Incident Investigation Self Guided Working Package PDF

INCIDENT
INVESTIGATION
Self-Guided Working Package
O n t a r i o Fo re s t r y S a f e Wo r k p l a c e A s s o c i a t i o n
INCIDENT
Self-Guided Working Package INVESTIGATION
Introduction
An incident is an unplanned event or gradual process that results in harm to people or damage to property. The im-
mediate goal of any incident investigation is to find out what happened and why, and the ultimate goal is to make
sure it never happens again.
The purpose of this self-guided working package is to promote the Internal Responsibility System by providing a
step-by-step process for thorough and effective incident investigations. The left-hand column of each page provides
a brief explanation of the step. The right-hand column consists of checklists that can be used by firms to verify that
they are building an effective incident investigation process.
Also included are two copies of a sample incident investigation form. One copy already has a sample of the
necessary information filled in to give you an idea of what to include in a report. The other copy has an explanation
of the type of information that’s required in each section.
The final part of this package, “How and why incidents happen”, examines the various aspects of the workplace,
work processes and manager, supervisor and worker roles that can become contributing factors in incidents.
All incident investigations are both reactive and proactive. Gathering facts about what led to the incident is the
reactive side of the investigation. Once the facts have been gathered, the proactive side of the investigation consists
of making recommendations to ensure that the incident never happens again. In addition to sudden events, incidents
can be the result of processes that happen gradually over time, such as poor ergonomic design that leads to a strain
and sprain injury or long-term exposure to excessive noise or vibration leading to health problems.
The Occupational Health and Safety Act makes it the responsibility of one or more worker members of the joint
health and safety committee – or the health and safety representative in workplaces where there is no committee
– to investigate an incident if it resulted in a death or a critical injury, or if there is a work refusal or a report of dan-
gerous circumstances. The incident investigation team should consist of joint health and safety committee (JHSC)
members, including a supervisor and worker representative. In workplaces where there is no JHSC, the investiga-
tion team should consist of a supervisor and the worker health and safety representative.
In addition to the legislated responsibilities to investigate fatalities, critical injuries, work refusals and dangerous
circumstances, a worker member of the JHSC or the health and safety rep may be asked to investigate a non-criti-
cal injury, an occupational illness or an incident without loss, commonly known as a near miss.
As a company best practice, a near miss makes an excellent investigation topic. Near misses are red flags that warn
of more serious incidents to come if nothing is done to control the hazards. These incidents provide valuable op-
portunities to identify factors that could combine to cause a serious incident before it happens.
There is no such thing as an unpreventable fatality, injury or property loss in the workplace. An effective incident
investigation process doesn’t just help prevent a recurrence of the incident that’s being investigated, it also reduces
the probability of all incidents by strengthening your company’s Internal Responsibility System.
INCIDENT
INVESTIGATION Self-Guided Working Package
Legislated responsibility to report and investigate □ Employer, supervisors and JHSC work-
Occupational Health and Safety Act, Sections 8(14), er member or worker health and safety
9(31), 43(4), 45: representative are aware of legislated re-
Workplaces that are required by the Act to have a joint quirements to investigate fatalities, criti-
health and safety committee (JHSC) or health and safety cal injuries, work refusals and dangerous
representative must have a worker member involved circumstances.
in the investigation of fatalities, critical injuries, work □ Employer is aware of requirement under
refusals and reports of dangerous circumstances. the OH&S Act to provide a written report
Occupational Health and Safety Act, Section 51(1): of any fatal or critical injury to the nearest
Employers are required by the OH&S Act to provide a Ministry of Labour office within 48 hours.
written report of any fatal or critical injury to the nearest □ Incident investigation team consists of
Ministry of Labour office within 48 hours. JHSC members, including a supervisor and
A critical injury, as defined by Regulation 834 of the Oc- worker representative. If there is no com-
cupational Health and Safety Act, consists of any one of mittee, the investigation team consists of a
the following physical effects: supervisor and the worker health and safety
• places life in jeopardy representative.
• produces unconsciousness □ Worker member of the JHSC or the health
• results in a substantial loss of blood and safety rep is available if asked to in-
• involves the fracture of a leg or arm but not a finger or toe vestigate a non-critical injury, occupational
• involves the amputation of a leg, arm, hand or foot but illness or near miss.
not a finger or toe □ As a best practice, a near miss reporting
• consists of burns to a major portion of the body and investigating procedure is in place
• causes the loss of sight in an eye to recognise and control hazards before
In addition to legislated responsibilities regarding fatalities, anyone is injured or killed.
critical injuries, work refusals and dangerous circumstances,
a worker member of the JHSC or the health and safety rep
may be asked to investigate a non-critical injury, an occupa-
tional illness or a near miss.
The incident investigation team should consist of JHSC
members, including a supervisor and worker representative.
In workplaces where there is no JHSC, the investigation
team should consist of a supervisor and the worker health
and safety representative.
As a best practice, a near miss makes an excellent investi-
gation topic. Near misses are red flags that warn of more
serious incidents to come if nothing is done to control the
hazards. These incidents provide valuable opportunities to
identify factors that could combine to cause a serious in-
cident before the incident happens. By investigating near
misses, someone doesn’t have to be injured or killed be-
fore attention is drawn to a problem or hazard.
INCIDENT
Step 1 – Fact-finding □ Investigation team members are instruct-
The incident investigation should begin as soon as possible ed to start their investigation as soon as
after the incident has been reported to a designated person possible after the incident has occurred.
in the company, appropriate medical assistance has been □ The investigation team is equipped with
given, the necessary agencies have been notified and the the necessary tools:
scene has been secured. □ Investigation report forms, checklists
In addition to filling out the text portion of the incident inves- □ Clipboard, pencils, markers
tigation report form such as the sample version on page 42,
investigators may want to take still photos or video footage □ Tape measure, flashlight, warning
of the overall scene, as well as detailed close-ups. A diagram ribbon
of the scene, including measurements, the location of people, □ Still and/or video camera
objects and other evidence, is also often helpful when the □ Copy of OH&S Act and Regulations
team begins to analyse the information they’ve gathered.
□ The investigation team is given full access
Eyewitnesses are a top priority because they are people who to witnesses and other relevant persons, and
saw all or part of what happened, or were the first people on witnesses understand that the investigation
the scene after the incident. Also important are people who is concerned with finding the causes of
had used the equipment involved in the incident, service the incident, not assigning blame for it.
personnel who had maintained or repaired the equipment,
and the injured person’s co-workers and supervisor.
□ The investigation team is given full ac-
cess to relevant company records:
Witnesses should be interviewed individually as soon as
possible after the incident, ideally in a quiet location away
□ Maintenance records
from distractions. The interviewer should reassure wit- □ Equipment specifications and operat-
nesses that the investigation is concerned with finding the ing instructions
causes of the incident, not assigning blame for it. □ Operator’s reports (circle check, re-
pair requisitions)
□ Production records
□ Training and certification records
□ Human resources files
□ Incident report files
□ Medical reports
INCIDENT
Step 2 – Analysis □ The investigation team has the mandate

