This training covers the definition of terms associated with incident/accident, importance of reporting near‐miss, investigation, follow‐up and close out of all type of accidents / incidents. It details what happened, the key lessons learned, the recommendations and corrective action taken. It also covers practical incident investigation. The purpose is to ensure that every incident, defined, is any event that requires investigation, either due to the harm it has caused to people, the environment, or property, or due to the potential that it could have caused such harm, is investigated and reported appropriately and evaluated for potential lessons.
An uncontrolled chain of events that results in / could have resulted in harm to people, damage to property , environment or reputation. The following incident types are distinguished:
An unforeseen incident that results in harm to people, damage to
property or loss to process including fires.
An event is an occurrence or happening which can be an accident,
incident, near miss or equipment failure that can behave actual or
potential impact on people, the environment, assets or the company reputation
is the death of employee resulting from work related injury or
illnesses regardless of time intervening between the injury and
Lost Workday Case (LWC)
is a work related injury which renders the injured person
temporarily unable to perform any regular job or restricted job on
any day after the day on which the injury was received.
Lost Time Injury Case (LTI)
is a work related injury which renders the injured person
temporarily/permanently unable to perform any regular job. In DEC system; Fatality and LWC are all considered LTI Case
Restricted Work Case (RWC)
Any work related injury other than a fatality or lost time injury
case which results in a person being medically unfit for full
performance of the regular job on any day after the occupational
injury. Work performed might be:
• An assignment to a temporary job.
• Part time work at the regular job.
• Continuation full time in the regular job but unable to
perform all the usual duties. Often a person is designated
for “light duties”.
Medical Treatment Case (MTC)
Any work injury that involves neither lost time nor restricted
workdays but which requires treatment by, or under, specific order of a physician or could be considered in the province of a physician. An incident will be a medical treatment case if there are complications requiring follow up medical treatment.
Examples of Medical Treatment
• Treatment of infection.
• Antiseptics during second or subsequent visits to medical
• Treatment of second or third degree burns.
• Use of prescription medications.
• Soaking therapy (hot or cold) during second or subsequent visits
to medical personnel.
• Cutting away dead skin (surgical debridement).
• Application of heat therapy during the second or subsequent
visits to medical personnel.
• Positive X‐rays diagnosis (query fractures)
• Admission to a hospital for treatment ( more than observation).
First Aid Case (FAC)
An injury other than a lost time injury which may result in a partial
absence from a shift but doesn’t otherwise interface with job
performance. Cases which are not sufficiently serious to be
reported as Medical Treatment Cases (MTC’s) and require minor
first aid, e.g. dressing on a minor cut, burns, removal of a splinter,
etc. before returning (usually immediately) to work. Such treatment and observation are considered First Aid, even if provided by a physician or registered medical professional personnel.
Near Miss Case
Near miss is an incident which potentially could have caused injury or occupational illness and /or damage (loss) to people, assets, the environment or reputation but did not. These are incidents which occurred without injury or damage to life or property
Occupational Illnesses Case
is any abnormal condition or disorder, other than an injury, which is mainly caused by exposure to environmental factors associated with the employment. It includes acute or chronic illnesses or diseases. Work related illnesses shall be determined and certified by the License Physician’s & accepted by the HSE Manager.
any damage to property of the Client, project property or Partner/Subcontractor resulting from an accident during construction activities.
Motor Vehicle Accident (MVA)
An Incident which has involved a vehicle and which has resulted in
injury. Illnesses and / or damage (loss) to people, assets, the environment or the company reputation.
any work related incident that can harm to environment such as
water pollution, oil spill, noise pollution, damage to forest etc.
any accidental burning of property or equipment that belongs to
Security Related Incident
any incident related to threat, robbery kidnapping, sabotage which involves company property or personnel working in the project.
• In order to prevent major incidents, it is important to identify the hazards in the Fatality work areas.
• Since a near miss is reflective 10 LTA’s of a possible hazard, recognising a near miss will 30 RWC’s help identify the hazard and
will offer an opportunity to carry out corrective action 600 Near Misses before a major incident can occur.
NEAR MISS REPORTING
Benefits of Near miss reporting • Identify the problem rectify it / hazard :problem, it, eliminate control the hazard..
• Provide wide source of information which can be analyses to identify trends and find areas of operation that require improvement.
• By getting used to near miss reporting, people will get used to
looking our for unsafe acts and conditions.
• Improve awareness.
ACCIDENT INVESTIGATION TEAM
An Incident Investigation Team to be facilitated by the Site HSE Manager will be organized when any one of the following incidents has taken place:
• All LTI cases.
• Near Miss that could result in a Fatality, LTI, serious property damage, serious environmental damage or serious loss of reputation.
• Failure or collapse of facility
• Serious damaged to environment
• Property damage that could result in a delay of the project.
For all other incidents an investigation report is required, including all learning points. The manpower required is depending on the damage, serious environmental damage, or serious loss of reputation. Investigations should be carried out as soon as possible after the incident, because the quality of evidence can deteriorate rapidly with time.
