Incident Investigation Richard Kohlhausen, Capital Risk Management Ronald Sawchak, ARM CNA Insurance Companies Slide 1
Welcome Incident investigation is a core safety program element Program overview Focus on worker incidents, but concepts apply to other areas Handouts Slide 2
Objectives Review benefits of an effective incident investigation process Review the reporting and investigation process Expand thinking regarding causes Identify and implement effective controls Discuss opportunities to share learning's Provide hands-on application via Case study Slide 3
Benefits Improve control over incidents and accidents Improve operating efficiencies Support on-going operations Spirit of continuous improvement Control costs and increase competitiveness Move incident investigation from a reactive response to a proactive safety strategy Slide 4
Safety My Two Cents No company is in business to run a safety program Safety person is NOT the safety program Strong correlation between a well managed company and a safe company Accident/incident costs have no return to a business If you say nothing about safety, you ve made a strong statement about safety Common sense ain t so common (Will Rogers) Slide 5
Incident vs. Accident Accident unplanned, unwanted event that results in an injury, property damage or loss of life. Incident - An occurrence or event that interrupts normal procedure or process, or precipitates a crisis. Slide 6
Incident Investigation The systematic identification and evaluation of incident causes and the determination of actions that will prevent the incident from occurring again. Slide 7
Why Investigate Incidents? Control recurrence Increase awareness to incident sources Identify trends Direct safety process Identify focus items for inspections Improve work procedures Identify training/learning needs Opportunity for a positive result Slide 8
Investigation Challenges Identify base, or underlying causes Understand worker behavior & motivation Identify effective corrective actions No follow-up No objective investigation of routine events Complacency No blood, no foul! Completing an incident report is not an investigation! Slide 9
Why Investigations Fail Lack of skills or knowledge to complete No clear procedure No incident response kit No accountability for completing Lack of motivation (risk/reward) Too much trouble Recognizes our failures No time, too much on the plate Slide 10
Which Incidents Should be Investigated? Serious Incidents Lost time incident Modified/Restricted work incident Medical treatment Property damage Near misses On-site and off-site incidents Workers, visitors and contractors All Incidents to some degree Consider possibility for recurrence (Frequent, Occasional, Rare) Expected severity (Major, Serious, Minor) Slide 11
Investigation Responsibilities Management Support incident investigation process Provide leadership Ensure accountability for process and controls Provide resources Safety Person Participate in investigation Provide technical expertise Adjust safety program Share learning s Manage corrective actions Slide 12
Investigation Responsibilities Worker Promptly report all incidents Seek medical attention Participate in investigation Follow-up on corrective actions Manager/Supervisor Secure the area Care for the worker Complete the report Investigate the incident Identify causes Follow-up on corrective actions Slide 13
Why the Supervisor? Familiar with job task and the worker Familiar with work practices Familiar with equipment Best position to make changes Has the ability to conduct the investigation immediately after the incident. Responsible for worker, area, etc. Accountable for results Slide 14
7 Steps Investigation Process 1. Report incident 2. Gather information 3. Evaluate contributing factors 4. Identify causes 5. Evaluate control measures 6. Implement controls 7. Share learning's Slide 15
1 7 Steps Report Incident Individual procedures Satisfy reporting of incident and investigative activities Critical Elements Prompt reporting of all incidents Near miss reporting Assigned responsibility Good upfront description of incident and injuries Incident investigation form Record the facts, only the facts Slide 16
2 7 Steps Gather Information Visit the scene Care for injured workers Secure area; protect against further loss Start the investigation promptly Assemble investigation team Avoid reenactments Review pertinent records Interview worker and witnesses Slide 17
2 7 Steps Gather Information Interview tips Put the person at ease Emphasize fact finding, not fault finding; Don t place blame Ask open-ended questions; avoid yes/no responses Repeat the story Talk to each person separately End on a positive note Slide 18
3 7 Steps Evaluate Contributing Factors People Who Supervision Experience Training Knowledge, Skills & Attitude Environment Lighting Weather Ventilation Housekeeping Surroundings Procedures Available Followed Adequate Cover non- routine Enforced Materials Hazardous Containers Handling Sanitation Equipment Guarded Appropriate PPE Condition Hand tools Other Non-routine Day/Shift Fatigue???? INCIDENT Who, What, Where, When, How, & Why Slide 19
3 7 Steps Evaluate Contributing Factors People Factor 1. Behavior 2. Behavior influenced? People Causes 1. Knowledge, skills & attitude 2. Risk/reward, culture, peers, leadership, etc. 3. Behavior forced? 3. Change equipment, tools, procedures, remove obstacles, etc. Slide 20
4 7 Steps Identify Causes Immediate Causes Base/Underlying Causes Most obvious Can be Unsafe Condition and/or Unsafe Act Correction does not always prevent incident from recurring Fix it Allowed the Immediate Cause to exist Heart of investigation Evaluate safety system Job Safety Analysis (JSA) Why? Why? Why? Why? Keep it fixed Slide 21
4 7 Steps Identify Causes Unsafe Conditions Physical conditions Often caused by behaviors Unsafe Acts or Actions At risk behaviors Influenced behaviors Forced behaviors Which causes more incidents? Slide 22
5 7 Steps Evaluate Control Measures Actions taken to control recurrence of the incident Address all causes consider people, equipment, materials, etc. be creative, expand your thinking, focus on base, or underlying causes. Fix it, keep it fixed Document all corrective actions; avoid open issues Slide 23
5 7 Steps Evaluate Control Measures Thought process Eliminate cause, source, hazard, exposure, etc. Minimize cause, source, hazard, exposure, etc. Implement engineering controls Administrative controls Personal protective Equipment (PPE) Worker training Slide 24
6 7 Steps Implement Controls Fit it, keep it fixed! Develop an action plan Assign responsibilities and target dates Set-up workorders Escalate resource issues Close the loop Follow-up on corrective actions Implemented? Hazard eliminated? Behavior changed? Slide 25
6 7 Steps Implement Controls - Example (Workers clothing caught in exposed chain/sprocket of conveyor drive; minor injuries) Fix it Install/replace machine guard Keep it Fixed Upgrade guard fasteners Retained fastener Extend grease fittings Inspection focus Maintenance review Reliability issue? Training/learning Slide 26
7 7 Steps Share Learning s Lessons from losses Create awareness, engage workforce Departmental review Safety committee review Route investigation Database Incident analysis and trends Slide 27
Case Study Complete the investigation, addressing each of these areas What are the contributing factors within each of these areas? Outline Action Items for each area Fix it (immediate causes) Keep it fixed (underlying, or base causes) Slide 28
Incident Solutions League of Minnesota Cities Insurance Trust (LMCIT) How d They Do That? Innovative safety solutions to real safety problems (www.lmnc.org) Slide 29
Review Incident investigation is an improvement opportunity, make it a proactive safety strategy Be objective, avoid complacency Engage people in the process Close the loop on the process Share learning s and successes Fix it, keep it fixed Slide 30
Thanks! Questions? Slide 31