An incident almost never has just one cause. Usually an inci- and is appropriately trained to identify
dent is caused by a particular combination of different circum- both the immediate causes and the un-
stances. Investigators need to identify two types of causes: derlying causes of the incident.
Immediate causes: The unsafe practices or conditions □ The following factors are taken into ac-
that led directly to the incident. (Example: equipment count when looking for immediate and
wasn’t locked out.) underlying causes:
Underlying causes: The factors that enabled the unsafe prac- □ People – the actions members of
tices or conditions to occur. (Example: lack of monitoring and management and workers took or
enforcement of the lockout procedure.) Underlying causes didn’t take, and their understanding
arise from gaps in the Internal Responsibility System. of how the work was to be done.
Immediate causes are usually quite apparent, but it often takes □ Equipment – the specific tools,
a bit of digging to get to the underlying causes. It’s important machines, vehicles and facilities in-
to find the underlying causes because unless they are identified volved in the incident.
and corrected, it’s quite likely the incident will happen again. □ Material – wood or wood products
The identification of an underlying cause such as the lack will usually be the main material in
of monitoring and enforcement of the lockout procedure forestry incident investigations. How
will often lead the investigation team to a deeper underly- was it being handled or processed at
ing cause. For example, the team may find that supervisors the time of the incident?
have not been adequately trained in monitoring and enforc- □ Environment – Environmental con-
ing safe work procedures. ditions can have a major influence
Risk level: The ultimate purpose of any incident investi- on incidents: a slippery road surface,
gation is to make sure the incident never happens again. a cluttered mill floor, an extremely
As part of its analysis, the investigation team needs to be cold day, a dimly-lit work area.
able to estimate the probability of a recurrence and the □ Process – The design of the work and
potential losses involved. All incidents can be analysed organization of the workplace. How
for risk using the following equation: the work was being done, and what as-
Risk = Exposure + Severity pects of the normal process and work
organization (or change from the nor-
“Exposure” refers to how often workers are exposed to the spe- mal process) led to the incident. The
cific hazard or hazards, and how many workers are exposed to impact that administrative issues such
the hazard or hazards. as written safe procedures and pro-
“Severity” is the potential seriousness of the loss if the incident duction pressures (or incentives) may
happens again. Loss could be death, critical injury, lost-time have had on the incident.
injury, no-lost-time injury or property damage. □ The investigation team analyses the risk
If the possible consequence of a given incident is death or criti- level of a recurrence of the incident by
cal injury, the severity is very high. If the possible consequence measuring the degree of worker exposure
is a sliver in the hand, the severity is low. to the hazard or hazards, and the poten-
If either exposure or severity is high, the risk rises. If both ex- tial losses associated with a recurrence.
posure and severity are high, the risk is extreme.
INCIDENT
Step 3 – Report and recommendations □ Five different types of solutions can be
Each factor that’s identified during the incident investi- recommended to control an identified
gation highlights a flaw in the company’s safety system. hazard:
The flaw may be related to the work environment, the □ Engineering changes that control or
equipment, the attitudes and practices of people, the way eliminate a hazard through the design
material is handled or the work process as a whole. The of the work area, work process or
incident investigation report’s recommendations on how equipment.
to control these hazards will flow naturally from the in- □ Work practice changes that control
vestigation team’s analysis of each factor. or eliminate a hazard by altering the
The team’s job is to ensure that each recommendation in way specific tasks are done.
the incident investigation report is practical, realistic and □ Administrative changes that control
persuasive. Impractical, unrealistic or poorly explained rec- or eliminate a hazard by establishing
ommendations can diminish the level of trust among the policies and procedures that control
workplace parties and reduce the credibility of the entire the worker rather than the hazard.
incident investigation process.
□ Personal protective equipment
If the recommendations come from the joint health and changes that control or eliminate a
safety committee or the worker health and safety repre- hazard by providing workers with ad-
sentative, management is required by law to respond in ditional protection from it.
writing within 21 days. (OH&S Act, Sections 8(12) and
9(20)) The response must include a timetable for acting □ Personal hygiene changes that con-
on the recommendations or, if the recommendations are trol or eliminate a hazard by guard-
not accepted, the reasons they are not acceptable. ing against worker exposure to haz-
ardous materials.
□ Management will respond in writing to
the investigation team’s recommendations
within 21 days. The reply will include a
timetable for acting on the recommenda-
tions or the reasons why the recommen-
dations are not accepted.
INCIDENT
Step 4 – Action □ Once recommendations are accepted, the

