work health and safety practitioner learning guide unit ... · bsbohs508b participate in the...

Work Health and Safety Practitioner

Learning Guide

UNIT BSBOHS508B PARTICIPATE IN THE INVESTIGATION OF

INCIDENTS

January 2012

®

BSBOHS508B PARTICIPATE IN THE INVESTIGATION OF INCIDENTS

Department of Commerce

Published by WorkSafe, PO Box 294, WEST PERTH WA 6872. E-mail: [email protected]

Original Authors: Bryan Russell and Stephen Lynch Reviewed and updated by: Dr Geoff Dell Protocol Safety Management Pty Ltd, PO Box 2069, Taylors Lakes, Vic 3037

® www.worksafe.wa.gov.au/institute

The SafetyLine Institute material has been prepared and published as part of Western Australia’s contribution to national work health and safety skills development.

© 2012 State of Western Australia. All rights reserved. Details of copyright conditions are published at the SafetyLine Institute website.

Before using this publication note should be taken of the Disclaimer, which is published at the SafetyLine Institute website.

PAGE 2 SAFETYLINE INSTITUTE JANUARY 2012

mailto:[email protected]

http://www.worksafe.wa.gov.au/institute


Contents

OVERVIEW ......................................................................................................................6

How to use this learning guide ..............................................................................7

Assessment.............................................................................................................9

Required readings and resources.........................................................................10

Further information .............................................................................................10

Glossary of terms.................................................................................................12

INTRODUCTION..............................................................................................................15

ELEMENT 1: FACILITATE AN INITIAL ASSESSMENT OF THE SITUATION .........................24

1.1 Check area to ensure it is safe and that arrangements have been made to meet initial needs of those involved in the incident ..........................................25

1.2 Establish and maintain integrity of the site and personnel in accordance with legal requirements and to ensure objectivity of information collected ....27

1.3 Identify statutory and legal obligations and, if required, advise relevant government agencies...........................................................................................30

1.4 Notify key persons within the organisation..................................................33

1.5 Determine factors affecting the complexity of the investigation ...............35

1.6 Identify stakeholders and interested parties, and notify as appropriate....42

Case Study 1 ........................................................................................................47

Activity 1..............................................................................................................50

ELEMENT 2: PARTICIPATE IN THE ESTABLISHMENT OF AN INVESTIGATION PROCESS ..51

2.1 Access and understand organisational policies and procedures for incident investigation ........................................................................................................52

2.2 Convene investigation team appropriate to the level of the investigation 56

2.3 Define scope of the investigation taking account of legislative requirements.............................................................................................................................60

2.4 Facilitate involvement of interested parties in accordance with legislative requirements .......................................................................................................63

2.5 Identify and source resources required to conduct the investigation, including the need for expert advice, if required ..............................................67

2.6 Identify and address barriers to investigation .............................................71

2.7 Ensure action plans and time lines are developed by the investigation team.............................................................................................................................78

Case Study 2 ........................................................................................................83

Activity 2..............................................................................................................86

JANUARY 2012 SAFETYLINE INSTITUTE PAGE 3


ELEMENT 3: COLLECT INFORMATION AND DATA FOR ANALYSIS...................................87

3.1 Identify and access sources of information and data ..................................88

3.2 Inspect incident site, equipment and other evidence .................................92

3.3 Facilitate information and data gathered by others ...................................95

3.4 Take and record statements, photographs, measurements and documentary evidence, taking account of objectivity, confidentiality and legal implications.............................................................................................................................98

3.5 Appropriately secure site, evidence and all necessary documentation ....110

3.6 Appropriately involve members of the investigation team .......................112

Case Study 3 ......................................................................................................115

Activity 3............................................................................................................118

ELEMENT 4: ANALYSE INFORMATION AND DATA GATHERED TO IDENTIFY IMMEDIATE AND UNDERLYING CAUSES AND PRACTICAL PREVENTION MEASURES ..........................119

4.1 Ensure the investigation team understands and identifies the conceptual basis for the analysis .........................................................................................120

4.2 Construct time line of events leading up to incident ................................123

4.3 Investigate causal factors............................................................................125

4.4 Identify conditions and circumstances that contributed to the direct causes of the incident ...................................................................................................128

