form of Energy

This descriptor identifies the undesirable or poorly
controlled energy flow that injures an operator, damages
equipment or impairs a process. For example, a person
suffering the effects of electrical energy (contact),
gravitational energy (falling objects or people), kinetic
energy (blow, repetitive movement, cut, pinning inside
automobiles), thermal energy (burn), chemical energy
(explosion), biological energy (infection), water
(drowning), radiation (x-rays), animal energy (bite),
sound energy (machine) or accumulated potential energy
(spring, metal deflection) (CSA Z796, 1998).

These four descriptors are directly related to the
mechanistic accident theory (Raymond, 1952). For
example, a worker can collide with a pole, a machine or a
piece of equipment with enough energy to cause an injury.
A band saw, an electric knife or a belt can strike him with
enough energy to tear off his fingers.




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                                  These descriptors are useful as they provide information
                                  on the direct cause of the injury, i.e., the final cause factor.

                                  Section 1.12: People who accompanied
                                  the investigators

                                  This section is reserved for identifying the names of people
                                  who accompanied you in investigation, even if you already
                                  mentioned them elsewhere in the report.

                                  This list identifies all people who saw you during the
                                  investigation and/or the analysis, or participated in part of
                                  them. It is better to identify more people than not enough.
                                  If their contribution is limited, specify which sections they
                                  were involved in.


                                  Section 1.13: Other interveners
                                  This section is easy to write. Only mention the name,
                                  phone number and agency name for all interveners of other
                                  official agencies were involved in some way at the accident
                                  site, even if you never met them personally:

                                  •   ambulance attendant;

                                  •   police officer;

                                  •   coroner;

                                  •   firefighter;

                                  •   provincial inspector, etc.



                                  Normally they have produced or will produce an
                                  investigation or trip report, which you will attach as
                                  appendices.




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Section 1.14: Witnesses and third parties
involved

We want to insist on the importance of this section, which
is why we have inserted it at the end of part I of the Table
of Contents, just before the detailed description of the
accident sequence.

You must identify the name, title, employer and phone
number of:

    all witnesses who saw, heard, smelled, tasted or
    touched (the five senses) something in relation to the
    accident phenomenon;

    all individuals who were not directly involved in the
    work system but who have something to say (or not
    say), or who may have some relationship to the hazard,
    conditions or activities of the accident phenomenon;

    all curious and passive bystanders who observed
    pertinent facts;

    all initial interveners who can identify certain
    characteristics of the damaged system components,
    especially if some of them were moved or modified
    before your arrival; and

    all people who personally know the management team
    and victim(s) and who were questioned by you, etc.

There is no limit to this section. Add any general
information you want to mention and did not indicate in the
previous sections.




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                                  Detailed Description of the
                                  Accident Sequence


                                  The factual phase is the most important step in the
                                  hazardous occurrence investigation process. During the
                                  preliminary information gathering stage, you have
                                  answered four initial series of questions:

                                  •   What are the damages? Injuries? Losses?
                                      Environmental disturbances?

                                  •   What type of hazardous occurrence occurred?

                                  •   What hazard or danger was present?

                                  •   In what system did the accident occur? At which site?
                                      At what time? Who was the victim? Who saw what
                                      happened?

                                  In describing the factual phase, you must first and foremost
                                  find out what the victim was doing when the accident
                                  occurred (normal task). Then, and only then, will you
                                  begin asking questions concerning malfunctions (accident
                                  phenomenon). We will explore the search for causal
                                  factors and information organization in the module on
                                  accident analysis.



                                  Section 2.1 : Terminology
                                  Section 2.1 is reserved for terminology specific to the
                                  report. In most cases, investigations cover very technical
                                  work systems and we recommend that you define technical
                                  terms used in the report. Only unknown or unusual words
                                  or expressions need to be mentioned. Keep in mind that
                                  potential readers do not all have a technical background
                                  and that this terminology may be new to them.




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It is not necessary to use dictionary definitions; a good
description in your own words is sufficient. When
workers and employers use French terminology,
we recommend that you put the French equivalent in
parentheses. Here are some examples:

SAW: Submerged Arc Welding, an electric welding
process where the arc is produced beneath a bed of
granular flux.

Center plate: central plate supporting the car body on
the bogey (crapaudine).

Huck bolt: a Huck-brand bolt (rivelon Huck).

Pad: the fiber pad in a panel filter (matelas).

SCBA: Self-contained breathing apparatus, a portable-
breathing device with full mask and air tanks.

Derailer: a device that allows a car to pass from one track
to another (speed change).



Section 2.2: Summary of statements,
documents and evidence
All these documents appear as attachments. Section 2.2
is designed to make the report easy to read without the
reader having to consult the attachments. These are brief
summaries of statements from witnesses, documents
received from the employer or gathered by officers, and
a brief description of evidence collected.

Using the example of P. Burner’s fall from the Transtainer
this section might look something like this:




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                                  “Summary of Testimony :

                                  Mark Simmons: Operator. He was in the cabin of the
                                  Transtainer. He saw P. Burner’s fall from halfway down to
                                  the ground.

                                  Bob Parenteau: Drives a Letro Porter. He was heading
                                  towards the front of the Transtainer, on the west side. He
                                  was approximately 50 meters north of the scene of the
                                  accident when he saw P. Burner topple over the guardrail
                                  of the bridge and fall to the ground.

