Course Transcript

[Course title: Incident Investigation and Reporting – Canada.] Incidents can and will happen unexpectedly – it's a fact. This is why health and safety legislation across Canada requires employers to establish safety programs and train their employees in safe work practices. This course, in line with the general duty clause of health and safety legislation, examines how investigation of incidents can help to prevent or reduce future accidents.

In this course, you'll learn about incident cause levels, investigation procedures, and how to interview witnesses. You'll also learn problem-solving techniques and how to report incidents.

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[Topic title: Cause Levels of Incidents.] You know how incidents – or accidents – happen… You think you're doing something right, but then something totally unexpected happens and throws you off.

Work-related incidents affect thousands of employees throughout Canada on a daily basis. The cause? People, equipment, supplies, materials, or surroundings failing to respond or behave as expected.

Each time a work-related incident occurs, an incident investigation is carried out – not to assign blame, but to determine the cause of the incident. The information gathered from such an investigation is used to prevent similar or more serious incidents from happening in the future.

There are various levels of classifying incidents. Classification is based on the severity of the incident and how quickly a corrective action or actions must be implemented. Refer to your own internal Incident Investigation Program for your workplace classification, but for the purposes of this course, the following definitions and classification of incidents will be used.

In a workplace, an incident refers to an unplanned event that results in personal injury, occupational illness, or property damage. If little or no treatment is required as a result of an incident, it's classified as a minor incident. If it results in a fatality or in permanent, partial, or temporary total lost-time disability, it's classified as a serious incident.

Then there are "near misses" – incidents that could result in injury or serious damage but are prevented just in time or have no immediate consequence. Near misses must also be investigated using the same techniques and reporting requirements as any other type of incident. The cause of a near miss situation could potentially be the source of a future incident.

Remember, all incidents – regardless of the extent of injury or damage – should be investigated.

Most incidents can be prevented by eliminating their causes. Causes have three levels, the first of which is root causes. These include personnel and environmental factors and poor management with regard to safety policies and decision-making.

Indirect causes – the second level – result from root causes. They include elements such as unsafe acts and unsafe conditions.

Finally, there are direct causes of incidents, such as an unplanned release of energy or hazardous material. These events may be traced to indirect causes and ultimately to root causes.

It's essential to know the differences between cause levels, as they may impact how future incidents can be resolved. Now let's take a short break for some practice questions. After you're finished, we'll pick up here.

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[Topic title: Investigation Procedures and Fact-finding.] No two incidents are exactly alike. Similarly, depending on the nature and result of an incident, investigation procedures differ. For instance, if the incident is fatal, the agency who has health and safety regulatory authority over the location – such as the provincial Ministry of Labour, or the federal Labour Program – determines the administrative and investigative procedures.

On the other hand, if the investigation is a nonregulatory or internal investigation, a workplace party, such as a supervisor or a member of the health and safety committee, oversees the investigation.

Once an investigator is assigned, that person must define the scope of the investigation, and may need to assemble a team of investigators to conduct specific tasks.

The preliminary briefing of the investigation team should detail elements such as the incident description; the time, date, and location of the incident; and the environmental conditions. Damage estimates and number of persons injured and the nature of their injuries, normal operating procedures, and local and general maps should be noted. And a list of witnesses and their statements, pre-incident events, and post-incident conditions should also be included.

Once assembled, the investigation team will need access to the company's investigation kit. As an employee, if you don't know where the investigation kit is located or who's responsible for obtaining it, consult your company’s incident investigation and reporting procedures.

An incident investigation kit should contain a camera with sufficient flash memory, an audio recording device, or even a cellphone to do both. Additionally, there should be report forms and writing paper, barricade tape, a flashlight, a tape measure, work gloves, and fresh batteries.

Consider the situation that June, Peter, Maria, and James found themselves in. Collectively, they're responsible for maintenance at an industrial plant. Maria is head of maintenance and works in an office, away from the work site. Peter is a site manager. And June and James are maintenance workers; together, they set up the equipment used to carry out the maintenance work.