4.5 Identify intervention points on the time line for prevention .....................131

4.6 Identify strategies to prevent the re-occurrence of the incident .............133

Case Study 4 ......................................................................................................140

Activity 4............................................................................................................143

ELEMENT 5: COMPILE AN INVESTIGATION REPORT......................................................144

5.1 Document results of analysis in a format to suit the required target audience and legal requirements ......................................................................145

5.2 Write report objectively, cite the evidence and reasons for conclusions.148

5.3 Include recommendations for prevention in the report ............................152

5.4 Disseminate relevant information and data to key personnel, stakeholders and external agencies as appropriate, following appropriate authorisation....153

5.5 Use findings from the report to develop further prevention strategies .....156

Case Study 5 ......................................................................................................159

Activity 5............................................................................................................160

ON-LINE UNIT TEST QUESTIONS ..................................................................................161

INTEGRATED PROJECT ................................................................................................162




ASSESSMENT ................................................................................................................163

Assessment portfolio from learning guide.........................................................163

Project review check-list ..................................................................................165

Third party (manager/mentor) report ..............................................................166

Skills checklist ...................................................................................................172

Interview questions ...........................................................................................174


OVERVIEW

Welcome to the Unit of Competence BSBOHS508B – Participate in the investigation of incidents. ‘WHS’ and ‘work health and safety’ are used in this guide because following harmonisation of legislation these terms are progressively replacing the use of ‘OHS’ and ‘occupational health and safety’. This unit specifies the outcomes required to participate in the planning, conduct and reporting of incidents which may have resulted in, or have the potential to result in injury to people or damage to property and equipment. The process of investigating why an incident occurred is part of a systematic approach to managing health and safety. The lessons learned from an incident and recommendations developed as a result will when properly implemented, contribute to preventing their recurrence in the future. In this way, the investigation of incidents is part of an organisation’s program for continuous improvement. - In order to participate effectively in the investigation of incidents, you will need to have an understanding of the features and application of WHS management systems, especially the concepts and processes for the effective management of risk. Therefore you are advised to be familiar with the principles in BSBOHS501 Participate in the coordination and maintenance of a systematic approach to managing OHS and BSBOHS504 Apply Principles of OHS Risk Management before commencing this learning guide. The methods described in this learning guide may be applied to straightforward investigations as well as to investigations of complex situations. Similarly, incidents may occur in an organisation of any size and, as such, this guide has application to small, medium or large organisations. The investigation of incidents is a sequential process involving a series of steps. This learning guide takes you through the processes involved in:



conducting an initial assessment of the situation;

establishing the scope and legal parameters of the investigation;

gathering relevant information and data;

conducting a systematic analysis of the information gathered; and

reporting on the outcomes of the investigation. The unit of competence consists of five elements and 30 performance criteria, which are reflected in the format of this learning guide. Each section covers a competency element and each sub-section covers a required performance criterion. You can access a copy of the actual competency unit from: www.training.gov.au

How to use this learning guide It is important that you read the Course Guide before commencing this learning guide, as it contains important information about learning and assessment. It is particularly important to read it if you feel you may already be able to provide evidence that you meet the performance criteria for this unit. You can access the Course Guide at: www.safetyline.wa.gov.au/institute The learning guide is designed to lead you through each of the elements and performance criteria. It introduces you to the key knowledge and information. Competency checks are listed at the end of each element and a case study is given to show how the knowledge would be applied in practice. The case study builds up through each element to show how the process and knowledge is cumulative. The activities at the end of each element tend to mirror the case study and guide you to achieving the performance criteria. Further assessment activities are at the end of the learning guide. Associated readings and resources are listed in the Overview. You may use this learning guide as general reading on the topic but if you are using it to develop and demonstrate competency and you plan to be formally assessed you need to be organised. Some suggestions for getting organised are given below.


http://www.training.gov.au/

http://www.safetyline.wa.gov.au/institute


Make sure you have some study space and create a directory on your computer to keep all the material for this unit of competency together. Have a folder for keeping all your hard copy material together, you may wish to put some dividers in the folder.