                                  Frank Kosfsky: Truck driver. He heard B. Parenteau
                                  scream on the radio and he went to the scene of the
                                  accident. Being a first aid attendant, he took P. Burner’s
                                  pulse and noted that he was dead.”

                                  “Documents Received :

                                  •   Transtainer operating manual, 32 pages, North-Transit
                                      Edition, 1997, (no ISBN number).

                                  •   Brochure from the course “La santé et la sécurité au
                                      travail, ça nous préoccupe” [Occupational safety and
                                      health concerns us all], 12 pages, written by G. Tomlin,
                                      the person in charge of prevention at the company, (not
                                      dated).

                                  •   Copy of the training register from 1990 to1995.

                                  •   Coroner André Robitaille’s report in which he
                                      pinpoints the direct cause of death as a skull fracture
                                      caused by the impact of the wrench and specifies that P.
                                      Burner was already dead before his fall.”

                                  “Evidence Collected:

                                      1. The TRW26-010 ratchet wrench broken into
                                         three pieces.

                                      2. The socket found on the rotor-head bolt of the
                                         forward hoist motor.”




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Section 2.3: Facts noted
Section 2.3 is crucial to a good understanding of the
investigation and of the analysis that will follow. It lists
the facts observed and noted in your notebooks
with reference to the accident. These facts essentially
support the testimony.

We recommend that you proceed in the order that the
facts were noted, starting with your arrival at the accident
site. Here is an example:

“Mr. Burner’s body had already been removed when
we arrived.”

“Constable Pullen from the Port of Montreal Police had
secured the site and he had personally made sure that the
scene of the accident was not disturbed before our arrival.”

“The TRW26-010 ratchet wrench was lying on the ground
in three pieces 28 meters north of the point of impact (see
sketch 1, Appendix 4).”

“There was a pool of blood under the Transtainer.”

Section 2.4: Description of the technical
operations of the normal task
Section 2.4 of the report accurately describes the normal
task of operators at workstations involved in the accident
occurrence in order to situate the accident in time and in
its proper context. Standardized task descriptions are
rarely useful, as they are too general. A detailed
description must be given of what the operator did, does or
would have done if the accident had not occurred, i.e., if he
had done his task “normally.”

The victim is the person who knows best how to explain his
job. He is aware of all signals he receives and commands
he executes. If the operator is unfortunately deceased, it is
advisable to find someone who has previously done the
same job, even if this means seeking information from an
employee in a competing industry.



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                                  The operations that make up a task are represented by a
                                  series of signals, decisions, commands and transformations:



                                  (S0,d0,C0, t0 )(S1, d1, C1, t1 )(S2,d2,C2, t2 )--> (Sf, df ,Cf, tf )

                                  Describing the normal task means separating the operations
                                  performed by the operator in order to uncover all the
                                  “decisions” he must make. It is very important to
                                  determine what the victim was trying to do, or what he was
                                  supposed to be doing or would have normally been doing if
                                  there had not been a malfunction.

                                  You must exercise judgment so as not to break down the
                                  task too much and lose sight of the key objective of the
                                  analysis: to determine the causes of malfunctions.

                                  The normal task encompasses only those sequences of
                                  operations that are expected and learned in order to reach
                                  the final step. Not included as part of the normal task is
                                  what another operator would have done in the victim’s
                                  place, or what is written in texts but never communicated
                                  to the operator. However, the normal task does include the
                                  sequences the operator should have known through his job
                                  experience or training, even though he did not execute
                                  them properly at the time of the accident.

                                  In many cases, the normal task is not definitive or is
                                  occasional and has therefore not been given a specific
                                  prior description. When the operator is free to organize
                                  the technical operations of his system, the normal task is
                                  defined by answers to the questions: “What had you
                                  planned to do?” or “What had you intended to do?” In
                                  such cases, even if intentional operations were virtually
                                  impossible to carry out, they constitute the normal task.

                                  For example, it was virtually inconceivable that Paul and
                                  Monica could remove such a large stone and, if they did
                                  manage to extract it, that they could lift it and set it down
                                  outside the trench. Even so, this is the normal task. It is
                                  the existence of the initial malfunction that will indicate
                                  whether the normal task could in fact be carried out or not.



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In the investigation report, we recommend describing the
sequence of normal operations according to a finite series:
signal, decision, command, and transformation. To keep it
short, many times we have deliberately left out one of the
four elements (transformations), because any new signal
indicates the transformation that has taken place.

How many times have we read descriptions of accident
occurrences without knowing the “tasks to be performed.”
This is an important missing piece, because how can we
link malfunctions with causes without knowing what is
“normally normal!” Contrary to other accident models,
we believe that all accidents occur during normal
operations and not during new operations.



Section 2.5: Description of the accident
sequence
The description of the accident sequence in this section is
a narrative text that lists the events that occurred one after
another. It is the accident “history,” described by an
uninterrupted series of technical operations in the form of
signals, decisions and commands. This description can be
recorded on a standard form for a simple accident
occurrence, but most investigators prefer using writing
paper for greater flexibility.

The basis of the change analysis model focuses on the
specific identification of malfunctions. You must pay
particular attention when questioning whether the
perceived signals are routine or different from the
anticipated signals, whether the decisions made by the
operator are consistent with or derive normally from the
perceived signals, whether the commands are efficient or
deliver what they are supposed to deliver and, whether the
machine correctly or incorrectly transformed the material.