In principle, the Investigation Team should consist of the following:
• Area Manager, Responsible for the area where the incident happened.
• Engineer/Supervisor responsible for the work that was carried out .
• HSE personnel responsible for the area where the event happened.
• Partner/Subcontractor Site Manager. (if necessary)
• Partner/Subcontractor Supervisor and crew leader carrying out
the work. (if necessary)
• Partner/Subcontractor HSE Manager. (if necessary)
• Witness of the event, if any.
• Client Representative.
The report and investigation procedures are as follows:
1) Determine the scope of the investigation
2) Select the investigators ) g and assign specific tasks to each member
3) Present a preliminary briefing to the investigating team, including
– Description of the accident, with damage estimates
– Normal operating procedures
– Maps and layout (local and general)
– Location of the accident site
– List of witnesses
– Event that preceded the accident
4) Visit the accident site ) to get updated information
5) Inspect the accident site
6) Interview each victim and witness
7) Determine what was not normal before the accident, where he
abnormality occurred, when it was first noted, and how it occurred.
8) Analyze the data obtained in step 7
9) Determine why the accident occurred, a likely sequence of events and problems causes, and alternative sequences
10) Check each sequence against the data from step 7
11) Determine the most likely sequence of events and the most probable causes
12) Conduct a post‐investigation briefing
13) Prepare the summary report
FEEDBACK FROM THE INSIDENT
The report of incident investigation shall be reviewed in a weekly
HSE meeting, and the findings and recurrence prevention measures shall be educated to employees as well as field engineers, supervisors and foremen. All accidents, incidents and dangerous occurrences including the preventive actions, recommendations by the investigation team and lesson learned from them shall be effectively channeled down to all levels of workforce through group meetings. The communication line shall be as follows: Accident/Incident Investigation Team → HSE Committee → Project Managers of Sub‐contractors → Construction Managers of Subcontractors → Site Engineers → Site Supervisors → Workforce.
We shall learn to:
• Develop an understanding of why incidents should be investigated
• Learn 8 common mistakes made when investigating incidents
• Learn investigation techniques to identify underlying and root
• Practice applying those techniques using simple scenarios
• Discuss what should, and should not, go in an accident report
WHY DO INSIDENTS OCCURE.
Incidents rarely have just one cause
One early concept was Heinrich’s Domino Theory:
INJURY caused by accidents.
ACCIDENTS caused by an unsafe act, injured person or an unsafe condition ‐ work place.
UNSAFE ACTS/CONDITIONS caused by careless persons or poorly designed or improperly maintained equipment.
FAULT OF PERSONS created by social environment or acquired by ancestry.
SOCIAL ENVIRONMENT/BACKGROUND where and how a person was raised and educated.
8 COMMON MISTAKES OF INSIDENTS INVESTIGATION
1. No Investigation Incidents not reported & so not investigated
2. Wrong type of investigation Depth of investigation does not match potential (or actual) severity
3. Investigation is Too Late Investigation too late to be effective
4. Assumptions become facts Statement made on the basis of rumors is written, and reported, as facts
5. Witness Statement Inaccurate Statement is what witness ‘thinks’ not ‘knows’ ‐ becomes accepted as ‘true’
6. Focus is Wrong Investigation is about the event & what happened after it, not why it occurred
7. Irrelevant Corrective Actions Corrective actions not related to root causes ‐ lack of focus
8. No / Inadequate Follow‐up Corrective identified but no follow‐up actions effective follow
Different techniques for different incidents:
• Logic of Fault Trees
• Multi Linear Events sequencing
• Events and Causal factor chart
• MORT (Management Oversight & Risk tree) Investigations may use specific tools to support them:
• Tap Root® / Tripod Beta® / SOURCE™
• These can be complicated
• Are generally used for the investigation of more serious incidents
• Require formal training and, in some cases, computer software in order to be effective. Most incidents can be successfully and correctly investigated using a more basic technique
INSIDENT_INVESTIGATION TECHNIQUES CONT
• From the 1st phone call, take notes (contemporaneous evidence) Date, time, people, details
• Depth of investigation should match incident potential
• Any incident which could have resulted in a fatality should be
investigated (as if it had been a fatality)
• Secure the site
• Work in affected area(s) should only re‐start if authorized
• Identify witness for Interview
• Get early comments
• Inspect the site
• Take photographs &, if possible, find photos prior to incident
• Secure key documents ‐Maintenance records Certificates Training / Induction / Orientation records Log books Notebooks QC records ect.
• Quarantine Key Components
WHERE DID IT HAPPEN?
WHEN DID IT HAPPEN?
WHY DID IT HAPPEN?
HOW DID IT HAPPEN?
WHO CAN CONTRIBUTE TO THE INVESTIGATION?
• Something that has actual existence (Miriam Webster)
• A thing that is indisputably the case (Oxford English)
• Is defined as something that is true, something that actually exists, or something that can be verified according to an established standard of evaluation. (Wikipedia).
