Incident investigations

02.07.2023 | WeeklySafety.com

Incident investigations, including a thorough root cause analysis, should be happening after any injury, property damage event, or near miss happens on the job. Following the investigation, appropriate corrective actions can be implemented to prevent future incidents

The term accident often used when referring to an unplanned, unwanted event. However, accident suggests an event that was random, and could not have been prevented. Since nearly all worksite fatalities, injuries, and illnesses are preventable, the term incident is more applicable in most of these unfortunate situations.

Investigating a worksite incident, which may be a fatality, an injury, an illness, property damage, or a close call, provides employers and workers the opportunity to identify hazards in their operations and shortcomings in their safety and health programs. Most importantly, it enables employers and workers to identify and implement the corrective and preventative actions necessary to prevent future incidents.

Incident investigations that focus on identifying and correcting root causes, not on finding fault or blame, also improve workplace morale and increase productivity, by demonstrating an employer’s commitment to a safe and healthful workplace.

Incident investigations are often conducted by a supervisor, but to be most effective, these investigations should include managers and employees working together, since each bring different knowledge, understanding, and perspectives to the investigation. In conducting an incident investigation, the team must look beyond the immediate causes of an incident. It is far too easy, and often misleading, to conclude that carelessness or failure to follow a procedure was the main cause of an incident. When the incident investigation fails to uncover the root cause(s) of the incident then the organization will fail to identify the systemic changes and measures that are needed to prevent future incidents.

Remember – before an incident investigation begins, all emergency response actions need to be completed and the incident site must be safe and secure for entry and investigation.

OSHA RECOMMENDS A FOUR-STEP SYSTEMS APPROACH TO INCIDENT INVESTIGATIONS.

STEP 1 – PRESERVE AND DOCUMENT THE SCENE

Preserve the integrity of incident location and prevent material evidence from being removed or altered. Use cones, tape, or other means of guarding to prevent unauthorized entry.

STEP

2 – COLLECT INFORMATION

Information about what happened before and during the incident can be collected through visual observation of the location, interviews, and document review efforts.

STEP 3 – DETERMINE ROOT CAUSES

There is often more than one root cause that can be uncovered during any incident investigation, and finding these root causes requires a deep evaluation of the incident.

STEP 4 – IMPLEMENT CORRECTIVE AND PREVENTATIVE ACTIONS

Steps taken after an incident to prevent future similar incidents, should be implemented in such a way that specifically addresses the root cause(s) found during the investigation.

When a program weakness is identified during an incident investigation, it is important to ask why it existed and why it was not previously addressed.

For example:

• If a step in the standard operating procedure was skipped, why was the procedure not followed exactly?

• Did production pressures play a role, and, if so, why were production pressures permitted to jeopardize safety?

• Was the procedure out-of-date or safety training inadequate? If so, why had the problem not been previously identified, or, if it had been identified, why had it not been addressed?

These examples illustrate that it is essential to discover and correct all the factors contributing to an incident, which nearly always involve equipment, procedural, training, and some other safety program deficiency. Simply placing blame on the employee, indicating that they made a mistake, or failed to follow the procedure, is not acceptable during an incident investigation.

A successful root cause analysis identifies all root causes—there are often more than one.

For simpler incidents, brainstorming and checklists may be sufficient to identify the root cause(s). For more complicated incidents, logic/event trees should also be considered. Timelines, sequence diagrams, and causal factor identification can also be useful tools.

Regardless of the tools used, the investigation should be seeking to answer these four important questions:

1. What happened?

2. How did it happen?

3. Why did it happen?

4. What needs to be corrected so it doesn’t happen again?

Addressing underlying or root causes is necessary to truly understand why an incident occurred, to develop truly effective corrective and preventative actions, and to minimize or eliminate serious consequences from similar future incidents.

To assist employers and workers in conducting effective incident investigations, and to develop corrective action plans, the following resources can help:

OSHA Fact Sheet: The Importance of Root Cause Analysis

During Incident Investigation

OSHA Incident Investigations: A Guide for Employers

NSC How to Conduct an Incident Investigation

Washington State Department of Labor & Industries

Accident Investigation Basics PowerPoint Presentation

How Management Leadership Can Improve Health & Safety

01.31.2023 | WeeklySafety.com

Management provides the leadership, vision, and resources that are critically needed to implement an effective safety and health program.

