INCIDENT INVESTIGATION, RECORDING AND REPORTING

This chapter is concerned with the recording of incidents and accidents at work their investigation the legal reporting requirements and simple analysis of incidents to help managers benefit from the investigation and recording process. 

Incidents and accidents rarely result from a single cause and many turn out to be complex. Most incidents involve multiple, interrelated causal factors. They can occur whenever significant deficiencies, oversights, errors, omissions or unexpected changes occur. Anyone of these can be the precursor for an accident or incident. There is a value on collecting data on all incidents and potential losses as it helps to prevent more serious events. (See Chapter 5 for accident ratios and definitions.) 

Incidents and accidents, whether they cause damage to property or more seriously injury and/or ill-health to people, should be properly and thoroughly investigated to allow an organization to take the appropriate action to prevent a recurrence. Good investigation is a key element to making improvements in health and safety performance. 

Incident investigation is considered to be part of a reactive monitoring system because it is triggered after an event. The range of events includes  

Incident/accident investigation is based on the logic that  

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Injury/incident investigation and reporting. This document contains the basic procedures and requirements for recording and reporting occupational illnesses and injuries as well as identifying the cause(s) of the accident or near-miss occurrence. In turn, this information can be used to implement corrective changes to preclude the recurrence of similar incidents. 

Incident Investigation Major incidents Near-miss reporting Follow-up and resolution Communication Incident recording Third-party participation as needed... 

Incident Investigation—In assessing this element, consideration must be given to major incidents, near-miss reporting, follow-up and resolution, communications, incident recording, and third-party participation as needed. 

Table 14-1 lists these requirements and provides a record of compliance for future analysis. Requiring completion of this record for each process incident investigated enhances the probability that all elements are covered. Auditing of incident reports against these requirements provides the forum for continuous improvement in meeting compliance requirements. 

The First Report Template can form the basis for the incident register. However, additional space should be provided for information to do with the formal investigation, the investigation team s report, and the findings and recommendations. Not only is the incident register used to record information to do with the event itself, it can also serve as a tool for managing the results of the subsequent analyses. 

The source of the data—insurance claims files and records of plant owners — cannot provide reliable accident causal data. From personal experience, 1 can say that insurance claims reports rarely include causal data. And my studies of incident investigation reports completed by supervisors require the conclusion that they are not a reliable source for valid causal data. 

Of the 15 variations of incident investigation reports received, six promote an overly simplistic and inappropriate approach to causal factor determination. They reflect this instmction, although somewhat ancient, given in a publication of the American National Standards Institute, the Method of Recording Basic Facts Relating to the Nature and Occurrence of Work Injuries—Z16.2. 

Monitor leading indicators using the Safety Scorecard Identify and report incidents, near misses, and unsafe conditions Track accident investigations and store causal factor data Assign and manage corrective actions / Collaborate with multiple departments for incident resolution Monitor the status of tasks and projects Manage OSHA-recordable and other injury records... 

Gather evidence from many sources during an investigation. Get information from witnesses and reports and observation. Get copies of all reports (documents containing normal operating procedures, flow diagrams, etc., maintenance charts, or reports of difficulties or abnormalities). Keep complete and accurate notes. Record pre-incident conditions, the incident sequence, and post-incident conditions. In addition, document the location of employee, witnesses, equipment, energy sources, and hazardous materials. 

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