You should begin your studies by printing out the learning guide and associated Readings and Resources from the SafetyLine web site.

Now you are ready to tackle the learning guide.

1. Read the Overview. Make notes; use a highlighter; whatever is your way of helping you understand new knowledge.

2. Read the assessment section at the end of the learning

guide so that you have an understanding of what is required of you at the end of your study on this topic.

3. Then start working through each element. Make sure you

read and understand the case study for each element.

4. Work through the activities for each element before you move onto the next element. When working on the activities refer to the case study for an example and also ensure that you address the criteria in the competency checks as appropriate. While the activities are listed separately under each element they are designed to build up into an integrated project which is described at the end of the learning guide. Also, you should clearly reference your work with full citations for any quotes or references, and list all materials that provided background information for completion of an activity.

5. Understanding terminology is a key part of your learning; the glossary will help you here. As you work through the elements and do some extra reading you may wish to expand the glossary with additional words and their definitions.



6. You should also collect any examples of your work that

enable you to demonstrate competency in any of the elements or performance criteria. This may be memos, reports you have written, training programs written or delivered, other notes and supporting information that demonstrate the necessary knowledge and understanding. This information should be collated in a folder under the appropriate element and performance criteria. For any key reports, training material, etc you should, where possible, obtain a statement from the workplace that it was your own work or, if you worked in a team, your role in the team and your contribution to the activity.

When collecting material for your assessment portfolio, please ensure that you protect the confidentiality of colleagues, workers and other persons, and block out any sensitive information. If you have any doubts about confidentiality issues, contact the organisation concerned.

Assessment Assessment is the process of checking your competence to perform to the standard detailed in each element’s performance criteria. At the end of each element of the learning guide are activities designed to enable you to collect evidence for assessment. They are also listed in the assessment section at the back of the guide. While access to an actual workplace is desirable, part of the assessment may be through simulated project activity, scenarios, case studies, role-plays or actual activities associated with the investigation of an incident. Where possible you should have a WHS professional as a mentor or coach to assist you to develop the practical skills to apply your knowledge. The case studies in this learning guide will enable your mentor or coach to take you through a workplace example of the whole element to show you how to achieve the performance criteria and apply the required knowledge and skills. When you have completed this learning guide you should contact a participating training provider (see



www.safetyline.wa.gov.au/institute) who will, for a fee, be able to have your competency in this unit assessed by a qualified assessor and subject expert. When collecting material for your assessment portfolio, please ensure that you protect the confidentiality of colleagues, workers and other persons, and block out any sensitive information. If you have any doubts about confidentiality issues, contact the organisation concerned.

Required readings and resources The on-line Readings and Resources section at the SafetyLine Institute web site provides additional essential material to help you understand and complete the activities in this learning guide.

Further information Each WHS jurisdiction in Australia has an Internet site to allow easy access to relevant WHS legislation and information. In some jurisdictions mining and petroleum safety is administered by a separate government authority, each with its own web site. Other web sites that may be of interest are: www.safeworkaustralia.gov.au – Safe Work Australia: national

government work health and safety body

www.comcare.gov.au –Commonwealth workplace safety, rehabilitation and compensation Regulator

www.amsa.gov.au – Australian Maritime Safety Authority - maritime safety Regulator

www.arpansa.gov.au – Australian Radiation Protection and Nuclear Safety Agency - nuclear and radiation safety Regulator

www.atsb.gov.au – National Independent Transport Accident Investigator - air safety, rail safety and marine safety investigation

www.nopsa.gov.au – national offshore petroleum safety authority - oil and gas safety Regulator

www.seacare.gov.au – Seacare Authority Australian seafarer’s work health and safety authority

www.austlii.edu.au – Australian Legal Information Institute for Commonwealth, state and territory work health and safety acts and regulations

www.standards.com.au – the Australian standards organisation



http://www.safeworkaustralia.gov.au/

http://www.comcare.gov.au/

http://www.amsa.gov.au/

http://www.arpansa.gov.au/

http://www.atsb.gov.au/

http://www.nopsa.gov.au/

http://www.seacare.gov.au/

http://www.austlii.edu.au/

http://www.standards.com.au/


www.saiglobal.com – for copies of Australian and international standards and codes

ohs.anu.edu.au – Australian National University’s National Research Centre for OHS Regulation

Other reference material, if desired

Kase, D.W. and Wiese, K.J. (1990). Safety Auditing – A Management Tool. New York, John Wiley and Sons.

