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Presented by: Donald L. Trussell DEP Safety Program Administrator 850-488-0878 or SC 278-0878. INCIDENT INVESTIGATION. “The Basics”. Introduction. BABYLONIAN LAW WHY PRACTICE SAFETY? SAFETY EXCELLENCE. SAFETY CULTURE. CULTURE PARK SAFETY CULTURE WAY OF LIFE TEAMWORK/PARTNERSHIP.
Donald L. Trussell
DEP Safety Program Administrator
850-488-0878 or SC 278-0878
An incident is………..????
Which is easier to see and report?
Establish the following:
Establish the person(s) who were involved in the incident, including witnesses. This includes all persons and not just an injured employee.
Describe in detail what happened.
Ensure times and dates are included in the statements.
Get specific about the location, to include what Site, what facility, road name, etc.
Make sure your description of the incident is clear and describes the factors that caused the incident.
Based on who/what/when/where/& how, you should be able to piece together why the incident happened. This involves piecing information together to form a conclusion of the cause & root cause of the incident.
From the who/what/when/where/how & why that you just gathered, you now need to determine both the cause and root cause of the incident.
“All things are hidden, obscure, and debatable if the cause of the phenomena be unknown, but everything is clear if this cause be known.”Louis Pasture
The “cause” of the incident should describe what the immediate symptoms are of the incident.
Example: An employee slipped on the floor because there was spilled coffee that made the floor slippery.
The “root cause” of the incident is the basic underlying reason, not always apparent, that caused the incident.
Example: The root cause of the incident was that the person who spilled the coffee did not clean it up or establish a warning method to alert others of a hazard.
Gather all of your facts previously obtained, in particular who/what/when/where/how/why,
and the cause/root cause of the incident.
Additionally, gather written statements, information on similar incidents, and pictures to support your position when needed.
Example of Fact GatheringOn July 29, 1999, on or about 10:45 am, Joe Employee was stacking concrete blocks and walked into a piece of steel re-enforcing bar that was protruding out of the end of the pipe storage shelving unit located inside the Project Materials compound, striking him in the face. A 1” cut was received across the middle of Mr. Employee’s forehead. He proceeded directly to the dispensary, where he received 4 sutures to close the laceration, then was released at 11:41am in a full duty status. He went to lunch, then informed his immediate supervisor of the incident upon returning to work at 12:30.
Your Conclusions:Cause: The incident was caused by Joe not paying attention to his surroundings and striking his head on the rebar.Root Cause #1: Somebody didn’t properly store the rebar and left it in a haphazard state that was obviously unsafe.Root Cause #2: The supervisor has not been taking responsibility for his work area by monitoring for unsafe conditions.
At this point you have gathered facts, interviews, pictures, and all pertinent information. You have made conclusions and determined what the cause and root cause of the incident was.
Question: What do you do with this information?
You take corrective action that would prevent the reoccurrence of this type of injury in the future, such as:
1. You look around for similar things in your work center that would present the same type of hazard and implement corrective action. Examples: pipe storage, lumber storage, conduit storage, etc.
2. You should counsel the work center supervisor on proper storage methods and his responsibilities.
Now write your conclusions (cause & root cause) in your report, and finally wrap up your report by a “Corrective Actions Taken” paragraph. Attach all supporting documentation to the back of the report. You are now done with your written report.
1. Toolbox Talks/Departmental Training
2. Use your written report to complete the Supervisor’s Incident Investigation Report
Now that you have completed your written report, you are finally ready to complete the Supervisor’s Incident Investigation Report.
This piece of paper is merely a standardized form to document your incident investigation. Filling out the form before doing an investigation is putting the cart before the horse and does not constitute an investigation.
Because for every Serious Injury, there are:
10 minor injuries
30 property damages
600 near misses
So where should you be looking?