On this occasion, Peter and June are on site while James repaints one of the offices. June is assisting James with painting while Peter inspects other damage to the building. When the ladder James is standing on breaks, causing him to fall, he is badly injured and has to be rushed to the hospital.

At the time of the incident, June was standing close to James. Later, Peter hears from a colleague that James used paint cans to prop up the ladder. Maria wasn't present, but she's aware of James' questionable work habits.

To start their fact-finding mission, the investigation team must visit, inspect, and secure the site of the incident. Evidence at the incident site must not be disturbed until inspectors have had an opportunity to examine it, except to the extent necessary to contain or control a hazard to employees or the public.

If you're part of the investigation team, be sure to avoid subjecting yourself to hazardous conditions or environments that may exist at the incident site.

Each injured person and witness must be interviewed, including those who were present before and after the incident. Accurate records of each interview must be maintained.

To uncover the facts of any incident, the investigation team must schedule their investigation in a way that allows evidence to be gathered from several sources.

Witnesses should be interviewed as soon as possible after an incident. In the case of James' incident, the only two people who can be interviewed are June and James – June because she was present and witnessed the incident, and James, once he's available, because he was involved in the incident.

Regardless of what Peter heard from a colleague or what Maria knows about James' work practices, they didn’t witness the incident, so they shouldn't be interviewed immediately.

Besides interviewing witnesses, investigators should also make their own observations. This is why the scene of an incident should be inspected before any changes occur.

Investigative team members need to take photographs and make labeled sketches of the undisturbed scene, and all pertinent data on maps or layouts of the incident site must be recorded. Additionally, investigators must obtain copies of reports, forms, or work orders related to the incident.

It's useful to obtain documents describing normal operating procedures, flow diagrams, and inspection reports. Maintenance charts and reports of difficulties or abnormalities may also come in handy. They can tell investigators about the pre- and post-incident conditions, as well as the incident sequence.

As part of the investigation, it's also useful to document the locations of those injured, witnesses, tools, equipment, machinery, energy sources, and hazardous materials.

To safeguard investigative documentation, investigators must keep complete and accurate notes in a secure place.

Remember, every action taken by an investigator is an important step toward finding the best solution to prevent future incidents.

Now, take a moment to answer some practice questions. We'll pick up here when you’re done.

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[Topic title: Interviewing Witnesses to an Incident.] In any crime television show, chances are good that every episode will include at least one scene where members of law enforcement interview a witness. There's a good reason behind this scene being so predominant: witness interviews play an important part in investigations.

Not everyone is equipped to conduct interviews. Because of the amount of care and attention that goes into interviews, only experienced personnel should conduct them.

Once the investigation team has selected an interviewer, a time and place is arranged to conduct one-on-one interviews with witnesses. Regardless of what's being investigated, it's critical that witnesses are interviewed as soon as possible after the incident. This way, the memory of the incident is still fresh.

When conducting an interview, the interviewer should begin by explaining the purpose of the investigation and putting the witness at ease. It’s also the interviewer's responsibility to obtain preliminary statements from each witness individually, and word each question carefully to ensure the witness understands. The interviewer should also listen attentively and let the witness speak freely.

During an interview, the interviewer should take notes in a way that doesn't distract the witness. It's important to record their exact words, so if a witness consents, it's a good idea to use an audio recording device – or a cellphone – to record their statement. The interviewer can use sketches, photos, and diagrams if necessary, to help the witness remember events. But they should never put words into a witness's mouth. Using a master chart, the interviewer must also locate the position and direction of view of each witness in relation to the incident scene. And hearsay must be labeled accordingly.

In addition to recording each witness's account of an incident, the interviewer should identify the witness's qualifications – for instance, their name, address, occupation, and years of experience.

Once the interview is complete, a copy of the statement must be given to the witness.

But that's not the end of the interview process. In some cases, witnesses are re-interviewed to clarify and confirm crucial points. Witness testimonies are then arranged in logical order, regardless of any disparities between statements. Once they're organized, the information is evaluated with data collected in the initial incident report.