During your search, you must avoid at all costs trying to
find causes or risk factors responsible for malfunctions.
Otherwise, you will be tempted to discuss these causes,
contradict the victim and witnesses, argue or lead others to
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                                  argue among themselves. You might also cut short your
                                  search or take it in a different direction, overlooking
                                  important facts.

                                  After returning to the office, either on your own or with a
                                  team, you write up the narrative history of the accident as
                                  concretely, concisely and objectively as possible. The best
                                  way to describe an accident is to make a paragraph for each
                                  decision made by persons involved in the accident, starting
                                  with the perceived and unperceived signals, continuing on
                                  to the decision made or not made, and ending with the
                                  command executed or not executed.

                                  Here is an example:

                                  •   John sees the tank overflowing (signal). Without
                                      hesitating, he runs the 10.5 meters required to reach the
                                      tap (decision) and tries to shut off the valve
                                      (command).

                                  •   The valve won't turn (signal). He thinks it might budge
                                      if he uses a strong bar (decision). He looks around for
                                      a solid tool of some kind (command) and finds a board.

                                  •   With the board firmly wedged between the valve
                                      handles (signal), he tries to open it (decision) by
                                      pushing downwards (command).

                                  •   He sees the board give way under the pressure (signal),
                                      he hears a sharp sound (signal) and feels pain in his
                                      right cheek (accident).

                                  Monica’s accident is described similarly :

                                  •   Noticing that the stone was offering more resistance
                                      than usual (signal), Paul stopped working (decision)
                                      and went to find an object to use as a second lever
                                      (command).

                                  •   Monica had a shovel in her hand (signal). Paul asked
                                      Monica to use her shovel to prop up the right side of
                                      the stone (decision). Monica did this (command).




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•   On the first try, Monica mentioned to Paul that the
    shovel handle did not seem solid enough because it
    was bending under the pressure (signal). Not finding
    any other tools nearby (decision), Paul went to find
    another bar in the workshop (command).

•   When the tool keeper told him there were no bars left in
    the shop (signal), Paul decided to report the situation to
    his foreman (decision) in order to obtain the help of a
    few other people (command).

•   Not knowing which worker he could assign to this task
    (signal), the foreman told them to make do on their
    own (decision). Paul went back to where Monica was
    (command).

•   Having to get by with the existing tools (signal), Paul
    asked Monica to insert the shovel under the stone as
    soon as he managed to lift it enough with the bar
    (decision). They did this (command).

•   Once the shovel was inserted (signal), they decided to
    combine their hoisting power in order to better lift the
    stone (decision). First attempt (command).

•   Since this was not enough to move the stone (signal),
    Monica decided to jump with both feet on the shovel
    handle to enable Paul to wedge his bar further down
    underneath the stone (decision). Monica jumped
    (command).

•   The handle broke (signal); Monica fell onto the part of
    the shovel still stuck in the ground and injured her thigh
    (accident).

A too-short description is not very useful, especially if the
operational analysis is done several months later. It is quite
likely that no one will remember the details of the event
that caused the accident. On the other hand, a description
that is too long is tedious to read and does not meet the
objectives of the operational analysis. You must decide
how specific the description will be on the basis of the facts
of each accident occurrence and from your own past
experience.

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                                  All human physiology and psychology are based on the
                                  principle of a network of links, such as “afferent
                                  message — message interpretation — efferent message”.
                                  Whether it be the development of a disease, a biochemical
                                  reaction, sensory, affective, intellectual or psychomotor
                                  behavior, or social, political or religious apprehension.

                                  Even in the case of natural or conditioned reflexes,
                                  humans react only when a message is received and when
                                  the awareness centers have interpreted this message. This
                                  basal functioning of systems is used as a guiding principle
                                  in operational analysis. Describing the series of technical
                                  operations of an accident occurrence requires identifying
                                  the signals (afferences), the decisions (interpretations of
                                  afferences) and the actions (efferences) taken by the
                                  persons involved.

                                  You must be able to arrange this information in a logical
                                  sequence of signals, decisions and actions. If in the course
                                  of recording the facts you identify a signal, you must
                                  automatically ask what the ensuing decision was, whether
                                  erroneous or not (a signal can sometimes be
                                  misinterpreted). If the operator made a decision, you must
                                  look for the signal received and the action taken or not
                                  taken (the action can be adapted or impossible). If you
                                  identify an action, there must have been a decision that led
                                  to it. If there are any missing links in the sequence of
                                  technical operations of the accident occurrence, you must
                                  return to the victim and witnesses to uncover the missing
                                  facts.

                                  Many accident descriptions seem confusing when several
                                  systems are involved in the accident occurrence, when
                                  several operators are involved in the technical operations
                                  or when certain systems were coactive before influencing
                                  each other. This confusion is often due to the fact that the
                                  investigator tries to explain the accident while at the same
                                  time describing it. Information organization is a separate
                                  step from the description. Here, the investigator describes
                                  only the facts.

                                  When several persons are involved or several systems
                                  have been affected by malfunctions, we recommend
                                  giving a new description for each operator or each
                                  system and describing separately the technical operations
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of each one, ignoring previous descriptions. It is during
information organization that relationships among the
facts are established.

