Incident Investigation and Reporting for Safety management

Incident Investigation and Reporting for occupational Health and safety

1. Occupational Health & Safety M.Sc. In Construction Management II Semester Lecturer: Er. Suman Bhattarai B.E. In Civil Engineering M.Sc. In Construction Management

2. Chapter Nine Incident Investigation and Reporting

3. Contents: Incident Reporting Procedures and Requirements Investigation Team Formation and Roles Gathering and Analyzing Incident Data and Evidence Root Cause Analysis Techniques Developing Corrective Actions and Preventive Measures Communication of Investigation Findings and Recommendations Continuous Improvement through Lessons Learned

4. Incident reporting systems is necessary for: The higher frequency of incidents provides greater insights into the relative proportions of particular classes of human ‘error’, systems ‘failure’, regulatory weaknesses. They provide a reminder of hazards. Incident reports provide a means of monitoring potential problems as they recur during the lifetime of an application. Feedback keeps staff ‘in the loop’. Incident reporting schemes provide a means of encouraging staff participation in safety improvement. Data (and lessons) can be shared. Incident reporting systems provide the raw data for comparisons both within and between industries. Incident reporting schemes are cheaper than the costs of an accident. The final argument in favor of incident reporting is that these schemes are increasingly being required by regulatory agencies as evidence of an appropriate safety culture.

5. Incident reporting procedures and requirements: Provide fundamental information: Type of incident Date and time of when the incident occurred Location of incident (be specific as possible) What was the work being done Describe the incident Attach or take photo of surrounding environment including any annotations.

6. Contd …. Take note of any damages and injuries: Incident category Describe in detail Attach or take photo evidence of damages or injury (where appropriate).

7. Contd …. Identify affected individuals: Were the people involved in the incident Name Sex Job title How long in this occupation Start time Hours worked Shift arrangement Training/Qualifications Contact number.

8. Contd …. Identify witnesses and take their statements: Were there witnesses Name of witness Contact number Statement Witness signature (if applicable) Take action: What actions will be taken to eliminate future repeats of the incident? (Assign action to respective member in the organization)

9. Contd …. Close your report: Management comments Name and signature of reporting person Supervisor sign.

10. Investigation team formation and roles: The guidelines for building the investigation team are as follows: The lead of the investigation team must manage the individuals, their contributions, tasks and timings. Their skills should be in management rather than being a subject specialist or expert. They also need to manage the logistics and running of the investigation according to the terms of reference and will be the main point to contact for senior management or other interested parties. Organize the team members and give responsibility to each member of team. The investigation team has to be as small as possible to achieve confidentiality and avoid information leaks. Provide each team member with the necessary clearance and authorization to complete assigned tasks.

11. A typical investigation team might include: Team Leader Certified fraud examiners Legal counsel Internal auditors Security personnel IT and computer forensics experts Human resources personnel A management representatives External consultants.

12. Roles and responsibilities: Team Leader: Direct the investigation Communicate and liaise with stakeholders and external parties as required. Assign duties to the team Schedule and coordinate investigation activities and resources. Supervise the preparation of the investigation report. Brief management on the team’s findings.

13. The team leader should: Be trained and competent in applying incident fact-finding and analysis tools. Have previous experience of comparable scale investigations. Be skilled in the effective management of a small investigation team. Be able to act as a liaison between senior management and the investigating team.

14. Role of Investigation Team: Collect data, facts, and evidence. Establish the sequence of events leading up to the occurrence. Analyze and integrate available information. Develop findings and conclusions. Determine the significance of the findings. Write the investigation report. Present the report to management.

15. The team should: Have an analyst who has been trained and experienced in incident analysis techniques and has facilitated at least two significant investigations successfully. Have collective managerial, technical and investigative skills. Have members with open and logical minds who are thorough, able to maintain perspective, and can overcome preconceptions or bias. Have at least two of the team who has attended formal accident investigation training. Include personnel with subject matter expertise in areas related to the accident. Have access to specialist consultants, advisors, or technical personnel as required. Have access to legal advice.

16. Gathering and analyzing incident data and evidence: An incident analysis is a systematic process of investigating and analyzing an incident that has occurred in a workplace or other environment. The purpose of an incident analysis is to identify the underlying causes of the incident, assess the impact of the incident on the organization or individuals involved, and develop strategies to prevent similar incidents from happening in the future. The analysis typically involves gathering information from various sources, such as witnesses, documentation, and physical evidence, and analyzing that information to determine the root cause of the incident.

