During the investigation you will look at all the information to work out what went wrong. This can involve a bit of detective work. This information includes:
- Observation – looking at scene of the incident
- Interviews – talking to witnesses
- Documentation – written evidence such as work instructions, maintenance records etc.
Working with other agencies
Depending on the type of incident, other agencies may be involved.
- Police – theft or fatality
- Ghana National Fire Service
- Environmental Protection Agency
- Metropolitan, Municipal and District Assemblies
- Association of Oil Marketing Companies (AOMC)
Co-operation with other agencies is vital to protect life and property. It is likely that other agencies will take the lead in their areas of expertise.
Starting the investigation
Begin as soon as possible after the incident has been reported, so you are more likely to get accurate data.
If necessary, work must stop.
Focus on what caused the incident, not placing blame. If you blame someone at the start, they will become uncooperative. Only at the end of the investigation can you decide if someone acted inappropriately
Start by looking that the NPA licence issued. During the investigation note if any of the licence conditions are not met.
Investigations that find human error was the cause (someone was to blame) have usually not got to the root cause.
What to cover: 4 Ps
Be thorough. To make sure you cover everything, think about the 4Ps.
Identify these in your audit report – for example if you are looking at a machine, what type of machine is it? the manufacturer? the model? the serial number? any modifications?
Plant – this includes equipment, machinery, vehicles. You should consider – Is it fit for purpose? good condition? well maintained?
Procedures – this is how the work is done. There may be written instructions or procedures, or you may have to ask how a task is carried out.
People – Who did the work? Did they know how to work safely and have qualifications and/or training? Are they supervised? Were they fit to work, or tired or distracted?
Place – Look at the environment where the accident happened – is it clean and tidy? are there distractions such as noise?
What sort of information should you look at?
Whilst carrying out the investigation think about what is in place, and compare this with what should be happening if they were following good practice and the licence conditions.
Documents
Make notes about the document you are looking at, so that it can be found again, or take a photograph of it. Note: what is the document, the date, who has signed it
Important documents may include:
- Plant – machine operating instructions, log books, maintenance records, risk assessments,
- Procedures – How work should be done (was this followed?), risk assessments (are hazards identified correctly and controls in place?), company accident book, first aid records, (has something similar happened before?)
- People – training records, qualifications, induction records (did the person have the skills and competence to work safely?)
- Place – fire evacuation records and tests,
Observation
Look carefully. Are you seeing the whole situation? Image 1 and 2 are of the same incident, but you will react differently to the 2 images.
Note where people were when the incident happened. Was anything unusual?
Observe what is in place, but also what is missing, inadequate or unused. For example, if Personal Protective Equipment (PPE) should be worn when carrying out a task – look – was the injured person wearing PPE? are other people in the work area wearing PPE? is PPE available so people could wear it if they wanted to?
Interview
Who to talk to:
- The injured person –
- Start with an overview: what was he doing prior to the incident. What happened? How are you hurt? Was he given first aid or some other treatment?
- Then ask more detailed questions: Was he working on his own? How long has he been doing this job for? Have there been problems before?
- Finish by getting their thoughts: What does he think caused the incident? How does he think it could have been prevented?
- Any witnesses – either to the incident or who were working in the area prior to the incident. – what happened? What was being done prior to the incident? Was there anything unusual or different? Why was this?
- Any supervisors or people who know how to do the task? – What should happen? what were the reasons this did not happen?
- Managers – What will be done to stop this type of incident happening again?
Tips for a good interview
- Start by explaining why you are carrying out the interview. The aim is to find the cause of the incident and take actions to prevent it happening again, making the workplace safer. The aim is not to find someone to blame.
- Interview soon after the incident so the witness remembers more details
- Interview witnesses individually and in private. Try to avoid witnesses discussing the incident before the interview.
- Try to interview at the location where the incident took place which may jog their memory and help them explain what happened by pointing to things.
- Do not blame the witness, or anyone else during the interview
- Listen well. Do no interrupt
- Phrase your questions well
- Start with open questions – Who? What? Where? When? Why? These will allow the witness to give you more information in their words.
- Check that you have understood correctly by using closed questions – when the answer is yes or no.
- Be compassionate, especially if there is a serious injury or death. This person has had a horrible experience and could be in shock. If necessary, delay the interview.
- Take good notes. Use the ‘any comments’ section at the bottom of the Proactively form to add further information.
Do not jump to conclusions
It is important to be open and honest through the investigation. From previous experience, you may think that you know how the incident was caused. This can lead you to miss the real cause.
Be sure to look at what really happens and how work is really done. Do not guess that this is what happened, even if it is written in procedures. Workers often take short cuts to make work easier or faster.
Make sure you are not biased:
- Investigators can make assumptions based on prior knowledge
- “I’ve done that job before myself, so I know how it it done”
- 20:20 hindsight when you assume that those involved in the accident should have known what you now know
- “It’s obvious that it’s a flammable liquid and therefore dangerous”
- Focus on the failure at the sharp end and ignore organisational failings
- The banksman was run over because he was standing in the wrong place….instead of …..”Why was he there? Poor systems of work? poor supervision? unclear instructions?
Using Proactively:
- the Incident investigation form in the mobile app will prompt you to ask the right questions.
- Take photos, particularly of the location where the incident took place.
- At the bottom of the form is a section for ‘any comments’ where you can add additional notes if needed.
Exercise
Exercise: A member of the public is dispensing fuel into a container. It spills. A nearby person is smoking. The spillage catches fire and 2 people are badly burnt. What data would you gather?
Firstly, try to answer the question, and then click to read the answer
Labelling and signage – no smoking
Adequate lighting
Provision of fire fighting equipment
Absorbent materials
Type of container being used