Section 2.6: Analysis of Cause Factors
Section 2.6 of the report is reserved for the analysis
of cause factors. This analysis was covered in module 4.



Primary Corrective and Preventive
Measures
A) Areas of Prevention
In order to prevent accidents, the preventionist must have
a very clear understanding of the circumstances that cause
them. Dozens of analysis techniques have been tested and
published by researchers. There is the “injury analysis”
using descriptors employed by compensation boards, the
“process checklist,” the “safety review,” the Dow and
Mond “hazard analysis,” the “What if analysis,” the “fault
tree analysis” and the “event tree analysis.” Unfortunately,
none of these techniques addresses the accident process,
meaning the degradation of the task towards an accident
occurrence. None of them examine the accident
phenomenon as a whole.

As in the example of Paul and Monica, all operators of
human-machine systems must counteract a series of
adverse events on a daily basis in order to maintain their
systems in balance. In addition to producing, their function
is to eliminate anything that could prevent the system as a
whole from producing.

Operators are the primary regulators of their own system.
At the start, they receive a set of instructions and aids to
enable them to perform their tasks normally. The systems
owner relies on the knowledge and experience of his
operators to maintain the systems in operation. Evidence
has shown for some time that workers know, after a more
or less lengthy learning period, how to control their
machine. And the more they work, the more knowledge

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                                  they acquire. The more experienced they become, the more
                                  they know how to correct malfunctions in their system.

                                  The change analysis model views an accident as a series of
                                  technical operations, i.e., a succession of work tasks that
                                  creates an imbalance in the human-machine system. The
                                  experienced and well-trained operator initiates several
                                  vicarious tasks before the system reaches the point of a
                                  final breakdown.

                                  By analyzing these vicarious tasks, the preventionist can
                                  draw a very clear distinction between those that frequently
                                  result in an accident and those that are most effective in
                                  restoring balance to human-machine systems. Logically,
                                  by reducing the occurrence of the first group and promoting
                                  the occurrence of the second group, he will be able to
                                  design a work accident prevention program.

                                  To meet this objective, the preventionist must clearly
                                  situate the purpose of the analysis technique he wishes to
                                  use within the specific framework of the accident process.
                                  For example, he cannot use the “What if” analysis to
                                  prevent accident occurrences, as this technique, when used
                                  properly, is chiefly for identifying possible mechanical
                                  malfunctions and establishing internal regulatory
                                  mechanisms. It is an a priori technique.

                                  Similarly, the descriptive analysis of injuries according
                                  to their type, severity and body part cannot be used alone
                                  to prevent accidents. This is an a posteriori technique.
                                  However, it is very useful for evaluating the hazard rate
                                  of human-machine systems and establishing emergency
                                  procedures.



                                  The use of an analysis technique for purposes other
                                  than those for which it was designed can only distort
                                  information and bury accident phenomena under a pile of
                                  data. The operational analysis was conceived in order to
                                  establish an overall picture of the origin of accidents in a
                                  system or group of systems, and to identify all causal risk
                                  factors that have contributed to promoting these accident
                                  phenomena.


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The ultimate aim of any preventive action is to eliminate or
at least reduce all damages resulting from the operation of
human-machine systems within a company. Practicing
prevention means taking action towards the worthy goal
of increasing the safety level of systems in which human
beings operate. By taking an aggressive approach, the
preventionist can take action at several stages of the
accident process.

The first possibility of mitigating risks is through direct
action on the hazard identified, in order to completely
eliminate it from the system or substitute it with one
that poses less risk, or more indirectly to transfer it to
those who know how to counteract it (Figure 10.3). All
actions on the hazard immediately affect the hazard rate
without influencing the system components and
interactions. Not surprising that these preventive actions
are the most effective.

Other areas of prevention become less effective the more
removed they are from the normal technical operations of
the system. Adaptation measures are almost as effective
as direct actions on the hazard. They are integrated into
the system without the operator knowing, for example,
improvements to machines, system engineering, purchasing
policy and personnel selection.

Internal and external regulation consists of safety
measures that are more or less effective aimed at modifying
the interactions among system components by introducing
planned vicarious tasks. Internal regulation encompasses
various system safety analysis techniques, the development
of safety procedures and the selection of tools, equipment,
instructions and aids as stopgap measures. External
regulation focuses primarily on training and information
for operators.

When there is no longer any means of working at
controlling or eliminating causal factors or in order to
compensate for the ineffectiveness of preventive measures
already in place, the preventionist introduces artificial
individual or group emergency and protection measures.

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                                  Finally, all prevention programs include post-accident
                                  mitigation measures aimed at saving the system or its
                                  components by combating the occurrence of and increase
                                  in damages (firefighting, rescue, evacuation...), preserving
                                  the survival of the system by compensating for damages
                                  and resuming production (insurance, compensation...)
                                  and repairing the adverse effects of accidents (treatment,
                                  readjustment, rehabilitation, repurchasing...). These are the
                                  least effective prevention measures because the harm has
                                  been done and because they require the injection of further
                                  resources without having increased the overall safety of the
                                  system.

                                  The operational model was created as an a posteriori
                                  technique to enable preventionists to take action at
                                  several levels of the accident process :

                                  •   In identifying malfunctions, they identify the initial
                                      causal factors triggering accident occurrences and
                                      suggest internal regulation mechanisms to control them.

