Question

Create a mock incident investigation report which outlines the incident and the steps conducted. This report should demonstrate the legal requirements of an incident investigation.

Answer 1

Incident Description:

Kristy was instructed to repair siding on the building. After climbing scaffolding, Kristy began prep work on the building. Approximately 45 minutes into her shift she turned around to grab a tool and fell off side of scaffolding.

Background Info on Kristy:

Construction worker with 2-years’ experience at the same company but new to the job site and task at hand (3^rd day on that specific task at that specific job site), working 1^st shift from 5:00 am – 3:00 pm. Previously worked 8:00 am – 5:00 pm at a less hazardous job site.

Injuries:

Broken arm, fractured ribs, and multiple contusions

Kristy’s Statement

“Was removing old siding off wall. Turned around to grab a pair of snippers and lost my balance and fell. That’s all I remember. Next thing I know I’m in the hospital.”

Additional Information:

Ben supervises a crew of 12 employees and the primary job at hand is to repair siding on the 2^nd level of a facility. He has been informed that the repairs need to be completed by the end of the day as the landscaping crew will be starting the next morning.   

Ben is working on the scaffolding along with new employee, Kristy, since the crew is short-handed and Kristy does not have much experience working at heights and has commented that she has a slight fear of heights, but wants to learn as much as she can so she can be promoted into a supervisor position within the next year.

Randy is on the ground picking up debris from the repair site. Randy has been a part of this crew for the past 5 years and has a very negative attitude about how the project is managed and thinks he should be in charge. Randy has been a supervisor of crews in the past, but was recently demoted due to previous attendance issues which he claims is due to the type of work he has done for the past 20 years. Randy knows something about everything and everyone on the job site.

Investigation Questions:

• Where did the incident take place?
• Where was the victim?
• Where were the witnesses?
• Where were the other items that were involved in the incident (vehicles, equipment, falling objects, etc.)?
• When did the incident take place (date, shift, time)?
• What was the weather/conditions?
• Is this the first time an incident like this has taken place? If not, when did the other incident(s) take place?
• Who was involved in the incident?
• Who was injured?
• Who was at the scene prior to the incident? What was the condition of the scene?
• Who were the eyewitnesses?
• Who heard the incident?
• Who came upon the scene after the incident?
• Who might have useful information about this incident?
• What happened?
• What are the circumstances surrounding the incident?
• What events led up to the incident?
• What factors appear to have caused this incident?
• What are the facts relating to this incident?
• What are the characteristics of the injuries?
• Why did this incident happen?
• Why has this incident happened more than once?
• Why did the equipment, environment, management, or employees fail in this incident?

Steps for Investigation:

Inspect the incident scene first hand….

1. Look at the overall scene. Does anything seem odd or out of place?
2. Collect evidence; get samples of possible material at the site; find any broken equipment pieces
3. Get photos from all sights and angles
4. Document the extent of damage to equipment, material or building facilities.

Interviewing witnesses…

1. Conduct the interview in a quiet and private place.
2. Put the person at ease by explaining that you are looking for facts – not for someone to blame
3. Give the witness an overview of what you want to achieve in the interview.
4. Use open-ended questions; avoid bias.
5. Confirm what is said by paraphrasing interviewee’s statements.
6. Ask for suggestions on possible causes.
7. Thank witnesses for their help.

Review paperwork…

1. First aid report
2. Incident Investigation report
3. Supervisors report
4. Injury/Illness record of employee
5. Company OSHA 300

Problem Solving Approach Tool

Specify the problem completely

• Describe the situation in detail
• Address the five W’s (Where, When, Who, What & Why)

List possible causes

• Include all possible causes, no matter how off the wall or remote they may seem.
• Eliminate non-possible causes, no matter how comfortable or preferred they may be.
• Use the Guide for Identifying Causal Factors and Corrective Actions.

Identify possible root causes

• Use a structured tool to help identify root causes
• Look for causes relating to equipment, environment, management and people
• Generally, there is more than one root cause to the incident and you will be able to identify a clear combination of root causes.

Test to determine if root causes have been identified

• Try a carefully staged re-enactment of the incident
• Try controlled testing
• Assemble a team of employees and talk through the root causes you have identified – does the team concur?

Recommend Corrective Action

1. Ask employees who will be affected by the corrective action to help you develop the action
   1. Solutions will be more effective
   2. Employees will be more likely to buy in to the solutions
2. The solution must solve the problem
   1. Must correct the current situation
   2. Must prevent recurrence of incident
3. The solution must not cause additional problems.
4. Assess the probable effectiveness of your recommended corrective actions.
5. The solution needs to be incorporated permanently into the system.
6. Corrective action should be relatively inexpensive and easy to implement.
7. Test your recommendations by applying them in a controlled situation or by talking through them with the people who will be affected by the changes.
8. Summarize the details of the recommendations clearly and concisely.
9. Have back-up corrective actions in case your main recommendations are not approved.

Follow Up

Importance of Follow Up

• To verify the effectiveness of your corrective actions over time.
• To ensure corrective actions and preventative actions become a permanent part of the system.
• To determine if there are any improvements that need to be made to the corrective actions.
• To identify system breakdowns and to determine how to address these breakdowns
• To ensure employees are involved in safety and are empowered to take appropriate actions.
• Failure to follow through on the recommended solutions can lead to criminal charges if the incident happens again.

How to Follow Up

• Have every supervisor complete an annual incident form – even if there are no incidents
• Set up a review process in which people are given specific goals to implement the corrective action and are evaluated on their achievement of those goals.
• Train supervisors and other employees on how to identify non-implementation and on what to do about it.
• Continue to trace and analyze data with the goal of identifying additional hazard trends.