Timeline for Completing Incident Investigations
- Initial First Report of Injury (FROI) and Near Miss reports shall be submitted within twenty-four (24) hours.
- If an injured employee is not available, their supervisors should complete the report as accurately as possible with the information they obtain from any witnesses.
- Team Incident Investigations (TII) shall be completed within three (3) business days.
- Three business days should provide enough time for the supervisor to gather their team and get a description of the incident from injured employee(s) and any witnesses.
Responsible Party for Conducting Investigations
FROIs should be completed by the involved employee(s)’ supervisor. If the supervisor is not present the day of the incident an, involved employee(s)’ supporting supervisor, crew chief or other designated responsible party can complete the initial FROI.
The Team Incident Investigation form should be completed by the involved employee(s)’ supervisor in conjunction with their investigation team.
Investigation team should include the following personnel for the specified types of incidents:
Hazard Assessments and Investigations
For an incident investigation, the applicable Hazard Assessment shall be reviewed to determine the following:
- If an applicable Hazard Assessment exists, did it capture the hazard/risk that was involved in the incident?
- Does additional hazard/risk need to be added to the assessment?
- Do the safeguards (e.g., PPE) need to be updated in the assessment?
- If an applicable Hazard Assessment does not exist, does one need to be developed or does an existing assessment need to be updated?
Risk Assessment Process
Conducting a Risk Assessment for the incident and the impact of the determined corrective action will ensure team participation and identification of the risk.
What is the risk?
Risk is not the identified hazard. It is what could occur due to the hazard. See examples in the table below:
| Hazard | Risk |
|---|---|
| Sharp material (e.g., light fixture edge) | Employee receives a laceration |
| Working from a ladder | Fall from ladder |
For identifying risk of an incident. The risk used for the assessment should be the result of the incident or potential result.
- Example: The laceration received by the employee could be the risk or the potential for a finger fracture.
- Team should pick what they perceive as the of higher risk
Quantifying the Risk
To measure the severity of the risk identified, the team will need to determine the following:
- What is the likelihood of the incident occurring without putting in place any additional safeguards?
- Remote: You would be surprised if this happened
- Unlikely: Possible, but not likely to happen
- Moderate: Likely to occur, but not frequently
- Likely: If employee is exposed to risk daily it is likely to occur several times in a month period
- Extremely Likely: If employee is exposed to daily often it is likely to occur at least weekly
- What would the severity of the incident be if it occurred without putting in place additional safeguards?
- Minor: Near miss or first aid treatment
- Moderate: Recordable treatment
- Critical: Lost time injury less than 30 days
- Catastrophic: Death, amputation or permanent total disability
- Determine overall risk rating factoring likelihood and severity together without additional safeguards and utilizing the risk table below.
| Likelihood/Severity | Minor | Moderate | Critical | Catastrophic |
|---|---|---|---|---|
| Remote | Very Low | Very Low | Very Low | Low |
| Unlikely | Very Low | Very Low | Low | Medium |
| Moderate | Very Low | Low | Medium | Medium |
| Likely | Very Low | Low | Medium | High |
| Extremely Likely | Low | Medium | High | High |
Corrective Actions
Corrective actions shall reduce the risk as low as feasibly possible.
- When selecting a corrective action, you should follow the Hierarchy of Controls.
- Elimination: Physically remove the hazard, such de-energizing equipment
- Substitution: Replace the hazard
- Engineering Controls: Isolating people from the hazard
- Administrative Controls: Change the way people work
- PPE: Personal protective equipment
- After determining the corrective action how does this impact overall risk?
- Does it lower probability?
- For example, if you lock out tag out the electricity, the probability of getting shocked goes from likely to remote.
- Does it lower severity?
- For example, if by putting on cut resistant gloves, the severity of a cut from sharp material goes from moderate to minor.
- Conduct the Risk Assessment over again with using the matrix to determine the potential risk with corrective action in place
- Does it lower probability?
If corrective action does not lower the risk or get it below high, then the corrective action is insufficient, and further investigation is required.
Fishbone Process
- The fishbone can be used as an effective tool for determining root cause(s) of an incident.
- Categories are used to organize thoughts and facilitate brainstorming.
- Identified contributing factors are placed in the category with the theme with which they are most consistent.
- The Fishbone Process is used to help identify surface contributors and systemic contributors.
- Not every category is required to be used.
Categories Explained
Below is a list each fishbone category with explanations on what contributing factors should be placed under them.