Incident Reporting and Investigation Procedure

Investigations involve the systematic collection and analysis of information with the goal of determining the underlying or basic causes of an accident or near miss incident. Once the underlying causes are identified it is then possible to develop reasonable recommendations for change. It is equally important to evaluate any corrective action taken to ensure that it is effective and does in fact create a greater level of safety.

Investigations should be carried out in a manner that focuses on prevention rather than on finding fault or placing blame on an individual. The depth and complexity of an investigation will depend on the particulars of the accident itself.

Investigation Team

In most cases the supervisor/manager responsible for the area, or the work or program activity, is responsible for taking the lead role in the investigation process. Depending on the situation, other individuals may become involved including those directly affected by the accident, witnesses and those with special knowledge or technical expertise (from within or outside Humber). Occupational Health and Safety (OHS) Services will provide assistance upon request.

In the event of a fatal or critical injury, OHS will, in cooperation with the supervisor/manager involved, coordinate the reporting and investigation process to ensure compliance with the specific requirements of the Act and Regulations. A designated union (worker) member(s) of the Joint Health and Safety Committee will also participate in the investigation in keeping with the Act.

Investigation Process

In order to minimize the likelihood of additional injury or property damage and to ensure a systematic approach to investigations, the following steps should be taken:

1. Initial Response
2. Securing and Preserving the Scene
3. Gathering Information
4. Analysis
5. Recommendations and Corrective Action
6. Documentation
7. Evaluation

i. Initial Response

The first consideration in responding to an accident scene is the personal safety of not only the individual(s) directly involved in the occurrence, but also of those responding.

1. The first employee to arrive at the accident scene is to:
   • confirm the area is safe to enter before proceeding
   • contact Public Safety if emergency response is required
   • if necessary, and if trained to do so, provide first aid
   • contact the supervisor/manager for the area if not already present
   • enlist assistance from those in area, as needed (e.g. to place calls)
2. The supervisor/manager shall coordinate the following, requesting assistance as required:
   • ensure medical assistance is obtained as necessary (i.e. emergency response, transport to hospital)
   • stop ongoing hazards (locking out equipment/machinery, roping off an area to prevent access)
3. Public Safety shall:
   • respond to the scene
   • coordinate emergency services (ambulance, fire department, police) by directing them to the scene
   • contact Facilities Management if building systems are affected (i.e. ventilation, electrical and fire and life safety systems, emergency power)
4. Occupational Health and Safety (OHS) Services:
   1. has the authority to shut down/lock-out equipment if it is deemed to present an imminent safety hazard. Whenever possible, this will be done in consultation with the supervisor/manager responsible for the area.
   2. will establish an investigation team as required.

ii. Securing and Preserving the Scene

1. The supervisor/manager responsible for the area shall, in the event of a fatal or critical injury, ensure the incident scene is preserved in accordance with the requirements of the Act. Public Safety will assist as required. 
2. In general when securing an incident scene, the supervisor/manager should do the following:
   • if possible, ensure the scene will not be disturbed until the investigation is complete;
   • if it is necessary to get the incident scene back to operating condition, capture as much information as possible through photographs, sketches and measurements
   • secure materials or equipment that may need to be tested (e.g. suspected malfunctioning equipment or tools, metal fragments, chemical residues)
   • identify all witnesses including injured persons
3. All incidents and near miss incidents are to be reported as outlined in Part A to ensure compliance with all notification and reporting requirements set out in the Occupational Health and Safety Act and Workplace Safety and Insurance Act. 

iii. Gathering Information

1. The supervisor/manager and other members of the investigation team should consider the following sources of information when conducting an incident or near miss investigation:
   • inspection of the incident scene itself: general condition of the work area; the tools and equipment in use at the time of the incident; people, materials and processes involved; environmental conditions; engineering, personal protective equipment and other control measures being used or worn at the time
   • statements from eyewitnesses
   • people with expertise in the work being performed: either from within Humber or outside consultants
   • operating manuals and instructions: often provide recommended procedures for use and maintenance
   • manufacturers and suppliers: may have knowledge about similar events or may have additional engineering or other data not generally found in operating manuals
   • review of workplace policies and procedures to be used in the work area, or related to the operation being undertaken at the time: recommended engineering controls, personal protective equipment, safe work practices etc.
   • training records
   • other records and reports: for example, maintenance schedules and records, warranty information, purchasing history

iv. Analysis

The next step in the process is to analyze the information obtained during the investigation to determine why the incident or near miss incident occurred. In most cases, more than one cause will be determined.