17. Communicating the findings of an incident analysis is crucial for ensuring all relevant stakeholders are aware of the incident, its underlying causes, and actions being taken to prevent future incidents. To develop an effective action plan, the incident response team should follow these steps: Identify the root causes of the incident. Develop goals and objectives. Identify strategies. Develop an implementation plan. Assign responsibilities. Monitor progress.

18. The objective is to fix the underlying problem that caused the incident, and ensure that it does not happen again in the future.

19. Root cause analysis (RCA) techniques: Root cause analysis is a systematic approach used to analyze the fundamental problems before trying to solve them. Plays an important role in any organization. RCA process involves data collecting, causal factor charting, root cause identification, and recommendation generation and implementation. It is a tool designed to help identify not only what and how an event occurred, but also why it happened. Root causes are specific underlying causes that can be reasonably identified, are within management’s control to remedy.

20. 1. Pareto Chart: A Pareto Chart is a simple technique of RCA which is a combination of a bar graph and a line graph. Pareto chart is a graph that indicates the frequency of defects, along with their cumulative impact. The Pareto chart is built based on a principle which states that 80% of the results are determined by 20% of the causes. Thus, you should try to find the 20% of defect types that are directly causing 80% of all defects.

21. Features of Pareto Chart: A Pareto Chart is one of the basic tools of quality control. It is a combination of a bar graph and a line graph. Each bar represents a type of defect or error. The bars are presented in descending order, and the left-most bar indicates the highest issues. The line in the graph represents the cumulative percentage of defects.

22. Benefits of Pareto Chart: Gives an idea of the cumulative impact of issues. Gives a focused, simple, and clear way to find vital few causes. Helps to improve problem-solving and decision-making skills. Useful in every form of leadership decision. Helps in problem-solving and decision making.

23. How to build Pareto Chart: Segmenting the range of the data based on different categories. Arrange the categories in descending order. The first graph represents the highest defects. Accordingly one must take the necessary action to reduce defects and errors.

24. Examples: 20% of employees do 80% of work. 20% of things in the warehouse occupy 80% of storage space.

25. 2. The 5 Whys: The 5 Whys technique is one of the simple, effective, and best tools for solving problems. It mainly aims at finding the exact reason that has caused a given problem by asking a sequence of ‘Why” questions. In simple words, it helps to focus on finding the root cause of any problem. Thus, encouraging each team member to share their ideas for continuous improvement, rather than blaming others.

26. Features of 5 Whys: It is an iterative approach to finding the underlying cause of a problem. It just not solves the symptoms, but also the root causes. It enables to solve root problems with symptoms. A holistic approach to problem-solving. Most powerful assessment methods of all non-statistical analysis.

27. Benefits of 5 Whys: Helps the team members to identify the root cause of a problem. Understands how one process can cause a chain of problems. Determines the relationship between different root causes. Highly effective without complicated evaluation techniques. Implementation is simpler and easy.

28. How to perform 5 Whys? Note the problem Create a team Define the issue Ask questions (5 Whys).

29. Example: Consider an example where a student comes late to the exam. Five Whys can be applied as: Why late? Why left late? Why woke up late? Why forgot? Why busy?

30. 3. Fishbone Diagram: The Fishbone diagram is considered one of the basic quality tools. The fishbone diagram identifies many possible causes for an effect or problem. It can be used to structure a brainstorming session. It immediately sorts ideas into useful categories. A fishbone diagram is a combination of the practice of brainstorming with a type of mind map template that determines cause and effect. It is also used in the range from product development to troubleshooting processes used to focus a conversation around a problem.

31. Features of Fishbone diagram: A tool used to visualize all the potential causes of a problem. It discovers the root causes. Visual representation of the factors that contributes to an observed effect that is being examined. It analyzes a problem statement and brings quality improvement. It built interrelationships among the possible causal factors.

32. Benefits of fishbone diagram: It identifies cause and effect relationships. The head of the diagram represents problems. Easy to understand and develop. Provides permanent solutions to the problems occurred. Helps in developing a logical approach to solving problems.

33. How to build a fishbone diagram: Consider a problem and create a problem statement. Place the problem to the rightmost side. Brainstorm major categories of problems. Based on the categories mention the problems.