Heilbron, G., et al. (2008) Introducing the Law 6th ed. Sydney, CCH.

Standards Australia, AS/NZS 4804:2001. Occupational health and safety management systems – General guidelines on principles, systems and supporting techniques, Sydney, Standards Australia.

Taylor, G.A., Easter, K.M., and Hegney, R.P. (2004) Enhancing Safety – A Workplace Guide, Chapter 5 Accident Prevention, Perth, West 1.

Hopkins A. (2001) Safety Culture and Risk (CCH).

Hopkins A (2002) Lessons from Longford: The Esso Gas Plant Explosion,,CCH.

Hopkins A. (1999) Making Safety Work – Getting Management Commitment to OHS; Sydney, Allen & Unwin.

Kletz T. (2001), Learning from Accidents, Oxford, Butterworth-Heinemann

ATSB (2010), Civil and Military Aircraft Accident Procedures for Police Officers and Emergency Services Personnel, Australian Transport Safety Bureau, Canberra, http://www.atsb.gov.au/media/1578568/civil&militaryaccidguide_v5.pdf

There are also a range of relevant working papers which may also be of interest to WHS practitioners at the National Research Centre for OHS Regulation website http://ohs.anu.edu.au/publications/index.php.

Your feedback We are committed to continuous improvement. If you take the time to complete the on-line Feedback Form at the SafetyLine Institute web site you will help us to maintain and improve our high standards. You can provide feedback at any time while you are completing this learning guide.


http://www.saiglobal.com/

http://ohs.anu.edu.au/

http://ohs.anu.edu.au/publications/index.php


Glossary of terms Make sure that you are familiar with the Glossary of terms before going any further. When they are first used, glossary terms are indicated with an asterisk*

Causative event The key event resulting in the particular outcome of injury or damage.

Condition A permanent workplace situation such as the type of equipment or workplace layout.

Circumstance A short-term situation which is relatively unusual eg a storm or when a key person is absent.

Hazard Hazard, in relation to a person, means anything that may result in injury to the person or harm to the health of the person.

Incident a) Unplanned consequence of events, or a missing or inappropriate response.

b) Any occurrence/event arising out of and in the course of employment which results in personal or property damage.

Incident site preservation

In the event of a notifiable incident, it is the responsibility of the person with management or control of the workplace to ensure, so far as is reasonably practicable, that the site (including any plant, substance, structure or thing associated with the incident) is not disturbed until an inspector arrives or otherwise directs.

Investigation A systematic process of gathering and analysing information to identify the cause(s) of an incident.



Jurisdiction

Geographic area or division of industry or the community in which government has the power and authority to administer and apply certain laws.

SDS A Safety Data Sheet (SDS) contains critical information about the health effects and appropriate control measures for chemicals used in workplaces.

Near miss A situation where no one is injured or damaged, but this could have been the case.

Person Conducting a Business or Undertaking

(PCBU)

A person conducts a business or undertaking: (a) whether the person conducts the business or undertaking alone or with others; and

(b) whether or not the business or undertaking is conducted for profit or gain.

Plant Includes any machinery, equipment, appliance, implement or tool and any component, fitting or accessory.

Root Cause The actions or deficiencies which allowed the direct cause to exist. These are usually the underlying causes of an incident.

Root Cause Analysis

A quality tool applying a multiple “why?” analysis, which is directed at identifying all causes responsible for an incident.



Worker A person who carries out work in any capacity for a PCBU as: (a) a worker; or (b) a contractor or subcontractor; or (c) a worker of a contractor; or subcontractor; or (d) a worker of a labour hire company who has been assigned to work in the person's business or undertaking; or (e) an outworker; or (f) an apprentice or trainee; or (g) a student gaining work experience; or (h) a volunteer; or (i) a person of a prescribed class.

