Occupational Health and Safety Reference

Investigation Techniques

Two common mistakes:

• Failure to make the distinction between the cause of

the injury and the cause of the accident.
• Failure to distinguish between what happened and
why it happened (The question WHY? Has to be asked
repeatedly.

Incidents are seldom, if ever, the result of a single cause. The majority
involve both sub-standard (unsafe) acts and sub-standard (unsafe)
conditions. (Majority of the time unsafe conditions exist because someone
did not act to correct them)

Immediate Causes (Symptoms):

Immediate causes are the factors that were directly involved in the
occurrence. It is not uncommon to have more than one substandard practice
or substandard condition, or a combination of the two.

Substandard Practice:

• Operating without authority

• Failure to warn or secure
• Operating at improper speed
• Making safety devices inoperable
• Using defective equipment
• Using equipment improperly
• Failure to us Personal Protective Equipment (P.P.E.)
• Improper leading or placement
• Improper lifting
• Servicing equipment in motion
• Taking improper position
• Horseplay
• Under the influence of alcohol or drugs

Substandard Conditions:

• Inadequate guards or protection

• Defective tool, equipment, substances
• Congestion
• Inadequate warning system
• Fire and explosion hazards
• Substandard housekeeping

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• Hazardous atmospheric conditions (fumes, gases,
dust, etc.)
• Excessive noise
• Radiation exposures
• Inadequate lighting
• Inadequate ventilation

Basic/Root causes of Incidents (Behind the symptoms):

Personal Factors:

• Inadequate physical or mental capability

• Lack of knowledge
• Lack of skill
• Stress
• Improper motivation

Job/Organizational Factors:

• Inadequate supervision
• Inadequate engineering
• Inadequate compliance
• Inadequate training or no training
• Inadequate program(s)
• Inadequate purchasing
• Inadequate tools and equipment
• Inadequate maintenance
• Inadequate work standards
• Wear and tear
• Abuse or misuse

Management/System Factors:

• Deficiencies in the management system

Fatality/Critical Injuries and Right to Refuse and Stop Work:

• Ministry of Labour (MOL)

• JOHSC (Certified Worker and Management rep)
• Workers Union
• Fatalities – Thunder Bay Police Department

Phases of Investigations:

1. Respond Promptly and Positively:

• Incidents need to be investigated to prevent re-occurrence.

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• Success can often determined in the first few moments
after an incident:
o Take control of scene
o Ensure first aid available/administered (If needed)
o Control potential secondary incidents
o Identify sources of evidence at the scene
o Preserve evidence at the scene
o Determine the loss potential
o Notify appropriate personnel
• Key Steps:
o Gathering Information
o Interviewing witnesses
o Take photos, make diagrams
o Examine equipment
o Analyze material failure
o Review records (Training, Inspection reports,
policies, legislation, etc.)

2. Gathering Information:

o Investigation kit:
• Graph paper
• Line paper
• Pencils/markers
• High visible marking tape
• Warning signs
• Flashlight
• Tape measure
• Camera
• Sample containers/bags
• Report forms/checklists
• Recorder
• P.P.E. (Where required)
o Survey incident scene and surrounding area (Look
above, below, behind, inside, listen for unusual
sounds, smell for unusual odors, temperature
extremes, excessive vibration)
o Itemize things that need explaining
o Make a list of people present (Who should be
interviewed?)
o Take photos
o Make diagrams
o Measure
o If Fatal or Critical injury – preserve scene as per
legislation OHSA – Part VII, Section 51(2)

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 o Remember PEME (People, Equipment, Materials
(How handled, stored, hazardous, etc.),
Environment (Surfaces, ventilation, lighting,
temperature, noise, tidiness, ergonomics, etc.)
o Interviewing witnesses (Should be immediately
while information is fresh in their minds):
• Relevant to the investigation
• First details often provide the symptoms of
the problem (starting point)
• Keep detailed notes
• In more than one witness, interview
separately (people are often influenced by others, information
overload)
• If there are contradictions – re-interview to
clarify
o Re-enactment – only if absolutely
necessary
• If cannot get information any other way
• If equipment is involved – isolate
• As soon as you have the information
required, stop the re-enactment.)
o Sketches, photos, etc.
• Capturing position of evidence (Helpful for
interviewing witnesses)
• Photos from all sides/angles/distances (far-
close up)
• Sketches do not have to be elaborate – focus
on only elements relevant to incident (i.e., location of people,
equipment, etc.)
o Record measurements
o Objects should be measured from at
least 2 reference points – verify accuracy
o Some times use architicural drawings –
should have layout already on them with distances and location of
doors, windows, etc.)
o Equipment Examination
• Is it right for the job
• Was it used correctly
• Was it in good condition
o Material Failure analysis
• JOHSC
• Engineers
• Make sure parts damaged or not are
saved for examination
o Records Review
• Other incident reports
• Logs
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 • Schedules
• Training records
• Legislation
• Policies/procedures