                                  •   In identifying accident occurrences, they identify the
                                      intermediate causal factors and provide operators with
                                      suggestions on external regulation methods to control
                                      them.

                                  •   In identifying the moment at which real accidents
                                      occur, they identify the final causal factors resulting
                                      in damages and suggest modifications likely to avert
                                      the unfortunate consequences of accidents.




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        Areas of                  Accident               Areas of        Consequences
       prevention                  origin                control



                                    SYSTEM


        HAZARD
                                  TECHNICAL                adaptation         normal
                                  OPERATIONS                                   tasks

                     initial
                     causal
                     factor

                                                            internal          control
                                 MALFUNCTION
                                                           regulation        operations

                  intermediate
                     causal
                      factor

       DANGER                     ACCIDENT                  external         vicarious
                                 OCCURRENCE                regulation          tasks
                      final
                     causal
                     factor                                                 INCIDENT


                                                                              fortunate
                                                                            consequences



                                                                              NEAR
                                                                            ACCIDENT


                                  UNFORTUNATE            emergency and
                                 CONSEQUENCES              protection

                 Probability
                 of occurring


     HAZARD RATE

                 Probability
                 of damage

                                                            rescue            injuries
                                   DAMAGES                 survival            losses
                                                         compensation         hazards




Figure 10.3 – The Genesis of an Accident


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                                  •   In identifying injuries, losses and environmental
                                      disturbances, they develop emergency procedures
                                      aimed at reducing or avoiding even more disastrous
                                      consequences.

                                  •   And finally, in identifying hazards, they estimate the
                                      hazard rate they present in terms of probability and then
                                      seek to reduce these probabilities.

                                  The change analysis model clearly shows the areas that
                                  need to be worked on in order to reduce the accident rate
                                  and increase the impact of preventive actions. It provides
                                  several levels of analysis that the preventionist can easily
                                  integrate into his own prevention program and safety
                                  management system.

                                  B) The Search for Solutions
                                  Searching for solutions involves making a list of actions
                                  that breaks the chain of malfunctions leading to an
                                  accident. Once the tree of malfunctions and causal factors
                                  is correctly established, all the facts needed to determine
                                  how the accident occurred are known. Logic states that by
                                  suppressing any one of these factors, the accident will no
                                  longer occur. This constitutes the preventive phase of the
                                  accident phenomenon.

                                  Experience shows that we cannot eliminate or correct
                                  all factors for a variety of reasons: some factors apply to
                                  only one accident; others lead to unrealistic actions; others
                                  require phenomenal expenses that are disproportionate to
                                  the degree of safety they provide; and finally, others are
                                  only transient and would never arise again. It is therefore
                                  necessary to sort out the various factors and choose the
                                  ones that suggest actions that are possible.

                                  The simplest technique for identifying preventive measures
                                  consists of using the tree of malfunctions and causal factors
                                  to draw up a list of preventive actions aimed at either
                                  suppressing the basal or external factors or rendering them
                                  consistent with the normal job task.



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In the first case, there is a direct action on the hazards,
and in the second case the action is one of adaptation,
regulation, protection or emergency.

With most accidents, the solutions are obvious and do not
require extensive research, for example, a faulty electrical
wire. However, in the case of some serious accidents, such
as a train derailment, the solutions require a more in-depth
search.

Our OHS Regulation is filled with mandatory solutions
for controlling certain hazards. Standards are also an
excellent source of ideas. Consider also the safety
practices recommended by professional, employer and
union associations, and by insurance companies.

Books, specialized publications and investigation reports
on the subject of hazards often help to identify corrective
and preventive measures that have been proven effective.

To make an inventory of possible solutions, the
preventionist or his appointed team reviews each of the
causal factors of the tree analysis by asking the following
questions. Note that the measures are in descending order
of effectiveness, as the more quickly action is taken when
an accident first occurs, the more effective the prevention
measure.

•   Is it possible to completely eliminate this factor so that
    it does not recur? (elimination)

•   Can it be replaced by a factor that will not cause the
    malfunction? (substitution)

•   Can the system operations be modified in order to take
    this factor into account? (adaptation)

•   Can the operator be given something to counteract this
    factor should it arise? (internal regulation).

•   Can temporary measures be put in place should this
    factor recur? (external regulation)




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                                  •   Can emergency equipment and methods be provided
                                      to protect the operator from the consequences of this
                                      factor? (protection, emergency)

                                  •   Can the damages caused by this factor be reduced?
                                      (rescue, survival, compensation)

                                  •   Are these measures necessary and sufficient to control
                                      the malfunction? (risk management)

                                  In answering these questions, the preventionist or
                                  committee generally uncovers more than one solution for
                                  each factor and even more for the accident occurrence as
                                  a whole. Theoretically, eliminating one malfunction is
                                  enough to prevent an accident of the same type. However,
                                  by superimposing several preventive actions for the same
                                  malfunction, the preventionist increases the prevention's
                                  effectiveness by that much more. Similarly, by acting on
                                  several malfunctions at the same time, he greatly reduces
                                  the risk of accident recurrences.

                                  Those involved in the process must first look for solutions
                                  that have a direct and therefore controllable impact on the
                                  human-machine system configuration. They then consider
                                  solutions that have an indirect and therefore partially
                                  controllable or uncontrollable impact.

