Team Incident Investigation Form Guidance

Timeline for Completing Incident Investigations

1. Initial First Report of Injury (FROI) and Near Miss reports shall be submitted within twenty-four (24) hours.
   • If an injured employee is not available, their supervisors should complete the report as accurately as possible with the information they obtain from any witnesses
2. Team Incident Investigations (TII) shall be completed within three (3) business days.
   • Three business days should provide enough time for the supervisor to gather their team and get a description of the incident from injured employee(s) and any witnesses.

Responsible Party for Conducting Investigations

FROIs should be completed by the involved employee(s)’ supervisor. If the supervisor is not present the day of the incident an, involved employee(s)’ supporting supervisor, crew chief, or other designated responsible party can complete the initial FROI.

The Team Incident Investigation form should be completed by the involved employee(s)’ supervisor in conjunction with their investigation team.

Investigation team should include the following personnel for the specified types of incidents:

• Required for all Incidents:
  • Involved employee(s)’ supervisor (lead Investigator)
  • Involved employee(s), or witness, if not available
• Required for all Recordable Injuries:
  • General Manager
  • Member of Environmental Health and Safety (EHS)
• Optional for all Incidents:
  • Department Director
  • General Manager
  • Crew Chief
  • EHS
  • Safety Committee Representative
  • Engineer
  • Any additional persons that might contribute to the investigation (e.g., Welding Shop for potential fabrication needs)

Hazard Assessments and Investigations

For an incident investigation, the applicable Hazard Assessment shall be reviewed to determine the following:

• If an applicable Hazard Assessment exists, did it capture the hazard/risk that was involved in the incident?
  • Does additional hazard/risk need to be added to the assessment?
  • Do the safeguards (e.g., PPE) need to be updated in the assessment?
• If an applicable Hazard Assessment does not exist, does one need to be developed or does an existing assessment need updated?

Risk Assessment Process

Conducting a Risk Assessment for the incident and the impact of the determined corrective action will team participation and identification of the risk

What is the risk?

Risk is not the identified hazard. It is what could occur due to the hazard. See examples below:

For identifying risk of an incident. The risk used for the assessment should be the result of the incident or potential result. 

• Example: The laceration received by the employee could be the risk or the potential for a finger fracture.
• Team should pick what they perceive as the of higher risk

Quantifying the Risk

To measure the severity of the risk identified, the team will need to determine the following:

What is the likelihood of the incident occurring without putting in place any additional safeguards?

• Remote: You would be surprised if this happened
• Unlikely: Possible, but not likely to happen
• Moderate: Likely to occur, but not frequently
• Likely: If employees exposed to risk daily it is likely to occur several times in a month period
• Extremely Likely: If employees exposed to daily often it is likely to occur at least weekly

What would the severity of the incident be if it occurred without putting in place additional safeguards?

• Minor: Near miss or first aid treatment
• Moderate: Recordable Treatment
• Critical: Lost time injury less than 30 days
• Catastrophic: Death, amputation, or permanent total disability

Determine overall risk rating factoring likelihood and severity together without additional safeguards and utilizing the risk matrix.

When selecting a corrective action, you should follow the Hierarchy of Controls.

• Elimination: Physically remove the hazard, such de-energizing equipment
• Substitution: Replace the hazard
• Engineering Controls: Isolating people from the hazard
• Administrative Controls: Change the way people work
• PPE: Personal protective equipment

Corrective actions shall reduce the risk as low as feasibly possible.

(The table below has examples of appropriate and inappropriate countermeasures)

Appropriate corrective actions will be determined by your assessment of risk.

After determining the corrective action how does this impact overall risk?

• Does it lower probability?
  • For example, if you lock out tag out the electricity, the probability of getting shocked goes from likely to remote.
• Does it lower severity?
  • For example, if by putting on cut resistant gloves, the severity of a cut from sharp material goes from moderate to minor.
• Conduct the Risk Assessment over again with using the Matrix to determine the potential risk with corrective action in place

If corrective action does not lower the risk or get below High, then the corrective action is insufficient, and further investigation is required.

Fishbone Process

• The fishbone can be used as an effective tool for determining root cause(s) of an incident.
• Categories are used to organize thoughts and facilitate brainstorming.
• Identified contributing factors are placed in the category with the theme they are most consistent with.
• The Fishbone Process is used to help identify surface contributors and systemic contributors.
• Not every category is required to be used.

Categories Explained

Below is a list each fishbone category with explanations on what contributing factors should be placed under them.

Human Factors

• Human behavior (e.g., not following policy, feeling rushed)
• Personal factors (e.g., physical limitations, not eaten)
• Experience (e.g., new employee)
• Training (e.g., didn’t understand)

Equipment/Machine

• Equipment or tool involved
• Not adequate (e.g., has tool, but not effective)
• Damaged (e.g., not working as intended)
• Not available (e.g., no tool, missing)

Process

• Unidentified hazards (e.g., missed during assessment)
• Inadequate hazards controls
• Procedures for job (e.g., none; inadequate)
• Training (e.g., inadequate; not finished)
• Wrong tool (e.g., procedures say hammer, but pry bar should be used)

Materials

• Characteristics of material (e.g., weight, temp, shape)
• How material was stored or secured

Environment

• Low staff (e.g., absenteeism)
• Employee Comfort (e.g., harassment?)
• Condition of workplace (e.g., disorganized)
• Workload (e.g., how work is distributed)

Problem

• This is the effect or outcome of the incident (e.g., employee strained a muscle, received a laceration)