Following a near miss incident, a systematic approach is crucial to prevent future accidents and maintain regulatory compliance. This involves several key steps that need to be thoroughly documented.
The steps involved in investigating an incident include:
- Report the Incident: Report the incident to a designated person within the organization.
- Provide Care: Provide first aid and medical care to any injured individuals and prevent further injuries or damage.
- Scene Management: Secure the scene and ensure it is safe for investigators.
- Witness Management: Provide support to witnesses, limit their interaction with each other, and conduct interviews.
- Data Collection: Investigate the incident and collect relevant data.
- Data Analysis: Analyze the data to identify the root causes of the incident.
- Report Findings: Prepare a report with findings and recommendations.
- Corrective Action Plan: Develop and implement a plan for corrective action.
- Evaluate Effectiveness: Evaluate the effectiveness of the corrective actions taken and make changes for continual improvement.
When performing an investigation, it is important to investigate as soon as reasonably possible. [5]
The incident investigation team should:
- Be experienced in incident causation models.
- Be experienced in investigative techniques.
- Be knowledgeable of legal and organizational requirements.
- Be knowledgeable in occupational health and safety fundamentals.
- Be knowledgeable in the work processes, procedures, and the industrial relations environment.
- Be able to use interview and other person-to-person techniques effectively.
- Be knowledgeable of requirements for documents, records, and data collection.
- Be able to analyze the data gathered to determine findings and reach recommendations.
[4] The investigation report should include:
- Date and time of the incident.
- Date and time the investigation began.
- A detailed description of the incident.
- The factors that caused or contributed to the incident, including direct, indirect, and root causes.
- A list of any relevant documents reviewed during the investigation.
- Documentation of relevant findings from the review of those documents.
- The Incident Investigation Team's recommendations.
- Interim measures implemented by the employer.
[6] Recommendations should be specific, constructive, identify root causes, and identify contributing factors. [3]
Follow-up actions include:
- Responding to the recommendations in the report by explaining what can and cannot be done and why.
- Developing a timetable for corrective actions.
- Monitoring that the scheduled actions have been completed.
- Checking the condition of injured worker(s).
- Educating and training other workers at risk.
- Re-orienting worker(s) on their return to work.
[2] Ensure that the investigation findings and recommendations are communicated with workers, supervisors, and management to ensure everyone understands how the incident occurred and the actions needed to prevent it from happening again. [1]
By following these procedures and documenting each step, organizations can effectively prevent future accidents and ensure compliance with safety regulations.
Important Safety Note:
Always verify safety information with your organization's specific guidelines and local regulations.
References
Page links are approximateCal/OSHA Regulations | Chapter 4 | Subchapter 7: General Industry Safety Orders | § 5189.1. Process Safety Management for Petroleum Refineries
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