After all parties involved (management, supervisors, joint following decisions are made:
health and safety committee or health and safety rep) □ What needs to be done?
have had an opportunity to review, discuss and perhaps □ Who will do it?
improve the recommendations, it’s time to translate them
into policy and action. □ How will it be done?
Six key decisions need to be made to convert the investiga- □ By what date will it be done?
tion report recommendations into practical and effective haz- □ Who will make sure it’s done?
ard controls. The decision-making starts with exactly what □ ho will follow up to make sure it’s
W
will be done to prevent the incident from every happening effective?
again. This is followed by decisions regarding who will do it,
how it will be done and by what date it will be done.
□ Actions taken are communicated and
explained to all relevant staff members
Once those decisions have been made, two important deci- and any necessary training is provided to
sions still have to be made: Designating the person who will make sure the changes are effective.
make sure the changes are made and the person or persons
who will follow up to make sure the changes are having the
□ Hazards are controlled at one or more of
the following locations:
desired effect of controlling the identified hazard.
It’s also important that the actions that are taken are com-
□ at the source of the hazard
municated and explained to all relevant staff members □ along the path of the hazard to the
through bulletin boards, staff meetings, signs and/or de- worker
cals, and that any necessary training be provided to make □ at the worker
sure the changes are effective.
Any action that’s taken will involve controlling specific haz-
ards at one or more of the following three locations:
At the source of the hazard. (Examples: installing a per-
manent guard on a piece of equipment; enclosing a piece of
equipment to reduce noise levels)
The most effective hazard control location is at the source,
but this kind of control is not always possible or practical. In
such cases, controls have to be put in place along the path of
the hazard to the worker or at the worker.
Along the path of the hazard to the worker. (Examples:
installing a ventilation system that keeps hazardous fumes
away from workers; setting up barriers that prevent workers
from approaching equipment)
At the worker. (Examples: safety glasses that protect the
worker’s eyes from flying debris; training that enables the
worker to perform the task safely)
INCIDENT
Step 5 – Follow-up □ The implemented hazard controls:
An effective hazard control has five important character- □ eliminate the danger to the worker
istics (listed in the right-hand column). These characteris- □ do not make the work more stressful
tics can be used by the person responsible for following or more uncomfortable
up on the changes – usually the front-line supervisor – to
assess the effectiveness of the changes. □ protect all workers who are likely to
be exposed
Supervisors will need to closely monitor both the new hazard
controls and the performance of workers affected by them. □ do not create external environmental
hazards
A process should be established to enable the JHSC or a
supervisor and the health and safety rep to review the haz- □ do not create any new hazards
ard controls after a specified period of weeks or months to □ Supervisors closely monitor the implement-
ensure that they continue to be effective in preventing the ed hazard controls and the performance of
incident from ever happening again. workers affected by the new controls.
□ A review of the hazard controls is under-
taken by the JHSC or a supervisor and
the health and safety rep after a specified
period to ensure that the hazard controls
continue to be effective in preventing the
incident from ever happening again.
INCIDENT Sample Incident Investigation Report Form - 1 of 8
INVESTIGATION Report Form: _____________
1 Company name: Quality Forest Products
Address: 44 Pine Road
City/town: Lumberton, ON Postal code: B1P 3G8
Telephone: 615-555-2333 Fax: 615-555-2334 Type of business: Sawmill
2 Name of injured worker: J. P. Martin
Address: 996 Hemlock St.
City/town: Lumberton, ON Postal Code: BIP Telephone: 615-555-6789

