Procedure for Investigating and Reporting an Incident or Near Miss
- Purpose of an Investigative Report
Incidents and near misses do not just happen, they happen because we have not reduced the risk to as low as reasonably achievable. The purpose of reporting and investigating, and thereby managing and reducing risk, is to:
- Ensure continuous improvement in the Health and Safety Management System, increasing the health and safety of every Yukon government employee.
- Determine the sequence of events that led to the incident or near miss (Who?, Where?, When?, What?, How?)
- Determine the root cause of the incident or near miss (Why?, Why?, Why?, Why?, Why?).
- Offer “corrective action recommendations” to prevent similar occurrences in the future
- To comply with all applicable safety regulations (G.A.M. 3.48 and OHS Act)
Reporting of incidents and near misses, no matter how small, assists all employees in looking at the reason why incidents and near misses occur and helps to determine what can be done differently to prevent injuries, illness and property/equipment damage in the future.
- Conducting an Incident or Near Miss Investigation
An incident or near miss investigation report should contain information that answers the questions: “Who, Where, When, What, Why, and How.”
Employer, injured person(s), other person(s) involved in the incident or near miss, witnesses and persons carrying out the investigation.
Place, location where incident or near miss occurred.
Date and time.
A brief description of the incident or near miss including the sequence of events that preceded the event.
Before the incident occurred:
- What were the events that led up to the incident or near miss?
- What process(es) was/were occurring immediately prior to the incident or near miss?
- What was/were the workers(s) doing immediately prior to the incident or near miss?
- What was the last event before the incident or near miss occurred?
At the time of the incident:
- What happened at the time of the incident or near miss?
- What process(es) was/were occurring at the time of the incident or near miss?
- What was/were the worker(s) doing at the time of the incident or near miss?
- What hazards(s) was/were the worker(s) exposed to?
- What hazards may have contributed to the incident or near miss occurring?
- What hazards did the worker(s) encounter?
- What personal factors may have contributed to the incident or near miss occurring?
- Collect evidence – if necessary, take photographs, samples of chemicals, if appropriate, broken parts or pieces
- Interview witnesses – individually, at the scene of the incident or near miss, immediately it possible, with an open mind
- Review records to identify trends – inspection records, previous incident reports, maintenance records
Causation - from the answers to “WHAT,” identify any unsafe acts, conditions, processes, procedures, or personal factors that in any manner contributed to the incident or near miss. Why did they occur? Why were the causation factors not addressed before the incident or near miss?
Incident and Near Miss Causation:
Incidents and Near Misses are caused by unsafe acts, unsafe conditions, inadequate procedures and personal factors.
Unsafe Act: is a specific action or lack of action by an employee that is under the employee’s control. It is the performance of a task or other activity that is conducted in a manner that may threaten the health and/or safety of employees. Examples include, but are not limited to:
- Operating equipment or machinery without qualification or authorization
- Lack of or improper use of PPE
- Failure to tagout/lockout
- Operating equipment at unsafe speed
- Failure to warn
- Bypass or removal of safety devices
- Using defective equipment
- Use of tools for other than their intended purpose
- Working in hazardous locations without adequate protection or warning
- Improper repair of equipment
- Wearing unsafe clothing
- Knowingly not following established rules
- Knowing not following established procedures
Unsafe Condition: is a condition in the workplace that is likely to cause minor or serious injury/illness, property or environmental damage. Examples include, but are not limited to:
- Defective tools, equipment, or supplies
- Inadequate supports or guards
- Congestion in the workplace
- Inadequate warning systems
- Fire and explosion hazards
- Poor housekeeping
- Hazardous atmospheric condition
- Excessive noise
- Poor ventilation
- Inadequate training
Inadequate Procedures: Indications that procedures are inadequate include, but are not limited to, the following:
- Procedures are not available in writing.
- Procedures do not identify inherent hazards.
- Procedures do not identify hazard control methods.
- Procedures do not identify safeguards that must be in place.
- Procedures do not address pre-operation inspection requirements.
- Procedures do not address lock-out requirements.
- Procedures direct improper use of equipment or tools.
A personal factor is a deficiency in skill or ability, a physical condition, or a mental attitude. Examples include, but are not limited to:
- Work fatigue due to manual exertion
- Distress due to emotional problems
- Influence of drugs or alcohol
- Allergic reaction – a condition causing an allergic reaction in some workers, but not all, should be
considered a personal factor, not an unsafe condition
The “5 Why?” Technique
a) By repeatedly asking the question "Why" (five is a good rule of thumb), you can peel away the layers of symptoms which can lead to the root cause of a problem. Keep asking yourself “Why did this occur?” until the answer is no longer meaningful.
b) Very often the obvious, but not necessarily the true reason for a problem will lead you to another question.
c) Although this technique is called “The 5 Why," you may find that you will need to ask the question fewer or more times than five before you find the issue related to a problem.
d) Asking the right questions is essential for success when using the “5 Why? Technique”.
e) Knowing what to ask, when you ask “WHY?” is the key to getting to the “root” of the problem. The point of root cause analysis is to dig below the symptoms and find the fundamental, underlying decisions and contradictions that led to the undesired consequences.
f) The final Why leads to a statement (root cause) upon which action can be taken to prevent recurrence. If you want your problems to go away, your best option is to deal with them at the “Root”.
An investigation report should recommend corrective actions to prevent similar incidents from occurring. Once it is known why an incident or near miss occurred, determine how to prevent recurrence. For example:
- Improve workplace inspection and maintenance programs
- Repair or replace equipment/building
- Install safeguards
- Establish or revise safe work procedures
- Train/retrain workers
- Improve Supervision
Additional Information for determining why an incident or near miss occurred:
To determine the most probable cause(s) of an incident or near miss, consider all details of the investigation, including witness statements and, where possible, the injured work’s statement, if applicable.
Determine if the incident or near miss was due to an unsafe act, an unsafe safe condition, unsafe or inadequate procedures, or a combination of these. Consider whether the accepted/current procedures adequately address safety concerns associated with the activity that was taking place when the incident happened. Consider training, supervision, equipment controls, safeguards, and lock-out.
Ensure that recommended corrective actions
a) Have been implemented properly
b) Are effective in eliminating or reducing future incidents
c) Do not create an unforeseen hazard