NOTE: A PCBU can also be a worker if they carry out work in the business or undertaking



INTRODUCTION

Incidents, cases of ill health, dangerous occurrences, near misses and property damage can have high human and financial costs. They can have a significant impact on the lives of individuals and may even threaten the viability of some organisations. It is vital that the person in charge of the business or undertaking (PCBU)* puts in place arrangements to identify, record and investigate incidents that occur. In the case of larger organisations these arrangements should be documented as procedures and policies which are integral to the organisation’s health and safety management system. Smaller organisations may need to engage the services of an experienced investigator to assist with their investigations to ensure all the lessons are learned and corrective actions identified. The purpose of investigating workplace incidents is to ascertain both the immediate and underlying causes and to put in place measures to prevent a re-occurrence. The process of investigation involves a systematic examination of the circumstances of the incident, the workplace, activities taking place at the time, plant and equipment in use at the time, and any supporting materials such as existing risk assessment and control standards as well as legal obligations. Incidents need to be examined in sufficient detail so that immediate causes and the underlying failures of systems for managing health and safety have been identified. This process may result in the need for immediate remedial action as well as longer-term changes. The type and depth of any investigation that you undertake will be guided by the significance of the incident. An important consideration is not only the actual consequences of the incident but also the potential outcome. A “near miss” by way of example may not result in any injury or damage. However, if that near miss had the potential to injure people severely or damage property significantly, then a detailed investigation would be warranted. The information outlined in this learning guide is based on the need to conduct an investigation into a significant workplace incident. The principles outlined may also be applied to the investigation of more minor incidents.



Background A good understanding of laws applicable to work health and safety (WHS) is important to participate effectively in the investigation of workplace incidents.

Commonwealth, state and territory legislation

Because Australia is a federation, WHS is the responsibility of the states and territories. However, Commonwealth law covers the WHS of Commonwealth workers and certain categories of workers, such as those on Australian registered ships and on offshore drilling rigs in Commonwealth controlled areas. In some states WHS law is divided further into coverage of mining operations and mineral processing plants, petroleum facilities and other workplaces, with in some cases separate or partly separate administrative authorities as for example in Western Australia. New South Wales and Queensland also have had mines safety legislation separate from that for general workplaces, and the administration of that legislation lies with separate government authorities. In most states and territories there is also separate legislation covering dangerous goods that applies generally in all workplaces. Other important pieces of legislation relating to WHS are radiation safety legislation and energy safety legislation, for example electrical safety legislation, which again applies generally to all workplaces. Safety in marine activities is also covered by separate state legislation, but generally the WHS legislation covering most workplaces also applies. Most aspects of aviation safety are covered by Commonwealth aviation safety legislation.

Workers’ compensation legislation

In most jurisdictions there is an interrelationship between WHS legislation and workers’ compensation legislation. This is particularly the case for provisions relating to the notification of accidents and reporting requirements for incidents. Statistics on state and national injury trends are compiled from workers’ compensation statistics that must be reported under workers’ compensation legislation.



Equal opportunity and industrial relations

Other pieces of legislation which may have an impact on WHS include equal opportunity legislation and industrial relations legislation. For example, some types of work with chemicals may impact on an unborn foetus, and hence have implications for equal opportunity in employment. Issues such as working hours and shift work, which have implications for WHS, may be dealt with under industrial relations legislation.

Common law “Duty of Care”

There is a body of law known as the common law, because it has been built up over the centuries by the decisions of the various courts when individuals have sued for negligence. One key tenet of the common law is of particular significance for WHS as it has been incorporated into WHS Acts as statute law. It is called the “general duty of care”, and one key aspect of this general duty is the PCBU’s duty to a worker. In its uptake into the WHS Statutes, the general duty has been interpreted as a duty to protect the worker’s health and safety; to not cause the worker harm.

Statute Law and WHS

Work health and safety legislation forms part of the law which is known as statute law, because it is written down in statutes or Acts passed by Parliament. The following is a brief background on the development of the modern OHS legislation in Australia which forms part of the Statute Law. Prior to the 1980s, WHS legislation was very detailed containing highly prescriptive requirements based mainly on manufacturing and construction activities.