                              Using this line of questioning, preventionists have prepared
                              tables to guide the search for solutions. For example, for each
                              of the risk factors identified, one must first look for a solution
                              appearing in Section A of Table 10.2, consider only one
                              solution found in Section B and avoid a solution listed in
                              Section C.




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Table 10.2: Relative Value of Preventive Measures



                                         Section A
                   Solutions Having a Direct Impact on Operations

      Redesigning the workstation.

      Modifying the operator’s available space.

      Adopting a sitting position.

      Changing work positions.

      Modifying movement patterns and their frequency.

      Reducing physical demands: strength used, energy required, less frequent handling.

      Reducing sensory demands.

      Improving signaling, command and regulation devices.

      Reducing mental demands.

      Reducing the demand of interpreting information and aids.

      Selecting or eliminating manual tools.

      Reorganizing work and modifying tasks.

      Improving the work environment: temperature, lighting, noise, vibration, and
      contaminant emissions.

      Reducing energy hazards: mechanical, electrical, chemical, radioactive.




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                                         Section B
                 Solutions Having an Indirect Impact on Operations

      Modifying work teams.

      Reduced operations by rotating teams.

      Maintaining worksites.

      Preventive maintenance and upkeep.

      Training needs.

      Wearing protective equipment.

      Modifying work supervision methods.

      Developing a company safety policy.




                                         Section C
                    Solutions Having Little Impact on Operations

      Modifying the company’s administrative structure.

      Programmed selection of personnel.

      Replacing operators with other operators.

      Improving operators’ social conditions.

      Improving operators’ physical fitness level.

      Boosting operators’ morale.




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Section 2.7: Corrective and preventive
measures
The principle of immediate decision-making consists of
addressing the causal factor that is most likely to prevent
a similar accident from recurring. In many companies,
the immediate actions taken by those involved are merely
compensation measures focusing partly on dealing with the
damages suffered by the victim and partly on repairing the
elements of the system that are making all operations
impossible.

For example, Monica is sent to the first aid station, then to
the hospital, and a new shovel is given to the person
replacing her. These preventive actions are aimed at
preventing the damages from spreading or persisting, but
these actions do not introduce any new system operation
that is likely to reduce or control the risk. Unfortunately,
on many occasions the only preventive actions taken
consist of a review of written procedures or a gratuitous
reprimand such as: “Not recommended!” or “Do not do
what that other person just did!” This is not what is meant
by immediate action.

By examining the tree of causal factors of a given accident,
the preventionist or health and safety committee can
quickly see that certain malfunctions are more at risk and
that certain causal factors can be more easily eliminated.

The causal factors that have the greatest chance of causing
damages similar to those that have occurred can be seen
at a glance. Often they are the initial causal factors
responsible for the initial malfunction, and the final causal
factors responsible for the final malfunction. An
immediate action would involve controlling one of these
two factors.

For example, to prevent an accident similar to Monica’s
from happening again, management can decide to
assign only strongly-built persons to do very physically-
demanding jobs (initial causal factor). A second-best
solution, since the factor is an external one. Management
should instead develop its labour policy at all costs. It
might also consider the possibility of increasing the

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                                  strength of handles (final causal factor) or reviewing its
                                  cost reduction policy.

                                  Interestingly, actions that influence the initial causal
                                  factor generally cover a broader preventive scope than
                                  others by addressing several human-machine systems: in
                                  this case, all workstations where heavy labour is carried
                                  out. Conversely, actions that control the final causal factor
                                  have a more limited scope and deal only with the accident
                                  occurrence under observation. Replacing shovel handles
                                  would reduce the risk only in specific cases, at most only
                                  in those systems where shovels are used as a lever.

                                  In the same way, actions that deal with the source of causal
                                  factors (external causal factors) have a more general scope.
                                  For example, if management decides to develop specific
                                  procedures for temporarily assigning persons to various
                                  positions within the company during production
                                  shutdowns (cause of the initial causal factor from the
                                  initial malfunction), it addresses a host of possible accident
                                  phenomena and not just positions requiring extraordinary
                                  physical endurance. Assigning the right people to the right
                                  job is one of the cornerstones of industrial accident
                                  prevention. In reviewing its entire cost reduction policy
                                  (cause of the final factor of the sixth malfunction),
                                  according to safety criteria, management raises questions
                                  not only on the quality and quantity of shovels in its
                                  possession but also on all tools and equipment necessary
                                  for production.

                                  Be careful! The cause factor most likely to prevent the
                                  same type of accident can also be found elsewhere in the
                                  tree. Consequently, in considering all causal factors of
                                  Monica’s accident, one of them in particular comes to
                                  mind: the lack of additional personnel to replace the
                                  two workers on sick leave (fifth malfunction). If this is
                                  a general policy, it is quite likely that other accidents will
                                  occur owing to a lack of human resources.

                                  In the investigation report, section 2.7 deals with measures
                                  put in place by the employer either as first aid and
                                  emergency measures, or as corrective and preventive
                                  action.


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Although you may be tempted to criticize these measures
(all preventive actions are good ones, even when not very
effective), you can comment by explaining why the
employer adopted these measures. Do not indicate what
you would have done instead. Part 2 of the report deals
strictly with the facts. You may well have certain
comments or judgements to make, but keep them for Part 3
of the investigation report.