34. Example:

35. 4. Failure Mode and Effects Analysis (FMEA):

36. Contd …. FMEA documents current knowledge and actions about the risks or failures to bring continuous improvement in their workplace. Failure mode and effects analysis (FMEA) is a structured approach that is used to discover potential failures that may exist within the design of a product or process. Failure modes are one of the ways in which a process can fail. Effects are one of the ways that these failures can lead to many wastes, defects, or harmful outcomes for the customer. So failure mode and effects analysis is designed mainly to identify prioritize and limit these failure modes.

37. Features: It provides a structured approach for evaluating, tracking, and updating the design. A systematic, proactive method for evaluating a process. Tool for improving both product and process design. It is qualitative and systematic tool. Most effective low-risk techniques for predicting problems.

38. Benefits: The higher capability of verification and validation of changes. Helps to find the possible causes of failures. Improved design for manufacturing and assembly. Lower cost solutions. Helps to document and identify wherein a process lies.

39. How to build FMEA: Identify the causes of failure Determine severity Examine the causes Failure detection.

40. 5. Root Cause Mapping: Root cause mapping is a visual diagram that depicts the relationship between a problem or defect and its underlying causal factors. It provides a clear picture of how various elements link together to produce the undesirable effect.

41. Steps to create a root cause map: Clearly state the problem at the top or left side of the map. List all potential contributing factors as branches from the problem. For each branch, ask “Why does this happen?” to identify sub-factors. Use lines and arrows to show relationships and direction of influence. Look for patterns; root causes are often the lowest-level factors. Propose solutions to address the true root causes.

42. Examples: A worker slips and falls on a wet floor near the building entrance. To analyze incident, a root cause map is created. The fall is listed as the problem. Contributing factors such as weather, floor condition, footwear, distraction, and lighting are explored through sub-branches. This reveals root issues like inadequate mats, poor drainage, lack of safety rules, etc. Solutions can then target those specifics.

43. 6. Change Analysis: Change analysis is a root cause analysis technique that involves comparing a situation before and after a change occurs. The goal is to identify the root causes of the change in results or outcomes.

44. Steps to conduct change analysis for root cause identification: Identify the change leading to the undesirable outcome (process, equipment, staffing, etc.). Gather data before and after the change, considering all available metrics. Compare before and after data to identify differences. Analyze differences to pinpoint potential root causes. Brainstorm potential causes by questioning what changed and what was different. Determine likely root causes based on evidence and data.

45. Example: A manufacturing facility recently upgraded a piece of equipment from a manual to automated model. Since the change, there has been an increase in product defects. To find the root cause, change analysis is used to compare metrics before and after the equipment upgrade: Operator hours: Decreased from 60 hours/week to 40 hours/week. Production volume: Increased from 1000 units/day to 1500 units/day. Defect rate: Increased from 2% to 5%.

46. Contd …. By analyzing the data changes, two potential root causes are identified: Lack of operator training on the new automated equipment. Faster production speed leads to uncaught defects. Additional investigation would determine which is the primary root cause to address.

47. 7. 8D Problem Solving: The 8D problem solving technique is a structured team-based approach for identifying, correcting, and eliminating recurring problems. The 8D refers to the eight disciplines or methodical steps required to address problems in a systematic way. 8D focuses on preventing problems from reoccurring rather than just implementing a quick fix. It brings together team members from different departments and functions to provide diverse insights into finding the root cause.

48. Example: An employee was injured when a heavy load fell on them from unsafe storage on a high shelf. An 8D team could be formed to analyze this incident: D1: Safety manager, warehouse manager, maintenance lead, and affected employee assemble the team. D2: The team develops a detailed problem statement documenting the exact incident. D3: As an interim containment, heavy loads are barred from being stored on high shelves. D4: By interviewing staff and inspecting the storage area, improper load securing is identified as the root cause.

49. Contd …. D5: A new load securing procedure is developed and tested. D6: All staff are trained on proper load securing and storage procedures. D7: Shelves are redesigned to prevent overloading. D8: The team is recognized for improving warehouse safety.

50. 8. Bowtie Analysis: Bowtie Analysis is a risk management technique that visually maps the processes leading up to a risk occurrence (the “knot”) and its consequences. When causes and effects are placed on either side of the core risk event, the diagram forms a bowtie. Bowtie Analysis shows all risk variables. This identifies crucial control points to prevent and mitigate incidents. Bowtie Analysis helps safety teams identify causes and create worst-case scenarios for workplace events.

