WINTER 2019 AVENUES 23 SAFETY & SECURITY or ‘no’ answers. Be objective, and do not ask questions that simply support pre-deter- mined conclusions. Ensure that workers are asked if they have any ideas about how to control or eliminate the hazard.” 3STEP 3: Put the evidence in order Put all the facts together in the order in which they occurred. This will help you develop a mental picture of what happened. Make sure you have enough evidence (avoid information gaps), that the evidence makes sense, and that each event interacts with at least one other incident event. 3STEP 4: Analyze your information Analyze your findings and identify why the incident occurred. “The ‘whys’ are the safety problems that must have existed for the inci- dent to occur. Incidents generally occur because of a combination of ‘symptom’ and ‘root’ safety problems.” Symptom safety problems are obvious, such as a broken piece of equipment, but they need to be analyzed to find out why they exist. Root safety problems are often management problems. “This can make it very difficult to be objective. Manage- ment responsibilities include: lack of/poor policy, procedures, training and supervi- sion, lack of accountability, and lack of adequate resources.” 3STEP 5: Recommend corrective action Look ahead to see how the risk of similar incidents can be reduced or eliminated. “Use your knowledge and the knowledge and expertise of workers when identifying potential solutions. Based on this informa- tion, recommend changes that are practical, will improve health and safety in the work- place, and upon which everyone can agree.” Recommendations may relate to policy/ procedure revision or development, training, supervision, and equipment repair, maintenance or replacement. Make sure your recommendations are specific for the identified safety problems (fix what does not work), effective and sound (no new safety problem is created); practical, affordable, and can be trusted to work. “Rank according to priority. If not all recommendations can be carried out at once, identify which ones are most important. Recommenda- tions should also be based on consultation. Worker expertise can be very helpful in achieving these goals.” 3STEP 6: Follow up on corrective action Follow up your corrective actions to deter- mine whether they have been implemented and, if so, whether they were effective. This information will help you when making corrective actions on subsequent incident investigations. Without follow-up, the effort of investigating may be wasted. 3STEP 7: Write an investigation report Write a report to explain what happened, why it happened and what can be done to prevent similar incidents. Your report should be objective and descriptive (clearly state the sequence of incident events so someone with no knowledge of the incident will be able to understand what happened). Iden- tify the hazard, why the incident happened, suggested corrective actions and include a schedule of follow-up dates. Leave space for follow-up comments. ENSURING QUALITY In terms of which of these steps are often overlooked or done poorly, Patricia Clausen, Loss Causation Model for Accident Investigation Accident Loss Investigation Loss Incident Immediate Causes Underlying/ Root/Basic Causes Management Control 1. Inadequate Programs 2. Inadequate Program Standards 3. Inadequate Compliance Personal Factors Job Factors People Property Process Contact with Energy or Substance Substandard Acts or Conditions “The steps quarry owners take after an incident are just as important as the steps they take to prevent it” PSHSA director of prevention, engagement and retention, points to the step of identi- fying substandard actions/conditions and root causes. “The underlying factors that caused the occurrence are overlooked due to lack of written procedures and training,” she notes. Another one is proper gathering of evidence through questioning. “An important compo- nent to training is conducting proper inter- view techniques and understanding the Loss Causation Model for Accident Investiga- tion (see Figure 1), so that the recommen- dations for control address all the causes,” says Clausen. “A well-written procedure that clearly identifies roles and responsibilities on who investigates the accident within the organization and provide training, including how to investigate an accident that includes effective interview techniques, will help determine effective controls to prevent re-occurrence.” • For more information on this topic, visit www. pshsa.ca/wp-content/uploads/2013/02/How_ To_Investigate.pdf FIGURE 1