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					  Investigation
Find the reason
 not the blame

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         Definitions

• Incident - an occurrence or
  event that interrupts normal
  procedure or precipitates a
  crisis




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 Definitions (con’t)

• Accident - a mishap;
  especially one causing injury
  or death; anything that
  happens by chance without
  an apparent cause.




      P bar Y Safety Consultants Alberta Canada
   Definitions (con’t)

• Loss - the identifiable and
  calculable monetary
  detriment that is suffered
  or will be suffered as a
  result of an act or event




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  Definitions (con’t)

• Near Miss - a narrowly
  avoided incident




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Why do an investigation?

 • Discover the cause(s) to keep the
   event from re-occurring in the
   future.
 • To meet legal obligations.
 • Identify deficiencies.

 • NEVER – to assign blame!

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                Causes

• Direct Cause – the event that
  immediately preceded the accident.
• Indirect Cause – these allow the direct
  cause to exist.
• Root Cause – are those factors that if
  corrected will prevent a similar incident
  from happening again.


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Energy – can always be found at the scene!

  an unwanted transfer of energy that
      produces injury to persons or
     damage to things as the level of
      energy exceeds the body’s or
     structure's ability to absorb the
                  energy.


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Investigation Best Practices

  •   Prevention Focus
  •   Fact Finding
  •   Confidentiality
  •   Consultation
  •   Communications
  •   Systematic Approach
  •   Training
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What to investigate?

• Incidents
• Illnesses
• Near Misses




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Accident Pyramid
          Serious Accidents
 1        (Lost-Time / Fatality)

                  Minor Injury
10                (Medical Aid Cases)


                          Property Damage or
30                        Minor First Aid Case


                                     Near Misses /
600                                  Close Calls


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Classifying (Severity x Re-occurrence)

Severity                           Re-occurrence
Catastrophic                       Probable
Critical                           Reasonably Probable
Marginal                           Remote
Negligible                         Extremely Remote




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               Classification Chart


                                 Reasonably                            Extremely
               Probable                                      Remote
                                  Probable                              Remote

Catastrophic      16                      12                       8       4

Critical          12                       9                       6       3

Marginal          8                        6                       4       2

Negligible        4                        3                       2       1


                       P bar Y Safety Consultants Alberta Canada
                     The Law

REPORTING WORKPLACE INJURIES
 AND ACCIDENTS
The Occupational Health and Safety Act requires
 workplace injuries and incidents to be reported
 to the nearest Workplace Health and Safety
 Office if they:


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            The Law (con’t)

• result in death
• cause a worker to be admitted to
  hospital for more than 2 days
• involve an unplanned or uncontrolled
  explosion, fire or flood that causes or
  has a potential to cause a serious injury


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            The Law (con’t)
• involve the collapse or upset of a crane,
  derrick or hoist
• involve the collapse or failure of any
  component of a building or structure
  necessary for the structural integrity of
  the building or structure.


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       Who to involve?

•   Investigator
•   Victim
•   Witness
•   Experts
•   Other Knowledgeable People



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            Investigation Kit

•   Clipboard                       • Chalk
•   Paper                           • Tape measure
•   Pens                            • Flashlight
•   Camera                          • Magnifying Glass
•   Accident Reports                • Convex Mirror
•   Tape Recorder                   • Identification Tags
•   Ruler                           • Specimen Containers
•   Barricade Tape                  • Gloves
                                    • Reflective Vest

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           Investigation Steps

1. Get an Overview of the Situation

       Gather information about who
      was involved, what the conditions
     were at the time of the incident, etc.

    (This step usually uncovers the direct cause.)

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         Investigation Steps (con’t)

2. Gather Physical Evidence

     •    Make notes of your observations.
              • Take photographs.
               • Draw diagrams.
         • If applicable, seal any physical
           evidence in an appropriate
             container or plastic bag.
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    Investigation Steps (con’t)

Look for things like:

• Positions of the injured,
• Condition or equipment and materials,
• Position of objects in relation to each other,
• Where the Energy came from,
• Any safety devices that were in use, and their
  positions,
• The overall condition of the facility, ie.
  Housekeeping, and
• What were the noise and lighting levels.
               P bar Y Safety Consultants Alberta Canada
 Investigation Steps (con’t)

3. Interview Witnesses

                           ASK the
        Who
          What
               Where
                  When
                      Why
            & How questions!
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 Investigation Steps (con’t)

4. Check Background Information

        • Maintenance Records
   • Previous Incident / Near Miss Reports
           • Safety Meetings
          • Hazardous Reports
           • Training Records
          • Safe Work Practices
    • Job Procedures / Codes of Practices

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  Investigation Steps (con’t)

5. Determine Causes

  Don’t stop once the direct cause is found!
    There is usually more than one cause
          and quite often you’ll hear,
        “it was a combination of…….”.


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     Investigation Steps (con’t)
6. Recommend Corrections

       From all of your research you’ll
           be able to recommend a
         corrective action to prevent
          this unwanted event from
       happening again in the future.

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 Investigation Steps (con’t)

7. Determine Costs
Consider items such as:
• Damage to/loss of material/equipment
• Wages (include any overtime)
• Medical Expenses
• Decreased output when the injured
   person(s) return to work
• Training replacement workers
• Your time
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      Investigation Steps (con’t)

8. Write the Investigation Report

               This is a summary
                of your findings!

         Using a standardized form will
         help you to not leave out any
            important information.
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  Investigation Steps (con’t)

9. Follow-up

               This is a pertinent step!

      Find out how the new equipment or
            procedure is working; and,
   have the appropriate personnel completed
    their tasks for follow-up on this incident?

  Make sure this incident doesn’t happen again!
               P bar Y Safety Consultants Alberta Canada
               Closing

• By investigating ALL incidents
  and near misses, you can
  improve the quality of your
  training and the level of safety
  in your workplace!




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Description: safety