51. Steps to create: To create a Bowtie diagram for analyzing risk: Identify the critical risk event or hazard (the knot). Map out potential consequences and outcomes after the risk event (right side). Drill down to specific failure modes on both sides. Add existing or proposed controls and recovery measures.

52. Example: A manufacturing facility wants to analyze the potential risk event of a hazardous chemical spill. They create a Bowtie Diagram with “chemical spill” as the knot. On the left side, they identify causes such as corrosion of chemical storage tanks, employee errors in handling, and equipment failures. On the right side, they map out consequences like toxic fumes, contamination of surrounding areas, injuries to workers, and environmental damage. Existing controls like protective equipment and spill response protocols are added. The analysis highlights the need for additional inspection and monitoring of chemical tanks as a critical point. This Bowtie Analysis provides a detailed risk management plan.

53. 9. Fault Tree Analysis: Fault Tree Analysis (FTA) is a type of logical failure analysis that tries to figure out why something bad happened, which is called the “top event.” It gives you an organized and visual way to look at the ways that a system can lead to this top event. For example, the fault tree shows the possible paths in a system that can lead to a bad result. This lets safety team figure out where stronger barriers or controls for prevention might be needed.

54. Steps to create: To conduct a Fault Tree Analysis: Define the specific undesired top event for analysis. Identify immediate causes as primary nodes on the fault tree diagram. Determine secondary causes for each primary cause. Add layers of causes, connecting them with logic gates (AND, OR, etc.). Analyze the fault tree for common causes and areas for improvement. Optionally qualify the fault tree by calculating the probability of the top event based on component failure rates.

55. Example: A fault tree could examine a top event such as “Worker injury from a robotic arm on the assembly line.” Possible primary causes may be “Robotic arm hits worker” and “Worker within range of the arm.” Another secondary cause for “worker within range of arm” could be “worker enters area without authorization.” The fault tree would continue from there, tracing back all the possible causes that may result in the worker getting injured by the robotic arm. This mapping can show weaknesses in safety barriers, training, equipment maintenance, alarms, and other key areas. The idea is to reduce the probability that the undesired top event will occur by reducing the probability of those faults further down the tree.

56. Developing Corrective Actions and Preventive Measures: Corrective actions are intended to stop current issues from recurring. Preventive measures are designed to prevent risks from happening in the first place. When a workplace incident occurs, or an inspection uncovers a safety hazard, the tasks required to remedy the issue are called corrective actions. Training is often considered a corrective action as well. The corrective action plan should be S.M.A.R.T. (Specific, Measurable, Attainable, Relevant, Timebound) and includes timeframes, costs, and signatories.

57. Contd …. The analytical aspects of a corrective action and preventive action process also align with the recognized Plan Do Check Act (PDCA) cycle as listed below: Plan – Define Root Cause Do – Research Solution Check – Verify Solution Works Act – Implement Solution

58. Corrective actions may be initiated as a result of: Hazard reports Incident investigation reports Workplace inspection or audit findings Inspection, testing, repair and maintenance reports Issues raised at WHS (Work Health & Safety) meetings, committee meetings or by Health and Safety Representatives Complaints Changes to procedures, processes, systems or documentation Management reviews

59. Contd …. Agencies or Companies should develop systems (procedures) for the documentation or recording of Corrective Actions and Preventive Actions, ideally using a corrective action report (CAR) form or appropriate software program, either of which include the following as a minimum: A description of the issues identified. Priority for action (high, medium, low). Responsibility for the action. Suggested controls or actions. Action taken to resolve the issue. Sign off and close out of action.

60. Communication of investigation findings and recommendation: Know your audience Highlight the key points Explain the benefits Seek feedback and input Follow up and monitor.

61. Continuous Improvement Through Lessons Learned: Continuous improvement is the ongoing process of analyzing performance, identifying opportunities, and making incremental changes to processes, products, and personnel. By analyzing and fine-tuning processes, company can save and deliver an overall better product. The main goal of continuous improvement is to transform company through small incremental changes. This improves employee engagement, boosts productivity and efficiency, and increases satisfaction. When you believe you always have improve your business.

62. Several ways to make continuous improvement work: Communicate constantly Capture and validate benefits Capture ideas for improvement Perform weekly reviews for projects .

63. THE END