In any organization, management typically refers to the business owners, managers, and supervisors. Effective management leadership, when it comes to workplace safety, means that the leaders of the organization behave in a positive way that promotes health and safety throughout the company.

Management leadership has a responsibility to create a culture of safety by making worker safety and health a core organizational value. To do this, management staff must be fully committed to eliminating hazards, protecting workers, and continuously improving workplace safety and health, even when things get tough, finances get tight, growth happens quickly, or production is maximized.

Management personnel should be setting an example for all workers through their own actions and by visibly demonstrating and communicating their safety and health commitment throughout the organization. A great way management can set the precedent that safety is important is by providing sufficient resources to implement and maintain the safety and health program.

A clear, written safety policy helps management leadership communicate that safety and health is a primary organizational value—as important as productivity, profitability, product or service quality, and customer satisfaction.

Organizations should establish a written safety policy signed by top management describing the organization’s commitment to safety and health and pledging to establish and maintain a safety and health program for all workers.

Once the policy is drafted and signed, management can communicate the policy to all workers and relevant parties including employees, contractors, staffing agencies, new and temporary workers, suppliers, and vendors, as well as visitors and customers.

When management has set safety standards for the organization, leadership staff should set a good example and follow the same safety procedures required of the workers. Safety and health should also be a considering factor in all business decisions, including contractor and vendor selection, purchasing, and facility modification.

By establishing specific goals and objectives, management sets expectations for managers, supervisors, and workers, and for the program overall. The goals and objectives should focus on specific actions that will improve workplace safety and health.

There should be realistic, measurable goals set for improving safety and health within the organization. Instead of focusing on injury and illness rates, goals emphasizing injury and illness prevention are preferred.

Management can develop plans to achieve the safety goals by assigning tasks and responsibilities to particular people, setting timeframes, and determining resource needs.

Management provides the resources needed to implement the safety and health program, pursue program goals, and address program shortcomings when they are identified. Resources needs will of course vary depending on the organization’s size, complexity, and hazard types. Resources for safety and health program development may include capital, equipment, supplies, staff time, training, access to information and tools, and access to safety and health experts.

After estimating and allocating the resources needed to establish and implement a safety program, management must allow time in workers’ schedules for them to fully participate in the program. Safety and health should not be an afterthought, but rather should be integrated into planning and budgeting processes of the company.

Management leadership is responsible for providing and directing resources to operate and maintain the safety and health program, meet the commitments that have been set, and then further pursue the program goals.

Once the safety and health program is established, management leadership has the right to expect performance. Management will lead the program effort by establishing roles and responsibilities and providing an open, positive environment that encourages communication about safety and health.

There is typically a safety department manager or safety team that leads the safety program effort, makes plans, coordinates activities, and tracks progress. This person or group becomes the bridge between management leadership and employees.

Management can provide positive recognition for meeting or exceeding safety and health goals aimed at preventing injury and illness, which may include actions like reporting near misses, attending training, and conducting inspections. Successful programs reward, rather than discipline, workers who identify problems or concerns. Maintaining a positive and encouraging tone is important. A successful safety and health program establishes ways for anyone in the organization to communicate freely about safety and health issues, without fear of retaliation.

OSHA Directors Have Increased Authority to Cite Certain Types of Violations

01.29.2023 | EHS Today

The changes are aimed to stop “employers from repeatedly exposing workers to life-threatening hazards or failing to comply with certain workplace safety and health requirements.”

On January 26, OSHA announced new enforcement guidance changes which can “save lives and hold employers to greater account for safety and health failures.”

The announcement said these changes will “target employers who put profit over safety.” It will do this by making the penalties “ more effective in stopping employers from repeatedly exposing workers to lifethreatening hazards or failing to comply with certain workplace safety and health requirements.”

OSHA Regional Administrators and Area Office Directors now have the authority to cite certain types of violations as “instance-by-instance citations” for cases where the agency identifies “high-gravity” serious violations of OSHA standards specific to certain conditions where the language of the rule supports a citation for each instance of non-compliance.