1. The supervisor/manager should first attempt to identify the “immediate causes” that lead to the event. Immediate causes can usually be seen or sensed and are therefore easiest to identify. Examples of immediate causes are listed in Appendix C.
2. Each immediate cause should then be analyzed further to determine the reason behind it. For example, a missing guard (immediate cause) may be the result of inadequate maintenance practices, inadequate equipment standards or lack of awareness and training (basic or underlying causes). Examples of “basic causes” are also listed in Appendix C.

v. Recommendations and Corrective Action

The most important part of the investigation process is the identification of corrective measures to prevent a similar or more serious recurrence. Specific remedial actions should be identified and recommended to address each of the basic causes identified.

1. The supervisor/manager, with assistance from the investigation team, should identify appropriate corrective measures and determine which can be implemented immediately and which may require additional time and resources to implement (i.e. budget, senior administrative approval, expert assistance).
2. The supervisor/manager is responsible for informing affected employees of the corrective actions taken and explaining how the changes may impact their activities.

vi. Documentation

1. The supervisor/manager shall document information related to each step of the investigation process including the specifics of any corrective actions taken and any additional corrective measures recommended to senior management. The Occupational Health and Safety Incident Report is to be used for this purpose. All additional information that cannot be included on the form, such as pictures, sketches and witness statements should be attached to the form.
2. Once completed, the Occupational Health and Safety Incident Report and copies of all additional information shall be submitted to OHS. Copies should also be forwarded to the next most senior management level.

vii. Evaluation

1. The supervisor/manager is responsible for conducting a follow-up assessment of the corrective actions taken to ensure that the measures are effective and that employees are familiar with any new processes or procedures developed.
2. If the corrective action(s) does not appear to be as effective or workable as planned, it will be necessary to consider alternative measures.

Employees

Employees are responsible for:

• contacting Public Safety if emergency response is required
• reporting all injuries and occupational illnesses to their supervisor
• reporting near miss incidents and workplace hazards to their supervisor
• participating in incident investigations upon request
• providing information related to an injury, as required by WSIB, to OHS
• maintaining contact with OHS and their supervisor through the recovery period and cooperating in the return to work process

Supervisors/Managers

Supervisors/managers are responsible for:

• contacting Public Safety if emergency response is required
• ensuring first aid is provided
• reporting and investigating all injuries and near miss incidents
• submitting completed Occupational Health and Safety Incident Reports to OHS
• immediately notifying OHS of all fatal and critical injuries
• preserving the scene of a fatal or critical injury until a Ministry or Labour, Immigration, Training and Skills Developement (MLITSD) inspector advises otherwise
• developing and implementing corrective measures based on findings of investigation
• monitoring corrective measures to determine effectiveness

Public Safety

The Department of Public Safety is responsible for:

• coordinating emergency response and providing first aid, as needed
• helping to secure and preserve scene
• notifying Humber Administration as appropriate (e.g. after hours)
• providing support, assistance and safety recommendations during investigations (non-critical) upon request
• notifying and submitting Public Safety incident reports to OHS 
• advising the Director, Communications of fatal/critical injuries or other significant events
• liaising with the Critical Incident Management Team
• tracking injury information and assessing trends

Student Wellness and Accessibility Centre (SWAC)

The Student Wellness and Accessibiligy Center is responsible for:

• providing first aid, as needed
• completing “Injury Treatment Report” forms and submitting copies to OHS
• maintaining confidential records

Occupational Health and Safety (OHS) Services

OHS is responsible for:

• coordinating all incident and near miss investigations in cooperation with Faculty or Department affected
• maintaining accurate records of incidents and investigations of injuries and near miss incidents
• tracking injury information and assessing trends
• notifying and providing reports to the JOHSC as required by the Act
• where required, reporting the injury or illness to other required external parties, including the WSIB and the MLITSD
• in the event of a critical injury, notifying the MLITSD, the JOHSC and, if the injured person is represented by a union, the appropriate OPSEU Local President or alternate
• liaising with the WSIB and administering/submitting all claims within the required time lines
• coordinating the return to work process in conjunction with the injured employee and their supervisor
• maintaining confidential records

Joint Occupational Health and Safety Committee

The Joint Occupational Health and Safety Committee is responsible for:

• designating one or more union (worker) members to investigate fatal or critical injuries; one of those members has the right to inspect the scene and prepare a report
• making recommendations to management regarding measures to improve health and safety based on participation in investigations and upon review of reports and information received