Action and Follow-up
Part 3 of the report is actually the end of your investigation.
It is divided into three sections that roughly correspond to:

•   the lessons learned from the accident (past);

•   the action taken to correct the malfunctions (present);

•   the long-term preventive measures (future).

Section 3.1: Conclusion
In section 3.1, you consider the causal factors identified
during the analysis stage in order to identify those factors
that contributed the most and those that were the most
preventable.

Sometimes a dozen or so causal factors contributed to the
occurrence of the accident, but upon closer examination,
these factors do not all have the same weight or the same
preventive scope. The weight of a causal factor is
measured by the quotation of risk, which we will define
later on. The scope of a causal factor is evaluated by the
effectiveness of the related preventive measures. The main
criteria for estimating a measure’s effectiveness are :

•   the stability of the measure;

•   the “cost” to the operator and the possibility of
    integrating the measure;

•   the non-transfer of risk;


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                                  •   the possibility of a broad application;

                                  •   the level of logical precedence;

                                  •   the timeframes.

                                  The Stability of the Measure

                                  The effects of a preventive measure must not disappear
                                  with time; otherwise the causal factor will resurface.
                                  This is notably why a reminder of safety procedures,
                                  for example, is not really an effective measure if it is
                                  not repeated. To a lesser degree, training has the
                                  same drawbacks if it is not followed up with frequent
                                  reminders. Measures relating to the operator are often not
                                  very stable, but these are not the only ones. If a protective
                                  device on a machine is easily removed, sooner or later it
                                  may well disappear.

                                  Furthermore, a preventive measure is all the more stable
                                  when it is better accepted by operators, and it is all the
                                  more accepted when it is developed in collaboration with
                                  those involved.



                                  The “Cost” to the Operator and the
                                  Possibility of Integrating the Measure

                                  Many preventive measures are particular operations that
                                  are added on top of production. Whenever safety is
                                  ensured by adding an operation that is not a necessary part
                                  of production, we know that the measure in question will
                                  be fairly quickly abandoned. In this case, we usually say
                                  the measure is not “adapted” to the production process.

                                  An adapted measure is a stable measure, for example, a
                                  machine that starts when you close the protective cover and
                                  that will not start unless it is closed. In contrast, many
                                  types of personal protection are rejected when, among other
                                  things, they make operating the equipment more
                                  complicated.




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Generally, all preventive measures that carry an additional
“cost” – real or imagined by the operator – prove to be
ineffective. This is true whether the cost involved is a
physiological cost, such as an increased physical or mental
load, a financial cost, such as a decrease in performance
pay, or even just a waste of time with no effect on salary or
production.

The Non-transfer of Hazard or the
Introduction of New Hazards

A preventive measure can be beneficial in one place but
have harmful consequences somewhere else.

For example, replacing old fork lift trucks with newer
machines, which have technological improvements making
them more reliable, can bring about a decrease in trip time
(which is fine) but can also cause a bottleneck at some
point in the process or a line-up where congestion can be
harmful to safety.

A preventive measure can also remove one hazard but
introduce another at the same workstation. Protective
earmuffs are effective if they block out enough noise to
prevent the worker from going deaf, but they must not
mask speech or signals that are necessary for performing
tasks. Otherwise, they introduce a new hazard.

The Scope or the Possibility
of a Broad Application

This criterion reflects the concern that the same preventive
measure involves as many workstations as possible; such a
measure would then have a broad scope. This is the case
when a measure eliminates a causal factor common to
several accidents because its elimination has a direct
positive effect on several workstations.

A measure that could be repeated at several workstations
also has a broad scope. For example, if a machine’s
operating instructions must be reworked to prevent an
accident from happening again, the action will have a broad
scope if the company has several such machines and if their
operating instructions are also modified.


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                                  The Level of Logical Precedence
                                  or Action on “Root Causes”

                                  Every tree shows that damages/injuries result from a series
                                  of occurrences that are logically linked. After examining
                                  several trees, we noticed that causal factors far upstream
                                  from the damages/injuries (upward and to the right) are not
                                  visibly dangerous, especially if we look at them out of
                                  context. Conversely, those that are very near the
                                  damages/injuries are obviously dangerous.

                                  The disruption of the work situation seems less and less
                                  harmful the further we get from the damages/injuries
                                  (reading the tree from right to left).

                                  In other words, the accident is the result of a work situation
                                  that deteriorates, very gradually at first, then faster,
                                  suddenly ending in damages/injuries. Therefore,
                                  preventing causal factors near the damages/injuries
                                  eliminates certain “effects” of hazardous situations, while
                                  preventing causal factors far upstream tends to actually
                                  eliminate the very “existence” of these situations.

                                  The Timeframes

                                  To prevent the same accident from recurring, a preventive
                                  measure must be applied right away. Nevertheless, such a
                                  measure must not exclude other possible actions; hence the
                                  importance of follow-up of measures. Measures that
                                  require longer timeframes to be completed very often have
                                  a broad scope (considering only this criterion).
                                  Unfortunately, in many cases the immediate measure is the
                                  only one adopted. To simplify, we can say that every
                                  accident must lead to at least two measures: one
                                  immediately applicable action and one deferred but more
                                  ambitious action.

                                  By considering the risk rate and the preventive scope
                                  of causal factors, you will determine which factors need
                                  your special attention and then explain this choice in the
                                  conclusion.