3G9
3  Injury (Classify the type 4  Fatality (Classify

of incident. More the type of
 Property damage than one type  Critical injury
may apply.)  Lost time based on
 Fire  No lost time what you
know at the
 Incident without loss  Occupational illness
time.)
5 Time:  AM
Date of incident: June 19/06 11.45
 PM
6 Time: 12:30  AM
Date incident reported: June 19/06
 PM
7 Location of incident: Kilometre 13, QFP Road (State the location as specifically as possible.)
8 Description of incident: (Give a brief description. Don’t speculate about the causes at this point.)
Frank Tedesco was hauling a load of pulpwood through a sharp curve at Kilometre 13
of QFP Road when he was rear-ended by a half-ton truck driven by Sylvain Lefebvre.
The right front of the half-ton truck struck the rear left of the pulpwood truck.
9 Description of injuries: (Describe the injuries using clear, simple language.)
J.P. Martin, a passenger in the half-ton truck, suffered a compound fracture of his
right leg and was taken by ambulance to Lumberton Civic Hospital. Neither Sylvain
Lefebvre nor Frank Tedesco were injured.
INCIDENT
Incident Investigation Report Form - 1 of 8
INVESTIGATION
Report Form: _____________
1 Company name:
Address:
City/town: Postal code:
Telephone: Fax: Type of business:
2 Name of injured worker:
Address:
City/town: Postal Code: Telephone:
3  Injury 4  Fatality
 Property damage  Critical
 Lost time
 Fire  No lost time
 Incident without loss  Occupational illness
5 Time:  AM
Date of incident:
 PM
6 Time:  AM
Date incident reported:
 PM
7 Location of incident:
8 Description of incident:
9 Description of injuries:
INVESTIGATION
10 Description of machinery or equipment involved: (Try to include the make, model number and type.)
Pulpwood haul truck, half-ton truck.
11 First aid given at  yes Injured worker transported by: Ambulance

scene?  no
Medical assistance rendered at: Lumberton Civic Hospital
Name of attending physician: Address:

Dr. Norbert Paine 817 Lakeview Court, Lumberton
12 Names and addresses of witnesses to the incident: (People at or near the scene of the incident.)
Frank Tedesco, 1250 High St., Lumberton

Sylvain Lefebvre, RR #1, Lumberton
13 Description of immediate measures taken to prevent a recurrence: (Short-term steps only.)
Water truck called in on afternoon of May 27 to control dust levels on QFP Road.
Other drivers informed of dust hazards on QFP Road due to several days of dry weather.
14 Date of this report: June Completed by: JHSC Telephone: 615-555-2335

24/06
15 Background information:
Dust conditions on QFP Road were very bad at the time of the collision and there was
no wind. The drivers of the two pulpwood trucks operating on QFP Road that morning
were in radio contact with each other, giving updates on their location. The driver of the
half-ton, who was on his way to a cut site with one passenger, did not have his radio
tuned to the proper frequency to receive communications from the two pulpwood trucks.
No speed limit signs were posted on QFP Road. The general company policy was that
the speed of company vehicles was limited to 80 kilometres per hour, and that weather
and road conditions were to be taken into account at all times.
(Typical questions to be answered are: What work was being done? What were the weather conditions?
How much experience did the injured worker(s) have? Had he or she received training?)
10 O n t a r i o Fo re s t r y S a f e Wo r k p l a c e A s s o c i a t i o n
INCIDENT
10
INVESTIGATION
Description of machinery or equipment involved:
11 First aid given at  yes Injured worker transported by:

scene?  no
Medical assistance rendered at:
Name of attending physician: Address:
12 Name and addresses of witnesses to incident:
13 Description of immediate measures taken to prevent a recurrence:
14 Date of this report: Completed by: Telephone:
15 Background information:
O n t a r i o Fo re s t r y S a f e Wo r k p l a c e A s s o c i a t i o n 11
INVESTIGATION
16 Description of incident (Use grid at end of section to make diagram if necessary):
While hauling his load through the sharp curve at Kilometre 13, Frank Tedesco
had to slow down when he drove into a thick cloud of dust created by another haul
truck a couple of minutes ahead of him. Sylvain Lefebvre, who was driving a half-ton
truck with one passenger, was not aware that a haul truck was that close to him, as he
wasn’t in radio contact with the other vehicles. Because of the angle that Sylvain veered
away from the truck in front of him, the right front portion of his half-ton truck took
most of the impact of the collision. J.P. Martin, who was in the front passenger seat, was
pinned in the vehicle and had to be removed by an emergency crew.
Neither driver was injured in the collision, but the passenger suffered compound
fractures of his right leg and will be off work for several weeks.
The haul truck sustained minimal damage but the right front end of the half-ton
truck was crushed.
(The description should be clear and detailed enough that anyone who reads it will have a vivid picture of
the incident.)
17 Immediate causes: What unsafe practices and/or conditions led directly to the incident?
Dust conditions due to several days of dry weather caused visibility problems on QFP
Road. The sharp curve also limited the vision of the driver of the half-ton truck.
The driver of the half-ton truck did not have his radio tuned to the proper frequency to
be in contact with other drivers on the road and know the location of their vehicles.
From witness testimony and investigation of the incident scene, the half-ton truck was
exceeding the company policy’s speed limit of 80 kilometres per hour just prior to the
collision. Excessive speed allowed very little time to react before the collision occurred.
(Unsafe practices are things that people did or things that they were supposed to do but didn’t. Examples
of unsafe practices include an improper procedure for a given task, violating a safety rule, or using the
wrong tool of equipment. Examples of unsafe conditions include faulty equipment such as bald tires or
worn brakes on a vehicle, lack of training for the task being performed, lack of supervision, or poor
ergonomic design of the work station.)
INCIDENT
INVESTIGATION
16 Description of incident (Use the grid at the end of this form to make a diagram if necessary):
17 Immediate causes: What unsafe practices and/or conditions led directly to the incident?
INVESTIGATION
18 Underlying causes: Why did the person(s) perform the unsafe practices identified in section 17,
and why did the unsafe practices and conditions identified in Section 17 exist?
Although our company has a general policy regarding speed limits on logging roads,
signs were not posted on the road and the speed limit policy has never been actively
monitored or enforced.
Supervisory staff had been told about bad dust conditions on QFP Road by drivers a
couple of days earlier, but no action was taken to control the amount of dust until after
the incident.
Haul drivers understand their responsibility to communicate by radio and this policy
is monitored and enforced, but employees who used logging roads on a casual basis were
more or less exempted from that requirement.
(Typical questions to be answered about unsafe practices are: Why were the safe procedures not
followed? Is there a long history of people doing it that way and getting away with it? Did it have to be
done that way because there was no practical alternative?)
(Typical questions to be answered about unsafe conditions are: Why were they allowed to exist? Have
they existed for a long time? Do conditions like these arise on a regular basis? Does everyone know that
they have to report unsafe conditions?)
19
Factors: What is it about the workplace and the way it’s organized that allowed or enabled
the underlying causes identified in Section 18 to exist?
No enforcement of the company speed limit on logging roads led to unsafe driving
practices. When supervisory staff and management don’t take road conditions such as
heavy dust seriously as a safety hazard, their casual attitude is also adopted by
employees who drive on those roads.
Road safety has not come up as an issue for training or information meetings in
more than 18 months. This is a symptom of a lack of health and safety accountability
within our company.
(Typical questions to be answered about incident factors are: What is it about the way we do things in this
workplace that created the underlying causes and allowed them to continue? Do we inadvertently
encourage unsafe practices and conditions?)
INCIDENT
INVESTIGATION
Incident Report Form - 4 of 8
18 Underlying causes: Why did the person(s) perform the unsafe practices identified in section 17,
and why did the unsafe practices and conditions identified in Section 17 exist?
19
Factors: What is it about the workplace and the way it’s organized that allowed or enabled the
underlying causes identified in Section 18 to exist?
INVESTIGATION
20 Loss potential: If an incident like this one is allowed to happen again, how serious could the
loss be next time?
Taking all the circumstances into account, the critical injury that resulted from this
incident could easily have been a multiple fatality if the driver of the half-ton truck had
not been able to swerve away from the rear of the pulpwood truck.
(Report on the full extent of the loss that could have occurred as a result of the incident, as well as the
potential injuries and property damage if it happens again. Could someone be critically injured or killed?)
21 Probability of recurrence: If no changes are made to the workplace or to the way things are
done, what are the chances of an incident like this happening again?
A collision of this kind if very likely to happen again if no changes are made.
(Calculate the probability of the incident happening again by considering how often workers could be
exposed to the hazards that caused the incident, and how many workers could be exposed.)
22 Risk analysis: Based on the possible consequences of an incident like this, and the probability
of it happening again, how serious is the risk posed by the practices and conditions identified in
Sections 17 to 19?
The risk posed by the practices and conditions identified in Sections 17 to 19 is very
high.
(Calculate the ongoing risk posed by the identified hazards or hazards by considering both the loss
potential identified in section 20 and the probability of recurrence identified in section 21. For example, if
the probability of recurrence is high and the loss potential is high, the risk is very high.)
INCIDENT
INVESTIGATION
20 Loss potential: If an incident like this one is allowed to happen again, how serious could the
loss be next time?
21 Probability of recurrence: If no changes are made to the workplace or to the way things are
done, what are the chances of an incident like this happening again?
22 Risk analysis: Based on the possible consequences of an incident like this, and the probability
of it happening again, how serious is the risk posed by the practices and conditions identified in
Sections 17 to 19?
INVESTIGATION
23 Recommendations:
1. Immediately begin active monitoring and enforcement of company speed limit policy
on logging roads.
2. Post speed limit signs on active roads and “Reduce speed” signs on sharp curves.
3. Schedule defensive driving training for all employees who use vehicles in their
work.
4. Require and enforce the use of radio communication devices by ALL employees who use
logging roads.
5. Include the condition of logging roads in JHSC inspections and hold periodic safety
meetings on safe travel on logging roads.
6. Schedule leadership and internal responsibility training for supervisory staff.
7. Conduct a general review of company safe work procedures to ensure that they are
adequate and are being monitored and enforced.
(Make recommendations for changes that you believe will prevent the type of incident you have
investigated from ever happening again. Your recommendations will flow naturally from the immediate
and underlying causes and risk analysis in sections 17 to 22.)
24 Report submitted by: Ron Smith, Health and Safety Co-ordinator Date: July 3/06
25 Reviewed by JHSC or Worker Representative: Karen Carruthers Date: July 3/06
Reviewed by management: Mike Gauthier, Woodlands Manager Date: July 5/06
All 7 recommendations have been accepted by management.

Timelines for implementation and follow-up on each
recommendation will be finalized by July 12/06.
(Acknowledge receipt and review of the report and by whom.)
26 Follow-up on recommendations: How, when and by whom will follow-up on these recommen-
dations be done?
Ron Smith is responsible for implementing Recommendations 1 to 4, 6 and 7. Ron will
follow-up on these changes with Mike Gauthier.
Karen Carruthers is responsible for implementing Recommendation 5. Karen will
follow-up on this change with Ron Smith.
(Describe the planned implementation steps and follow-up, with target dates and persons responsible.)
INCIDENT
INVESTIGATION
23 Recommendations:
24 Report submitted by: Date:
25 Reviewed by JHSC or Worker Representative: Date:
Reviewed by management: Date:
26 Follow-up on recommendations: How, when and by whom will follow-up on these recommen-
dations
INCIDENT Incident Investigation Report Form - 7 of 8
INVESTIGATION
Notes: Use this page for any additional information or for notes continued from previous sections.
INCIDENT
INVESTIGATION
Diagram: Use this section to sketch a diagram of the incident scene.
INCIDENT “Near Miss” SECTION 8 – INCIDENT INVESTIGATION PROGRAM
Report Form
INVESTIGATIONAppendix B: “Near Miss” Report Form
1. Company name and

address (Optional)
3. Environmental damage? 4. Property damage?

