IncidentInvestigationProcessandExerciseINTRODUCTIONAnincidentisanunplannedorundesiredeventthatadverselyaffectsacompany’sworkoperations.Incidentsincludework-relatedinjuries,occupationalillnesses,propertydamage,spills,firesornearmisseventsthatcouldhaveresultedinanyofthese.Allincidentsshouldbeinvestigated.Anincidentthatresultsinaseriousemployeeinjury,considerablepropertydamage,amajorfire,orspillobviouslywarrantsanextensiveinvestigation.Aminorincidentornearincidentalsorequiresathoroughinvestigationandmayrevealsignificantpotentialforaseriousincidentiftheconditionsareleftuncorrected.Therearetwomajorcomponentsthatcontributetothecauseofanincident.Theyarethe“workelement”andthe“rootcause”.•The“workelement”istheconditionoractthatdirectlycausedtheincident.Anexampleofaworkelementmightbeasmallspillofoilonthefloorthatsomeoneslippedon.•The“rootcause”isthesystemfailurethatallowedtheworkelementtobecomedeficientortooccur.Forexample,arootcausemaybealackofpreventivemaintenancethatresultedintheforktruckleakingoilonthefloor.Athoroughinvestigationwillrevealtherootcauseoftheincident.Thepurposeofanincidentinvestigationistodeterminetheworkelementandrootcausesofincident,andtoassistinprovidingthecompanywithasolutiontopreventrecurrence.Companiesshouldhaveanincidentinvestigationprocesstoensurethat:•Allincidents(includingnearmisses)areinvestigated•Correctiveactionaredeterminedthatidentifytherootcause•Correctiveactionsaretrackeduntiltheyarecompleted•Trendsarereviewed,gapsareidentifiedandimprovementplansaredevelopedtopreventfutureoccurrences.INVESTIGATIONPROCESSPropertrainingandaclearunderstandingofrolesandresponsibilitiesisessentialtotheinvestigationprocess.Allemployeesandpeoplethatwillbeinvolvedinanincidentinvestigationshouldbeawareofwhattheirroleisintheprocessandhowtoperformtheirassignedresponsibilitiesduringaninvestigationprocess.Employees:•Reportallwork-relatedincidentsinatimelymanner•Participateintheinvestigationprocess,asneededSupervision/Management:•Iftheincidentwasveryrecent,securethesceneoftheincidenttoensurethesafetyofanyemergencyrespondersandotheremployees,andtopreserveanyevidencethatmaycontributetotheinvestigation•Ensuretheinjuredpersonisproperlycaredfor•Ensuremanagementorothercompanypersonnelwhorequireitarenotified.OSHAoranothergovernmentagencymayalsoberequiredtobenotified,dependingonthetypeand/orseverityofanincident.(Forexample,inOSHA1904,recordkeepingrequirementsrequirethatanyfatality,oranyhospitalizationof3ormorepersonsbecauseofaworkrelatedincidentbereportedtoOSHAwithin8hoursoftheincident.)•Ensuretheinvestigationbeginsassoonaspossibleaftertheincidentoccurs•Identifythepotentialsourcesofinformation,suchastheinjuredperson,witnessesandanyphysicalevidence•Gatherthefactsabouttheincident•Ensuretheinvestigationidentifiestherootcause•Makeand/orimplementrecommendationstocontroloreliminatethehazard•Ensureallregulatoryandcompanyrequirementsaremet(OSHArecordkeeping,notification,writtenreports,insuranceclaims,etc.)•Performanytrendanalysesofpastincidentsthatmayidentifyadditionalhazardpreventionmethods(i.e.training,maintenance,procedures,etc.)Theultimateresponsibilityforanincidentinvestigationrestswithmanagement.Supervisorsmusttakechargeofathoroughincidentinvestigation.Dependinguponthetypeandscopeofanincident(i.e.majorspillorfire,orseveralemployeesinjuredinoneincident),ateama...
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