Existing guidance on instance-by-instance citations are outlined in the OSHA Field Operations Manual, and CPL 02-00-080, “Handling of Cases to be Proposed for Violationby-Violation Penalties.”

These conditions include lockout/tagout, machine guarding, permit-required confined space, respiratory protection, falls, trenching and for cases with other-thanserious violations specific to recordkeeping.

The change is intended to ensure OSHA personnel are applying the full authority of the Occupational Safety and Health Act where increased citations are needed to discourage non-compliance. The new guidance covers enforcement activity in general industry, agriculture, maritime and construction industries, and becomes effective 60 days from Jan. 26, 2023. The current policy has been in place since 1990 and applies only to egregious willful citations.

In a second action, OSHA is reminding its Regional Administrators and Area Directors of their authority not to group violations, and instead cite them separately to more effectively encourage employers to comply with the intent of the OSH Act.

“Smart, impactful enforcement means using all the tools available to us when an employer ‘doesn’t get it’ and will respond to only additional deterrence in the form of increased citations and penalties,” explained Assistant Secretary for Occupational Safety and Health Doug Parker, in a statement.

“This is intended to be a targeted strategy for those employers who repeatedly choose to put profits before their employees’ safety, health and wellbeing,” Parker added. “ Employers who callously view injured or sickened workers simply as a cost of doing business will face more serious consequences.”

Osha

Release 01.26.2023 | US Department of Labor

Facing manslaughter charges in worker’s 2021 trench collapse death, Colorado contractor who willfully ignored federal law surrenders to police.

A4S LLC did not use legally required trench protection systems.

BRECKENRIDGE, CO – The owner of a Vail construction company facing felony manslaughter charges has surrendered to local law enforcement after the Summit County Sheriff’s Office in Breckenridge, Colorado, issued an arrest warrant on Jan. 24, 2023, related to the findings of a federal safety investigation into a deadly trench collapse in November 2021.

In May 2022, the U.S. Department of Labor’s Occupational Safety and Health Administration cited Peter Dillon, owner of the now-defunct A4S LLC, after a worker installing residential sewer pipes suffered fatal injuries when the trench around him caved in. The collapse resulted from deteriorating conditions at the project, which A4S LLC could have prevented by using legally required trench protection systems.

OSHA issued three willful citations to A4S LLC for not ensuring the excavation was inspected by a competent person, failing to instruct employees on the recognition and avoidance of unsafe conditions and not having a trench protective system in place. Investigators also issued an additional serious citation for not having a safe means of egress within 25 lateral feet of employees working in a trench.

The agency proposed penalties of $449,583 and placed the company in OSHA’s Severe Violator Enforcement Program.

The department referred the case to the 5th Judicial District Attorney’s office recommending criminal charges for A4S LLC’s refusal to require safety protection, despite worsening trench conditions that included at least one trench collapse.

A4S LLC has since shuttered and Dillon agreed to forfeit any future ownership, leadership or management position that involves trenching or excavation, or the oversight of workplace safety and health.

“There is no excuse for Peter Dillon’s failures to protect workers when federal requirements clearly outline and require safety measures proven to save lives,” explained Regional Solicitor of Labor John Rainwater in Dallas.

“Today’s arrest by the Summit County Sheriff’s Office cannot recover a life lost in this senseless tragedy but it is a step toward seeking justice for the family.”

Collapses and cave-ins pose the greatest threat to trenching and excavation workers. In 2022, OSHA reported that at least 39 industry workers died, 22 of them in the first six months of the year. The Bureau of Labor Statistics reports that 166 workers died in trench collapses from 2011 to 2018.

“Let this tragedy serve as a reminder to other employers who willingly fail in their responsibilities to keep workers safe that the U.S. Department of Labor will exhaust every resource to hold employers accountable for protecting workers, including recommending criminal prosecution. OSHA has pledged to work with state prosecutors to raise the stakes in appropriate trenching death cases, and this is an example,” added OSHA Regional Administrator Jennifer S. Rous in Denver.

OSHA has a National Emphasis Program on trenching and excavations. Trenching standards require protective systems on trenches deeper than 5 feet. Additionally, trenches must be inspected by a knowledgeable person and have a safe means of entering and exiting prior to allowing a worker to enter.