Yes No Yes No
2. Loss potential
(see back of sheet)
5. When did it happen? Date: Time:_____ a.m. p.m.
6. Where did it happen?
7. What equipment (make

& model) was
involved?
8. What happened and

how did it happen?
9. Why did this incident

occur? (substandard
acts or conditions)
10. What is recommended

to prevent this from
happening again?
Name of contact for more information? (Optional)
Name:___________________________ Telephone:____________________________________
SWO Resource Manual

ONTARIO
22 FORESTRY SAFE WORKPLACE ASSOCIATION O n t a r i o Fo re s t r y S a f e Wo r k Version
- 91 - p l a c e A 3.0
ssociation
INCIDENT
SECTION 8 – INCIDENT INVESTIGATION PROGRAM
How to Fill Out the Near Miss Report Form
How to fill out the “Near Miss” Report Form INVESTIGATION
Box 2: Loss potential
This information is intended to identify how likely the incident is to recur and how serious the
effects on the company could be if it happened again. Please use the chart below to choose the
letter-number combination that best represents the loss this incident could pose to your
company.
POTENTIAL SEVERITY (Likely to Cause)

PROBABILITY
OF Death, Permanent Serious Injury/Illness, Minor Injuries or
RECURRENCE Disability or Extensive Temporary Disability or Non-Disruptive
Property Damage Serious Property Damage Property Damage
Frequent A-1 B-1 C-1
Occasional A-2 B-2 C-2
Rare A-3 B-3 C-3
First decide how likely this incident would be to recur if no action was taken to prevent it.
(“Rare” means the incident could happen, but it’s not likely. “Frequent” means it could
happen at any time.) Then decide the possibility of injury or damage. For example, if you
believe the chance of the incident recurring would be rare but that it could cause a worker’s
death or more than $100,000 of damage if it did happen, put A-3 in Box 2.
Box 3: Environmental damage

Answer “yes” if the incident caused actual damage to the environment (for example, a spill) or
could potentially have caused damage.
Box 4: Property damage

Property damage is damage to buildings, equipment, vehicles or other materials. Answer “yes”
if the incident caused actual property damage or could have caused damage.
Box 9: Why did this incident occur?

This incident may have been caused by actions or conditions that were below standard. Identify
these immediate causes. Try to describe what you believe were the underlying causes of this
incident. A flaw in equipment design? A breakdown in procedures? A lack of training?
Box 10: What is recommended to prevent this from happening again?

What steps can be taken to prevent a recurrence? Is more training required? Do procedures have
to be more strictly enforced or new ones developed? Are equipment design changes required?
Do guards need to be modified?
SWO Resource Manual

O n t aONTARIO
r i o Fo re s FORESTRY
t r y S a f e WoSAFE
r k p l a cWORKPLACE
e A s s o c i a t i o nASSOCIATION - 92 - Version 3.0 23
INCIDENT
How and why incidents happen
Incident theory #1: The domino theory

Industrial safety expert H.W. Heinrich studied
thousands of insurance and injury/illness reports in
the early 1930s and developed the domino theory
to describe how incidents happened. The domino
theory placed much of the blame for incidents on
workers. It described a sequence of causes as a
chain reaction of toppling dominoes:
Domino #1 is the worker’s background – in other
Adapted from the Forest Resources Association Inc.
words, his or her lifestyle and personality