Keep in mind, not everyone responds the same way in certain situations. For instance, someone who witnesses an incident from far away may recount a different story compared to someone who witnessed the incident close up.

And some witnesses may change their stories after discussing an incident with others, which is why it's crucial to get their statements as soon as possible after an incident. However, even the reason behind a change can provide additional clues.

By following the recommended guidelines during the interview process, interviewers are more likely to uncover the facts of an incident, which ultimately affect the resolution.

With that in mind, let's take a short break for some practice questions. After you've finished, we'll pick up here.

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[Topic title: Problem-solving Techniques for Investigations.] As humans, when things go wrong for us, we tend to ask, "Why did this happen to me?" Similarly, when something goes awry in a workplace, investigators ask, "Why did this incident happen?"

Now, we already know how important it is to get witness statements while investigating an incident. But, while witness statements are essential in finding out what happened, they don't always immediately answer, "Why?"

To uncover that answer, investigators may make use of several procedures to analyze collected information. These procedures help to determine root causes of incidents. Two of the most common procedures are change analysis and job safety analysis.

Let's discuss change analysis first. Change analysis involves analyzing changes or differences in a process or procedure to determine the cause of a problem. To solve a problem using this procedure, you look for deviations from the norm and then consider all problems resulting from the unanticipated change.

The change analysis technique has seven steps. The first step is to define the problem by describing what happened. Then you establish the norm by clarifying what should have happened. Once you establish these "should haves," you identify, locate, and describe the nature, location, timing, and extent of the change. In the fourth step, you specify what was and what wasn't affected. Then you identify the distinctive features of the change and list its possible causes. In the final step, you select the most likely cause.

This brings us to the second common procedure – job safety analysis. This technique is used in many existing incident prevention programs to determine the events and conditions that led to an incident.

Using job safety analysis, you first divide a job into basic steps. Then, you identify the hazards and controls associated with each step.

Essentially, job safety analysis is a chart that lists these steps, hazards, and controls. This chart should be reviewed during an incident investigation if an analysis has been conducted for the job.

These commonly used problem-solving techniques play a significant role in helping to uncover root causes of incidents.

Now it's time to take a short break for a practice question. We'll pick up here when you're done.

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[Topic title: Investigation Reporting.] Once all the data gathering is complete, the final stage of an incident investigation involves completing a report and submitting it to the proper company authorities. Regardless of the type of incident, there are four key elements that must be included in an incident report. One of them is necessary background information on the incident.

Background information includes where and when the incident happened, what task or activity was going on, what people and equipment were involved, and the identity of operating personnel and other witnesses.

The next element of the incident investigation report is the account of the incident. The purpose is to determine what happened – the sequence of events, the extent of the damage, the incident type, and the source of energy or hazardous material.

The third element of the incident report, discussion, includes an analysis of how and why the incident occurred. The discussion section details the direct cause, such as energy sources or hazardous materials; the indirect cause, such as unsafe acts and conditions; and the root cause, such as personnel and environmental factors.

A key purpose of incident investigation is to prevent similar incidents in the future. So the final element – the recommendations section – of an incident report is very important. This section contains recommendations for short-term and long-term actions that can be taken to prevent a recurrence.

These recommendations should address the root causes, such as an outdated procedure; the indirect causes, such as failure to follow correct procedures or work practice; and the direct causes, such as improper protective equipment for the specific hazardous materials.

Occasionally, a report may need to be extended to include a cover page and title page, names and signatures of investigation team members, and a table of contents. It may also include an abstract, commentary, and discussion of probable causes. In addition, the report can include conclusions, recommendations, and an appendix or attachments. Investigators can make use of special report forms, which are available in many cases.

Additionally, any information or evidence uncovered during incident investigations that would be of benefit in developing a new regulatory standard or in modifying or revoking an existing standard should be promptly transmitted to the applicable labour authorities.

It's important to remember that an incident report is not considered complete if any of the four key elements are missing.

With that in mind, let's pause here to answer some practice questions.

Here, you can access a job aid to review an example of results of an incident investigation. Good work! You have completed the course instruction. You now move on to the course test

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