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Section 3.2: Corrective and preventive
actions taken
In section 3.2, you indicate the corrective and preventive
actions taken, and explain them with reference to the
identified malfunctions.

Section 3.3: Recommendations
In section 3.3, you can use your imagination to try
to identify “potential accident factors” among the causal
factors and preventive measures implemented. These
potential factors have a broader scope and lead to
preventive measures with respect not only to the accident
that resulted in their application, but also to other
workstations and groups, or to other work situations in
general.

If you see, for example, that during an accident the drive
shaft of some machine was not protected, you can
recommend to the employer that other mechanical
equipment that could present the same danger be examined
right away. In doing this, you consider any accessible and
unprotected moving mechanism an accident factor. You
make a general statement about a problem in which the
drive shaft is only one particular instance. Formulating a
general statement allows the lessons learned from one
accident to be applied to potential accident situations.

By focusing your recommendations on potential accident
factors, you lead employers to concentrate on a potential
factor that they will strive to systematically detect during
their daily rounds of the company. The advantage of this
extensive detection is that it can be done without needing a
long list of factors. Therefore, it can be done as soon as
just one accident occurs. This approach is highly
recommended for routine inspections by company health
and safety committees. It is equivalent to drawing up
questionnaires or checklists for a particular machine,
facility, workstation, workshop or plant.




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                                  Signature
                                  To conclude and before going on to the attachments, the
                                  person in charge signs the report, above his/her typed or
                                  printed name. If other persons are mentioned on the cover
                                  page, they must also sign.

                                  Attachments to the Report
                                  All documents collected during the investigation that
                                  helped in writing the report must be attached to the report.
                                  These include:

                                  •   the preliminary hazardous occurrence report filled out
                                      by the employer;

                                  •   photographs, videos, sketches;

                                  •   written confirmation of compliance received from the
                                      employer or employee;

                                  •   written statements;

                                  •   documents obtained;

                                  •   reports on evidence and the chain of evidence custody.

                                  Explanatory texts useful to the understanding of the report
                                  but too long to be included in the body of the text can also
                                  be attached. For example:

                                  •   pages from an instruction manual or a book explaining
                                      a particular point made in the report;

                                  •   excerpt from employer procedures;

                                  •   detailed description of a device or the workings of a
                                      piece of equipment;

                                  •   external expert reports requested by the person in
                                      charge;

                                  •   sampling, police, coroner, ambulance reports;




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 Appendix
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                                           Glossary


Accident: state of a work system deviating from its initial objective and producing a specific
unplanned adverse effect

Accident occurrence: state of a work system with inappropriate or unplanned control operations
on the malfunctions

Accident phenomenon: adaptation failure of the technical operations of a work system having
an impact on the integrity of its human component

Adaptation: series of pre-planned operations of a work system aimed to transform the input into
output without malfunction

Aids: rules useful or necessary in achieving the operation of a work system

Analysis report: content of an accident report

Basic cause factor : factor that does not require a search for any previous or more detailed
causes

Causal factor: something or someone acting either on the work system’s components or their
interactions, modifying them and leading either to the origin of an accident or an aggravation of
its consequences

Damages: material, equipment or production losses, or environmental disturbances resulting
from an accident

Danger: any existing or potential hazard or condition or any current or future activity that could
reasonably be expected to cause injury or illness to a person exposed to it before the hazard or
condition can be corrected, or the activity altered, whether or not the injury or illness occurs
immediately after the exposure to the hazard, condition or activity (Canada Labour Code,
122.(1)).

External cause factor: factor that is outside the scope of the human-machine system under
study

Environment: atmospheric, aquatic, terrestrial, alimentary and animal characteristics found in
proximity to the work system in time and space and which may influence its operation

Evidence: sample of any material or substance or any biological, chemical or physical agent
taken or removed for analysis, and material or equipment taken or removed for testing

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Hazard: any form of energy that threatens or compromises the safety or existence of a work
system or one of its components

Hazard rate: probability of loss or injury expressed as a ratio, a percentage, a quotation, or any
combination of the probability of the hazard being activated in a danger (frequency) and the
probability of damages arising as a result of an accident occurrence (severity)

Hazardous Occurrence: includes both an accident and incidents in the workplace

Human-machine system: combination of human and non-human energy intended to transform a
material or offer a service

Incident: state of a work system slowing down or temporarily interrupting its normal operations
after a malfunction; or accident occurrence that has not caused injuries or illnesses, but that
could have, had the circumstances been different

Investigation: series of steps and activities carried out to gather the facts and evidence needed to
identify the cause factors and analyze an accident phenomenon in order to specifically determine
the prevention process required

Near-accident: Incidents

Organization: functions related to workplace management, including the accident prevention
program, selection of personnel, their training and education, and task supervision

Re-enactment: repetition of the actions of an hazardous occurrence

Risk: possibility that an occurrence can cause damages to the work system in the presence of a
hazard that is more or less foreseeable by the designer and system operators

Risk factor: result of risk assessment based on the statement of relative risk level according to
specified frequency and severity criteria

Risk rate: probability of loss or injury

Root cause: basic cause factor or external cause factor causing a malfunction

Statement: the act or process of stating or presenting orally or on paper

Task: set of technical operations performed by persons assigned to the partial or total production
of goods or services




                                              A-2

				
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