 Definition of Terms.  Analyzing the Evidence.

 Writing the Report.

 Purpose of Incident
Investigation.  Incident Investigation
methodologies.
 Incident Investigation
preparation.  Conclusion.

 Visiting the Incident Scene.

 Interviewing Witnesses.
 Able to know all details of incident investigation.

 Determine the approach of incident investigation method.

 Determine the root causes.

 Gathering KPIs from the incident investigation findings.

what is process safety?
what is process safety?
 Definition of Terms

 Accident

Any unforeseen event, which causes

injury or property damage Incident
 Near Miss

Any unforeseen event that causes a

disruption in the workflow, however it Accident Near Miss
does not cause any injuries or property
damage.
Purpose of Incident Investigation
 The prevention of another future incident is the purpose of incident
investigation, not to lay blame or find who’s at fault.

 The investigation should identify the causes of the incident so that

controls can be put in place to prevent the same / similar incident from
happening again.

 The findings from the investigation should be recorded and kept on file,
however these findings should not be used to discipline anyone.

 This encourages individuals to report all incidents and it also

encourages witnesses to tell investigators everything they know about
the incident.
 Moral, financial and legal reasons.
Incident Facts

o The majority of accidents are forecasted by near misses in the

workplace.

o By investigating all incidents you can eliminate the causes.

o Unless causes are eliminated then the same / similar incident will
likely occur in the future.
 Heinrich Theory

1
In 1931, Herbert Heinrich stated in his
Major
book that for every accident that causes Injury
a major injury there are 29 accidents that
cause a minor injury and 300 accidents
that cause no injury. 29
Minor Injuries

300
Near Misses
 Incident Investigation Should

 Determine what happened.

 Determine the true cause of the accident.

 Identify corrective actions.

 Prevent future occurrence of the same / similar incident.

 Incident Investigation Preparation

 When investigating an incident, time is your worst enemy.

 There should be very little time between the occurrence of the

incident and the investigation.

 The preparation before an incident is necessary to make sure that

all your resources are available at the time of the incident.

 Preparation for incident investigation is just as important as the

investigation itself.
 Incident Investigation Team

 Upper Management
 Workers from the area not involved in the incident (Hourly)
 Maintenance Supervisor
 Safety Supervisor
 Supervisor from affected area
 Safety Committee Members
 Visiting the Incident Scene

 When it comes to incident investigation, speed is crucial &

important.

 Preserve evidence and record eyewitness accounts before they

are forgotten.
 Essential Tasks at Incident Scene

1. Make sure the area is 5. Identify potential sources

safe for you and others of information such as
witnesses, injured
2. Ensure the injured personnel, and any
personnel are properly physical evidence
cared for
6. Sketch the scene
3. Ensure management is
notified of the situation 7. Take photographs

4. Secure the affected area 8. Collect any critical

evidence that will have to
be analyzed at a later
date
Sketching the Scene

 Place important information in the center and

draw relevant information around it.

 Measure the area and draw the scene as close to

scale as possible.

 Note the position of personnel and evidence

 Photographing The Scene

 Start by photographing the general area to get an idea of

where the incident took place.

 After photographing the general area, photograph the

specific scene of the incident.

 Take photos from all angles and viewpoints.

 Use a straight edge ruler in some photos to give a better

idea of the size of the object you are photographing
Interviewing the Witnesses

 Once the witnesses have been identified you need to

separate them so that they don’t lose their individual
perceptions of the incident.

 Have each witness write out what they saw happen before,
during and after the incident.

 Interview witnesses as soon as possible while the incident

is still fresh in their minds.
Types of Witnesses

1. Those who actually saw the incident happen or were

involved in the incident.
2. Personnel who came on the scene immediately after the
incident.
3. Personnel who witnessed events leading up to the
incident.
4. Personnel who have expertise in the work tasks that
were being performed when the incident happened.
 Putting the Witness at Ease
 Let them know that your primary goal in conducting the investigation
is to prevent the recurrence of the same or similar incident.

 Inform the witness that you are not there to get anyone in trouble or
point finger at the guilty parties.

 Choose a private location to conduct the interview.

 Place yourself between the witness and the exit door. This eases the
witnesses feelings of being trapped.
Interviewing Questions

 WHAT happened
 WHO witnessed or was involved in the incident
 WHERE did the incident occur and where was the witness
in relation to where the incident occurred
 WHEN did the incident happen
 By answering the previous questions you are able to
answer WHY and HOW the incident happened
Use Open Ended Questions Such As

 Tell me what you saw?

 Tell me about…

 Explain how this job is done?

 Where were you at the time of the incident?

 Who else saw the incident?

Common Mistakes to Avoid

 Do not ask leading questions (e.g. “Do you think that…)

 Do not intimidate the witness (e.g. “That was a stupid thing

to do”)

 Do not introduce your own personal opinions of the incident

 Note taking should not interfere with the interview process

 Do not interrupt the witness while they are talking

 Do not use a tape recorder during the interview. This

usually makes the witness uncomfortable.
 Analyzing the Evidence
 Review the (SOP) for the task that  Review photographs that were taken
was being performed when the at the scene
incident happened
 Review training records of
 Require that maintenance analyze personnel involved in the incident
any equipment involved and review
equipment manuals  Review Environmental factors

 Review Witness statements and  Review whether management had

cross reference each of them to enforced the policies and rules
point out any discrepancies. If
discrepancies are found then you
will have to re-interview witnesses
Writing the Incident Report

 The intent of the incident report is to effect change so

that the same or similar incident does not happen again
in the future.

 The report should not place blame and it should be filed

away for future reference.

 The written incident report can also be used as a training

tool.
 Incident Report include :
Six Sections of an Incident Report

 Who, Where, When

 Description of the Incident – What Happened

 Findings

 Corrective Actions and Improvements

 Conclusion

 Appendix
 Section I

 Who  When

Injured party Date

Witnesses Time

Shift
 Where

Location of Incident
 Section II

 Description of The Incident

What happened prior to the incident

What happened during the incident

What happened after the incident

 Section III

 Findings

 Direct Cause - The act that directly caused the incident

(e.g. the grinding wheel on the bench grinder exploded)

 Indirect Cause - The root cause of the incident (e.g.

improper training on using a bench grinder –
management system failure)
 Section IV

 Corrective Actions

 How the hazardous conditions that directly caused the

incident will be eliminated and the target date these
actions will be completed
 System Improvements

 Improvements to procedures, element of

management failure and policies that indirectly
caused the incident and the target date for these
improvements to be implemented
 Section V

 Conclusion

 Estimated cost of incident (direct and indirect costs)

([Link]

 Name of personnel responsible for implementing the corrective

actions and system improvements

 Description of the intended results and positive impact of the

suggested changes

 Date that corrective actions and system improvements have

been implemented and the results of those actions. This is also
the date that the report is closed.
Prepared by
 Section VI

 Appendix

 Printouts of all the photographs taken

 Sketch of the scene

 Witness statements

 Investigation notes
Incident investigation different methods

 5W

 SCAT

 CLC

 FTA

 ETA
 Conclusion
 For the incident investigation process to be effective, management
must have a plan in place for implementing the corrective actions
and making system improvements.

 Management must also periodically evaluate the quality of the

incident investigation process to make sure that it is still an
effective tool.

 Retraining after an incident is necessary for all parties involved

 Thanks for your Attention

Any Question ?