• What was the injured employee’s explanation?
• What were they doing at the time of the accident?
• What was the position at the time of the accident?
• What is the exact nature of the injury?
• What operation was being performed?
• What materials were being used?
• What safe‐work procedures were provided?
On the morning of 2nd March, shortly after shift start, a section of the trench wall collapsed, trapping two workers.
On the morning of 2nd March 2006, 4 workers were building formwork in a trench at EAP EPC NGL II BRT expansion site, Nigeria. Running north to south, the trench was approximately 20m L x 2m
W x 4 m D.
At approximately 07:45 a section of the trench wall (4m back from the south end of the trench) collapsed, trapping two workers.
• Where did the accident occur?
• Where was the employee positioned?
• Where were eyewitnesses positioned?
• Where was the supervisor at the time?
• Where was first aid initially given?
Create an accurate ‘timeline’
• Went on shift at ‘x’ on ‘y’ date
• Incident occurred at ‘z’ hours (use 24 hour clock)
•Assumed /approximate times should be started as such
• Considering using evidence such as: Stopped clock
Data logging from process unit
CCTV camera systems
Security swipe card systems etc
When did the accident occur?
When did the employee start his/her shift?
When did the employee begin employment?
When was job‐specific training received?
When did the supervisor last visit the job?
Planning the interview
• Schedule the witnesses
• For major incidents, keep key witness apart
• Allow sufficient time for each interview
• Develop structured questions in advance
• Allow witnesses to have a friend/safety representative to present if They want
• They are to be observers not talkers
• Put the interviewee at ease
• Choose a quite location
• Sit on the same side of the table
• Reassure interviewee:
• “This interview is to establish the facts”
• “I will be asking you describe what you saw, and what you know, in your own words”
• Allow the interviewee to see your notes
• Right down what is said, not how you interpret it
• Who was injured?
• Who was working with him/her?
• Who else witnessed the accident?
• Who else was involved in the accident?
• Who is the employee’s immediate supervisor?
• Who rendered first aid or medical treatment?
How did the accident occur?
How many hours had the employee worked?
How did the employee get injured (specifically)?
How could the injury have been avoided?
How could witnesses have prevented it?
How could witnesses have better helped?
HOW COULD THE COMPANY HAVE PREVENTED IT?
Ask WHY 5 times:
Why did he fall?
• He fell through the hole in the grating
Why could he fall through a hole in the grating?
• The grating was removed to pull cables and there was no barrier
Why there was no barrier?
• The crew pulling cables did not put one in place
Why did they not put a barrier in place?
• Waiting for scaffolders to erect a barrier would delay the job
Why would it take too long for scaffolders to arrive?
• It’s big site and there are only 3 scaffolders
• It was a short‐notice rush job and there was not enough time to
plan the scaffolding
Open & Closed questions
Open – cannot answered with a ‘Yes or No’
• “What is your job?”
• “What time did you arrive?”
• “Describe what you saw.”
• “What did you do next?”
Closed – can be answered “Yes or No”
• “So you’re a welder”
• “You arrived at 7 o’clock with the others”
• “Did you see the scaffold collapse?”
Repeat the answer back
• Make sure you understood the answers
Sure the interviewee verifies earlier responses
• Use whiteboards, walls or windows
• Develop timeline of events on ‘post‐it’ notes
One event per ‘post it’ include witnesses/ date/ time/ location
• For complex incidents use a site plot plan to identify key actors,
witness location and other critical data
• Identify which events were critical to the incident occurring
Continue timeline through the event to point recovery:
• Fatal incidents
Deceased removed from site and authorities permit re‐start
• Injury events
Injured person arrives at hospital/ clinic for treatment
• Pollution events
Until pollution controlled and clean‐up operations underway
• Damage only events:
Equipment repaired/ process re‐start
• Analyze each of these to identify root causes
• Anything which is an assumption should be clearly marked as such
WRITING THE REPORT
Set the scene, describe work in progress at time of incident
2. Executive summary
Summarize incident, causes, findings, key recommendations
3. Description of incident
Detailed description of incident, timelines, photos, etc
Describe the underlying and root causes
Summarize what and why happened
List recommendations, set deadlines, responsibilities for action
Photos, witness statements , associated records
WHAT TO CONSIDER
What will be the impact to your report:
• Can you justify each finding?
• Are the recommendations realistic?
What resources required to implement the recommendations?
What could be the cost?
Have you set realistic deadlines?
• Are there reasonable short‐term fixes for longer term solutions?
• What training will be required?
• Does it conflict with regulatory requirements?
• Do you need to share with peer groups/ industry?
• In order to prevent major incidents, it is important to
identify the hazards in the work areas.
• Every incident should be reported and properly
investigated to know all the root causes and to
• All lesson learned from every incident should be
disseminated to site employees through TBT’s, HSE
Bulletin Boards and any other means of