3. Investigating Meeting (Analyze the accident)

o Break down information and data

gathered
o Immediate cause might be apparent
o Find all the contributing factors
• People
• Equipment
• Material
• Environmental
• Process
• Ergonomic
o Check these factors against the facts
gathered by all investigating team members
o Timeline by either a Tree or Fishbone
Diagram (Mapping the evidence, sequence of
events, etc.)
o Basic Causes identified
• The answers closet to the
sequence of events is usually immediate
causes (knife cutting finger, stove burning
arm, etc.) The answers furthest from away
are usually basic causes (poor procedures,
wrong tool, no P.P.E., Improper or no
training, etc.)
o Temporary Actions
(Immediate Actions)
• Can be done immediately
• Correct only the symptoms
• Not the final actions
o Permanent Actions (Long Term Actions)
• Solve problem
• Remedy unsafe conditions
• Treat oversights, omissions in
systems, standards, policies, procedures
• Time involved to implement

4. Preparing the Report

o Comprehensive report
• Identifying causes and making
recommendations for remedial actions
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 • Description of incident
• Consequences
• Causes
• Corrective action taken
• Recommendations for further
action
o Should be written in the
same order as causes
(Risk assessment can be done to
prioritize which
recommendations/actions)
• Communicate critical facts to people who
have to act on them
• Satisfy legislative requirements
• Provides a permanent record
• Include diagrams/sketches/photos
• Forward copies to JOHSC – OH&S Dept.
• May have to amend – if testing on
equipment/materials hasn’t come in.
• No personal opinions – they need to be
substantiated.

5. Review findings and recommendations

o Other staff
o Supervisors and manager
o Other departments
o JOHSC

6. Follow up
o Recommendations need to be followed up
(especially ones with timelines)
• Maintenance
• Policies/procedures
• Training
• Equipment monitoring
• New equipment

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 Occupational Health & Safety

EMPLOYEE RISK ASSESSMENT FORM

Dept.: ___________________________________________ Date: __________________ _________

Task: ____________________________________________________________________________________________________________________
Specific Hazards: ___________________________________________________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Employees: ________________________________________________________________________________________________________________
Risk Controls: ______________________________________________________________________________________________________________
Reviewed By: ______________________________________________ Date: ___________________________________________________________

How to Use the Risk Assessment Chart:

1. Determine the probability and frequency of exposure. 2. Draw a straight line from the probability through the frequency to the tie line.
3. Determine the severity. 4. Draw a straight line from the tie line intersection through the severity to the Risk Level.
5. The risk level completes the evaluation. 6. Identify the required risk controls.
7. (Name) Signature of “Reviewed by”. 8. Is a Policy or Procedure in place? YES __ NO __
9. If NO and the risk level is High or Very High a procedure is required to be developed. Safety/Employee Risk AssessmentForm.2007

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 Incident Investigation Checklist
Tasks Ye N
s o
Make a list of people who were present (To be interviewed later):

Survey scene:

Take Photos
Take Measurements
Make diagrams
Take samples if possible
What type of incident was it:
STRUCK AGAINST AN OBJECT(S) □
INHALING A HAZARDOUS SUBSTANCE □
STRUCK BY AN OBJECT(S) □
ABSORBING A HAZARDOUS SUBSTANCE □
CAUGHT IN, ON OR BETWEEN AN OBJECT(S) □
SWALLOWING A HAZARDOUS SUBSTANCE □
SLIP/FALL ON THE SAME OR TO A DIFFERENT LEVEL
□ OVEREXERTION □
CONTACTING TEMPERATURE EXTREMES □
REPETITIVE MOTIONS □
CONTACTING ELECTRICAL CURRENT □
AWKWARD POSITIONS/STATIC POSTURES □
Interview person(s) involved in incident

Interview Witness(s)

Were there substandard practices (Acts) Were there substandard conditions

OPERATING WITHOUT AUTHORITY □ INADEQUATE GUARDS OR PROTECTION □
FAILURE TO WARN OR SECURE □ DEFECTIVE TOOLS, EQUIPMENT, SUBSTANCES □
OPERATING AT IMPROPER SPEED □ CONGESTION □
MAKING SAFETY DEVICES IMOPERABLE □ INADEQUATE WARNING SYSTEM □
USING DEFECTIVE EQUIPMENT □ FIRE AND EXPLOSION HAZARDS □
USING EQUIPMENT IMPROPERLY □ SUBSTANDARD HOUSEKEEPING □
FAILURE TO USE PERSONAL PROTECTIVE HAZARDOUS ATMOSPHERIC CONDITIONS, GASES, DUST, FUMES,
EQUIPMENT □ □ ETC.

IMPROPER LEADING OR PLACEMENT □ EXCESSIVE NOISE □

IMPROPER LIFTING □ RADIATION EXPOSURES □
SERVCING EQUIPMENT IN MOTION □ RADIATION EXPOSURES □
TAKING IMPROPER POSITION □ INADEQUATE LIGHTING □
HORSEPLAY □ INADEQUATE VENTILATION □
DRINKING AND/OR SUBSTANCE ABUSE □
Set up investigation team meeting
Contact investigation team for meeting date and time
Prepare and distribute report
Any follow-up needed on recommendations
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