Incident investigation under OSHA

Scope

Incident investigation is required under OSHA’s Process Safety Management (PSM) Standard at 1910.119(m). Employers covered by the standard must investigate each incident that resulted in, or could reasonably have resulted in, a catastrophic release of highly hazardous chemical in the workplace. The regulation requires employers to start an incident investigation as promptly as possible, but no later than 48 hours after the incident. Employers must:

• Put together an investigation team;
• Prepare a report after the incident and keep it for five years; and
• Create a system to address recommendations and document corrective actions.

Non-PSM facilities

Except in relation to PSM, OSHA does not require employers to perform incident investigations. However, some states do require them, so be sure to understand your particular state laws and regulations. In addition, many insurance companies require you to conduct incident investigations as a condition of your coverage.

OSHA’s voluntary “Safety and Health Program Management Guidelines” recommends that employers “provide for investigation of accidents and near miss incidents, so that their causes and means for preventing repetitions are identified.”

Regulatory citations

• 29 CFR 1910.119 — Process safety management of highly hazardous chemicals (PSM)
• Non-PSM facilities, as a best practice, should still conduct incident investigations whenever warranted.

Key definitions

• Accident: An unplanned event that results in injury, illness, death, and/or property damage.
• Immediate cause: A symptom of an underlying root cause of an incident
• Incident: An unplanned, undesired event that adversely affects completion of a task.
• Near miss: An incident where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have occurred.
• Repeat incident: Any incident that occurs more than once in a workplace.
• Root cause: The true cause of an incident.

Summary of requirements

PSM-covered facilities. Facilities covered by OSHA’s Process Safety Management program must investigate each incident that resulted in, or could reasonably have resulted in a catastrophic release of a highly hazardous chemical in the workplace.

The investigation must take place within 48 hours of the incident.

• Form an incident investigation team: The incident investigation team must be made up of at least one person who understands the proves involved in the incident. This person may be a contract employee if he or she is the person with the appropriate knowledge and experience to thoroughly investigate and analyze the incident.
• Write up a report: OSHA requires PSM-covered facilities to prepare a report at the conclusion of the investigation with the following information:
  • Date of the incident;
  • Date the investigation began;
  • A description of the incident;
  • The factors that contributed to the incident; and
  • Recommendations resulting from the investigation.
• Review the report with all employees whose job tasks are relevant to the incident findings (Include contract employees where applicable.).
• Set up a system to address the hazards: After the investigation, the employer must set up a system to promptly address and resolve the incident report findings and recommendations. Document the resolutions and corrective actions.
• Retain reports and other documentation for five years.

Non-PSM facilities.

• Make a plan (preplanning): Effective incident investigation starts before an incident occurs with the establishment of a well thought-out incident investigation procedure. Preplanning for incident investigation is especially important because the quantity and quality of relevant information begins to diminish immediately following the incident
• Organize your incident investigation team: The incident investigation team should be organized before an incident happens so team members can be trained in incident investigation procedures. Train team members to:
  • Visit the incident scene before the physical evidence is disturbed;
  • Sample unknown spills, vapors, residues, etc., noting conditions that may have affected the sample;
  • Prepare visual aids, such as photographs, field sketches, and other graphical representations to provide data for the investigation;
  • Obtain on-the-spot information from eyewitnesses, if possible;
  • Observe key mechanical equipment as it is disassembled;
  • Review all sources of potentially useful information (e.g., as-built drawings, operating logs, recorder charts, previous reports, procedures, equipment manuals, oral instructions, change-of-design records, design data, employee training records, computer simulations, laboratory tests, etc.);
  • Determine which incident-related items should be preserved; and
  • Document the sources of information contained in the incident report.
• Developing a written plan: At a minimum, a written plan should contain a complete listing of the chain of command, including noting who will:
  • Be in charge of the investigation;
  • Gather physical evidence;
  • Take notes and photographs;
  • Interview witnesses and victims;
  • Prepare the final report; and
  • Receive copies of the final report.
  The written plan should also include:
  • A list of personal protective equipment (PPE) that will be needed; and
  • A list of special transportation or communication needs.
• Assemble an incident investigation kit: Keep the kit in a central location that all supervisors are aware of, such as the office of the safety director. Some examples of basic equipment to assemble include:
  • First aid kit;
  • Barricade tape;
  • Reporting forms;
  • Photography equipment;
  • Tape recorder (for personal notes, not for interviewing purposes);
  • Gloves (both work gloves and surgical gloves);
  • Clipboard and notebook;
  • Tape;
  • Pens and pencils;
  • Chalk and chalk line;
  • Sketching materials;
  • Large envelopes;
  • Measuring tape;
  • Scissors; and
  • Identification tags.
• Mark and label all evidence: Evidence is anything that is real, has substance, and helps to establish the facts of an incident investigation. Physical evidence can be seen, touched, smelled, or tasted; it can be large or small, and it can be in solid, semisolid, or in liquid form. You will also want to label and mark the incident scene itself to warn other employees to stay away from the area while the incident is being investigated.
• Conduct the investigation: Conducting an effective incident investigation will involve the following steps:
  1. Control the scene. Correct any immediate hazards, secure the area, and preserve evidence. You may need to correct hazards such as fallen electrical wires, falling debris, fires, chemical spills, or other physical or health hazards. You may also need to provide PPE, isolating pressurized systems, and emergency lighting to ensure the safety of workers responding to the incident site.
  2. Identify and collect evidence. Take pictures of the scene, take samples of spilled materials, interview witnesses, review health and safety records and training records, and consider operations errors such as unguarded or defective equipment, poor ventilation or lighting, toxic gases, excessive noise, radiation, or floor openings. This step includes taking notes that can help you develop your final incident investigation report.
  3. Determine the root cause(s) of the incident: Review all of your collected evidence and facts surrounding the incident. The root cause is the true cause of the incident. For instance, if an employee is injured in a fall and was not wearing fall protection, the obvious cause of the incident would be the employee not wearing fall protection. However, if you look further, you’d see that the employer did not consistently enforce the company policy requiring fall protection. Therefore, the root cause would be the employer not enforcing the work rule. Other root causes can include lack of training, faulty equipment, failure to maintain equipment, lack of equipment guarding, etc.
  4. Develop corrective actions. Work to reduce or eliminate the chances of another incident occurring. Usually, corrective actions directly address the root cause of the incident For instance, if an employee was injured by falling off a ladder, corrective actions could include eliminating the need to climb the ladder through the use of extender poles or other engineering solution; ensuring that workers know how to properly use ladders and are trained to use them correctly and developing, implementing, and enforcing a safety and health program.
  5. Communicate findings. Report your findings to upper management and other affected departments. In order to effectively communicate the findings of the investigation, provide the following information in the final report:
     • A description of the incident (including date, time and location);
     • The facts determined during the investigation (including chronology as appropriate);
     • A list of the suspected root causes; and
     • The recommendations for corrective and preventive action (including timing and responsibility for completion).
  6. Implement corrective actions. Ensure the corrective actions you’ve developed are actually carried out.