9.6 Summary
All investigations have the task of preventing injury and ill health, meaning they should be conducted with care and precision. This chapter examined the key steps involved in an incident investigation. Every employer must ensure they have trained incident investigators and an incident investigation toolkit on site. There are action items that need to take place following a workplace incident, some to meet internal expectations and some to meet external expectations, such as government and legal requirements. An employer needs to know who to contact under which circumstances, when to contact them and which forms to complete. Every employer needs to be prepared to conduct a thorough and timely incident investigation in order to meet expectations and protect its people.
Discussion Questions
- Why is it important to collect all the information before beginning the analysis step?
- Why should investigations focus on root cause and what are some of the ways that investigators can lose sight of it?
- How might accurately reporting the cause of an incident result in blaming workers for their own injury?
Exercises
Read the following scenario describing a workplace incident:
Amy worked for Chris’s Catering, a small catering company that specializes in special events.[1] On June 12, Amy was dispatched to work a small outdoor wedding taking place in a park overlooking the river. The size of the job called for two chefs in the kitchen (the husband and wife co-owners), one wait staff responsible for clearing plates after guests were finished, and two porters who would set up the serving tables and carry chafing dishes (hot metal pans for buffet-style serving) and other serving trays from the kitchen to the serving tables. Amy was assigned as a porter and was required to wear a short-sleeved black uniform with the company’s logo.
The wedding was located outside a community hall. The kitchen was inside the hall. The buffet table was at the opposite end of the small park, about 100 metres away. It was a hot and sunny afternoon. The other designated porter, Andy, called in sick at the last minute, leaving Amy to do the job alone with occasional help from the wait staff. As the time of the reception neared, the chefs were running behind schedule. Amy began shuttling chafing dishes to the buffet table. The dishes weighed approximately 12 kg each when filled with food. Amy used dishcloths to protect her hands from the heat of the dishes. She delivered eight dishes to the table.
As Amy was about to place the ninth and final tray, containing a hot minestrone soup, she took a sudden step backward, bumping into a guest behind her. The collision caused Amy to lose control of the dish, which spilled over her and the guest. It also caused Amy to fall into the buffet table. Amy suffered a severely sprained ankle, burns on her arms, and some bruising to her face and arms. The guest also experienced some minor burns.
Write 200-word answers to each of the follow questions:
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- How would you conduct the investigation? What tools and techniques you would use and who you would interview?
- How you would analyze and report the information you gathered?
- Identify the potential causes of the incident, distinguishing between proximate and root causes.
Check Your Knowledge
Notes
- Quoted in Adams, C., & Rowney, M. (2014). What was behind the deadly B.C. sawmills explosions? Global News. http://globalnews.ca/ news/1604346/16×9-investigation-what-was-behind-the-deadly-b-csawmills-explosions/
- Dyble, J. (2014). Babine Explosion Investigation: Fact Pattern and Recommendations. Victoria: Government of British Columbia.
- Hasle, P., Kines, P., & Andersen, L. (2009). Small enterprise owners’ accident causation attribution and prevention. Safety Science, 47(1), 9–19, p. 17.
- Heinrich, H. (1936). Industrial accident prevention. New York: McGraw-Hill.
- Reason, J. (1990). Human error. Cambridge: Cambridge University Press.
- Sklet, S. (2004). Comparison of some selected methods for accident investigation. Journal of Hazardous Materials, 111, 29–37.
- Lundberg, J., Rollenhagen, C., & Hollnagel, E. (2009). What-You-Look-For-IsWhat-You-Find—The consequences of underlying accident models in eight accident investigation manuals. Safety Science, 47, 1297–1311.
- Canadian Centre for Occupational Health and Safety. (2006). OHS Answers Fact Sheet: Accident Investigation. http://www.ccohs.ca/oshanswers/ hsprograms/investig.html. Accessed September 30, 2015.
- CBC News. (2016, January 12). B.C. sawmill explosion victims suing WorkSafeBC. http://www.cbc.ca/news/canada/british-columbia/b-csawmill-explosion-victims-suing-worksafebc-1.3400506
- This story is fictionalized. Any resemblance to actual people or companies is purely coincidental.
- This story is fictionalized. Any resemblance to actual people or companies is purely coincidental. ↵