Domino #2 is the worker’s personal characteris-
tics – his or her attitudes, knowledge level, physical and mental conditions
Domino #3 is the unsafe act or acts and unsafe conditions causes by the factors in dominoes #1 and #2.
Domino #4 is the incident itself.
Domino #5 is the injury and/or property damage that result.
The idea behind the domino theory was that if you removed any one of the dominoes, the possibility of
any kind of loss occurring was reduced.
Heinrich felt that domino #3 – the unsafe act or condition – was the primary domino to focus on removing
from the sequence. The purpose of personal protective equipment (PPE) is to remove domino #5 (injury)
from the sequence even if the other four dominoes have toppled.
Heinrich emphasized that the incident, not the injury or property damage, should be the focus of attention.
If a person slips and falls there may or may not be an injury, but an incident has nevertheless taken place
and its causes should be investigated to prevent any future injury.
Incident theory #2: The energy contact theory
Dr. William Haddon’s energy contact theory of incidents, developed in 1970, describes a process in which
incidents occur when energy that is out of control puts more stress on a person or property than the per-
son or property can tolerate. This theory shifted the focus for incidents to the engineering and work design
aspects of the workplace, combined with human factors.
Energy contact theory
• Incidents occur when excessive energy puts more stress on a person or property
than the person or property can tolerate.
• All incidents that result in injury involve contact of some kind with excessive energy.
• Hazard controls usually involve altering, isolating or absorbing the energy:
• Shutdown and lockout for altering energy
• Guards or barriers for isolating energy
• PPE, cushions or mats for absorbing energy
INCIDENT
All incidents that result in injury involve contact of some kind with excessive energy, usually kinetic en-
ergy. For example, a flying or moving object has kinetic energy that is transferred to the body or structure
it strikes. If the amount of kinetic energy is high enough, injury or property damage occurs. The same
process can take place with electrical energy, thermal energy, radiant energy and chemical energy.
Incident theory #3: The ILCI incident sequence
In the mid-1980s the International Loss Control Institute (ILCI) developed a five-part incident sequence that
combines elements of all the previous models into one that continues to provide a solid basis for effective
incident investigations.
The ILCI incident sequence provides an updated ver- ILCI Incident sequence
sion of the domino theory that includes management
1. Lack of control (because of inadequate
systems, engineering and work design issues and hu-
program, inadequate program standards,
man factors. This incident sequence covers all of the
or inadequate compliance with standards)
key elements that need to be examined in order to
control and prevent workplace incidents. 2. Underlying causes (personal factors
and/or job factors)
1. Lack of control
The ILCI identifies control as one of the four es- 3. Immediate causes (substandard work
sential management functions (the other three practices or work conditions)
are planning, organizing and leading.) When 4. Incident (unwanted transfer of energy)
management control of health and safety pro- 5. Loss (people, property, product, environ-
grams, systems and procedures breaks down, the ment, service)
incident sequence gets underway.
The three main causes of this lack of control are:
• An inadequate health and safety program – meaning too little management, supervisor and worker train-
ing, too few planned inspections, incident investigations, etc.)
• Inadequate health and safety program standards – they’re not high enough, clear enough or specific
enough. Standards tell people what is expected of them and allow measurement of how well people
perform relative to the standards.
• Inadequate compliance with program standards. Most managers feel this is the main reason incidents happen.
That’s why continuous monitoring and enforcement of health and safety are so important.
2. Underlying causes
The ILCI divides underlying causes into personal factors and job factors.
Personal factors include:
• Inadequate physical capability (including height, weight, size, fitness, sensory deficiencies, disabilities, etc.)
• Inadequate mental/psychological capability (ability to comprehend, memory, reaction time, fears/
phobias, etc.)
• Physical stress (fatigue due to workload or lack of rest, existing injury or illness, drugs, etc.)
• Psychological stress (emotional overload, monotony, judgment/decision demands, conflicting or confusing
demands/directions, frustration, etc.)
• Lack of knowledge (orientation, training, experience)
• Lack of skill (initial instruction, practice, infrequent performance, coaching)
• Improper motivation (lack of incentives, improper supervisory example, rewards for improper practice, pun-
ishment for proper practice, etc.)
INCIDENT
Job factors include:

• Inadequate leadership and/or supervision (unclear or conflicting chain of command and responsibilities,
poor work planning, hazard assessment training, etc.)
• Inadequate engineering (ergonomics, work process design, etc.)
• Inadequate maintenance (preventive and reparative)
• Inadequate tools and equipment (inappropriate for the purpose, poorly designed or unavailable)
• Inadequate work standards (process design, work flow, safe procedures, etc.)
• Wear and tear (inadequate inspection/monitoring/maintenance, use by unqualified or untrained people,
inappropriate use, etc,)
• Abuse or misuse (intentional or not unintentional, condoned or not condoned by supervision)
Underlying causes are the factors in the workplace that permit the immediate causes of the incident.
3. Immediate causes
Immediate causes are divided into substandard practices and substandard conditions.
Substandard practices include:
• Failing to warn of a dangerous condition
• Removing guards and other safety devices or making them inoperable
• Not shutting down or preventing access to hazardous or improperly operating equipment or area
• Not locking out equipment before doing maintenance or repairs
• Operating equipment without authority
• Using defective or inappropriate equipment
• Not using personal protective equipment properly
• Ignoring safe procedures
Substandard conditions include:
• Inadequate guards or barriers
• Inadequate or improper PPE
• Defective tools, equipment, materials
• Inadequate warning systems
• Poor housekeeping
• Hazardous gases, dusts, smokes, fumes or vapours
• Excessive noise, heat, cold
• Inadequate or excessive illumination
• Inadequate ventilation
According to the Management Oversight and Risk Tree (MORT) system of analysing workplace incidents, a
substandard physical condition exists for nearly every substandard practice. The vast majority of these sub-
standard conditions involve poor ergonomic design of machines, equipment and the work environment.
INCIDENT
It’s important to think of substandard practices and conditions as symptoms of an underlying problem. In
order to get to the underlying cause of the substandard practices and conditions, two important questions
need to be asked:
1. Why did the substandard condition or practice exist?
2. What failure in our health and safety control system permitted it to exist?
4. Incident
Every incident involves an unwanted transfer of energy. Here are some of the most common types of energy
contact in incidents. The terminology is from the CSA “Coding of Work Injury or Disease Information” (Z795-
96): which is used by WSIB when it processes workplace injury claims.
• Struck against an object. This involves bumping into, stepping on or being thrown into or against an object.
• Struck by an object. This is when the worker is hit by a moving object. (It would have been the injury coding
used for the death of William Powell in the video, since he was struck by a moving stack of boards.
• Caught in or compressed by equipment or objects. The worker is squeezed, crushed or pinched between two
or more objects, or between parts of an object.
• Fall to a lower level. This coding is used when the point of contact that caused the injury is lower than the surface
that was supporting the worker before the fall occurred.
• Fall on the same level. This is when the point of contact that caused the injury is at the same level or above the
surface that was supporting the person before the fall occurred. Slips or trips are the usual cause of this type of
fall.
• Bodily reaction refers to situations when the motion of the worker’s body puts stress or strain on some
part of the body. This usually involves an unnatural position or voluntary or involuntary motions caused by
sudden noise, fright or trying to recover from a slip or a loss of balance. Many musculoskeletal disorders fall into
this injury category.
• Overexertion refers to excessive physical effort directed at an outside source of injury, usually by lifting or low-
ering it, pushing or pulling it, holding, carrying, wielding, or throwing it.
• Repetitive motion is when the injury from bodily motion is due of the repetitive nature of the task.
5. Loss
The type of loss produced by an incident can vary from the trivial to the catastrophic. The type of loss depends
on the circumstances of the incident and on the actions that were taken to minimize loss. The loss can include:
• Death
• Injured worker’s time and quality of life
• Medical attention and rehabilitation costs
• Co-worker and supervisor time
• Production time
• Equipment and property damage
• Ministry of Labour orders, fines, higher WSIB premiums
• Reduced employee morale
INCIDENT
The WSIB estimates that an average lost-time injury in Ontario in 2006 cost the employer $19,560 in direct
costs such as medical attention, rehabilitation, etc. But this accounts for only a fraction of the true cost.
Examples of indirect costs include damage to equipment and/or property, lost production, Ministry of La-
bour orders, fines and increased WSIB premiums. If we factor in these and other indirect costs, the WSIB
estimates that the average cost to the employer of a lost-time injury in 2006 was $98,000. And that’s with-
out taking into account the biggest losses of all: a human life if it was a fatal incident or, in the case of an
injury, the effect on the worker’s overall quality of life.
The Management Oversight and Risk Tree (MORT) rule of workplace incidents and loss is a simple one:
“What can happen will happen – the only uncertainty is when.”
“When a system fails, it does not fail for any one reason. It usually fails
because the kinds of people who are trying to operate the system, with
the amount of training they have had, are not able to cope with the
way the system is designed, following procedures they are supposed
to follow, in the environment in which the system has to operate.”
- Alphonse Chapanis, pioneer of modern ergonomics
The message of the above quotation is that an incident is a process rather than an isolated moment. The
purpose of all incident investigations is to provide a detailed description of the entire process that allowed
it to happen in order to make sure it never happens again.

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INCIDENT

Step 2 – Analysis □ The investigation team has the mandate

Step 4 – Action □ Once recommendations are accepted, the

INVESTIGATION Report Form: _____________

1 Company name: Quality Forest Products

Address: 44 Pine Road

City/town: Lumberton, ON Postal code: B1P 3G8

Telephone: 615-555-2333 Fax: 615-555-2334 Type of business: Sawmill

2 Name of injured worker: J. P. Martin

Address: 996 Hemlock St.

City/town: Lumberton, ON Postal Code: BIP Telephone: 615-555-6789

3  Injury (Classify the type 4  Fatality (Classify

9 Description of injuries: (Describe the injuries using clear, simple language.)

City/town: Postal code:

Telephone: Fax: Type of business:

2 Name of injured worker:

City/town: Postal Code: Telephone:

Pulpwood haul truck, half-ton truck.

11 First aid given at  yes Injured worker transported by: Ambulance

Medical assistance rendered at: Lumberton Civic Hospital

Name of attending physician: Address:

Frank Tedesco, 1250 High St., Lumberton

13 Description of immediate measures taken to prevent a recurrence: (Short-term steps only.)

14 Date of this report: June Completed by: JHSC Telephone: 615-555-2335

11 First aid given at  yes Injured worker transported by:

Medical assistance rendered at:

Name of attending physician: Address:

12 Name and addresses of witnesses to incident:

13 Description of immediate measures taken to prevent a recurrence:

14 Date of this report: Completed by: Telephone:

25 Reviewed by JHSC or Worker Representative: Karen Carruthers Date: July 3/06

Reviewed by management: Mike Gauthier, Woodlands Manager Date: July 5/06

All 7 recommendations have been accepted by management.

24 Report submitted by: Date:

25 Reviewed by JHSC or Worker Representative: Date:

Reviewed by management: Date:

1. Company name and

3. Environmental damage? 4. Property damage?

5. When did it happen? Date: Time:_____ a.m. p.m.

6. Where did it happen?

7. What equipment (make

8. What happened and

9. Why did this incident

10. What is recommended

Name of contact for more information? (Optional)

SWO Resource Manual

POTENTIAL SEVERITY (Likely to Cause)

Box 3: Environmental damage

Box 4: Property damage

Box 9: Why did this incident occur?

Box 10: What is recommended to prevent this from happening again?

SWO Resource Manual

How and why incidents happen

Incident theory #1: The domino theory

words, his or her lifestyle and personality

Job factors include:

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Step 2 – Analysis □ The investigation team has the mandate

Step 4 – Action □ Once recommendations are accepted, the