Then the 1980s was a period in which significant reforms were made in most states and territories, mainly in response to the 1972 report of the UK Committee of Inquiry into Safety and Health at Work, chaired by Lord Robens1, that favoured a work health and safety system based on the general duty of care, capable of addressing safety in all workplaces and supported by consultative obligations and codes of practice. Accordingly, modern WHS legislation is based on an expectation that organisations will have systems in place for identifying and managing the risks that may arise from their undertakings and PCBUs have the general “duty of care” to not cause harm to their workers and others who may enter or otherwise be affected by their workplace activities. This systematic approach has been increasingly reflected in WHS legislation throughout Australia and overseas. While the Robens approach and general duty of care remain key features of Australian WHS legislation, the regulation of safety and health continues to evolve in response to changing socio-economic conditions. Technology, work methods and workplace arrangements have changed rapidly in the past two decades. The nature of work, industrial relations and employment relationships have also changed substantially. Regulators throughout Australia are faced with the challenge of reviewing and amending WHS legislation to ensure that it remains current and relevant to new working arrangements, such as labour hire and a move to casual, part time and sub-contract relationships. Further changes will take effect in most States from January 1, 2012 as new common “harmonised” WHS legislation is enacted across Australia. However, the new legislation will still encapsulate the principles of the Robens style legislation and maintain the current three-tiered structure consisting of a WHS Act, the Regulations and codes of practice.

1 Robens Lord (1972) Safety and Health at Work: The report of the Robens Committee. Cmnd 5034, HMSO, LOndon


The WHS Act imposes the broad general duties on a range of workplace participants including PCBUs, self employed persons, occupiers/controllers of workplaces, manufacturers, suppliers and designers of plant and workers. The Regulations provide greater detail by outlining specific measures which must apply in certain circumstances. Codes of practice provide practical guidance on how to achieve particular outcomes. The Act and Regulations are both enforceable, the Codes of practice are not, yet they do provide a benchmark against which the arrangements and performance of organisations and individuals can be tested by the Courts, if the organisations’ or individuals’ own arrangements have been found to be wanting. WHS practitioners must ensure that they have a sound understanding of these legislative bases for systematically managing health and safety; and that they are familiar with changes which occur in the various pieces of legislation.

Required WHS knowledge and understanding

The Activities at the end of each element will guide you to achieve the performance criteria. However, you will also need to acquire and demonstrate the necessary knowledge and understanding of the key principles which underpin a WHS investigation. Therefore, you should include relevant notes and supporting evidence in your assessment portfolio and ensure you can explain:

roles and responsibilities under WHS legislation, of PCBUs and workers including supervisors and contractors;

legislative requirements for collection and retention of WHS information, WHS related data

workplace consultation requirements;

rights of WHS inspectors

requirements for record keeping that addresses WHS, privacy and other legislation;

state/territory/Commonwealth WHS legislation and links to other relevant legislation such as industrial relations, equal employment opportunity, workers’ compensation, etc;

structure and forms of legislation including regulations, codes of practice, associated standards and guidance material;



concept of common law duty of care;

methods of providing evidence of compliance with WHS legislation;

principles and practices of continuity and validity of evidence retention, which are related to potential legal action;

requirements for reporting under WHS and other relevant legislation, including obligations for notification and reporting of incidents;

requirements under hazard-specific WHS legislation and codes of practice, such as dangerous goods legislation;

basic principles of incident causation and injury processes;

hazard types, their characteristics, modes of action and units of measurement ;

hierarchy of control and considerations for choosing between different control measures, such as possible inadequacies of particular control measures;

standard industry controls for a range of hazards;

principles and practices of systematic approaches to managing WHS;

internal and external sources of WHS information and data;

how the characteristics and composition of the workforce impact on risk and the systematic approach to managing WHS eg, labour market changes, structure and organisation of workforce (eg part-time, casual and contract workers, shift rosters, geographical location, language, literacy and numeracy, communication skills, cultural background/workplace diversity, gender, workers with special needs);

ethics as related to professional practice of WHS;

knowledge of organisational policies and procedures relating to workplace processes;

nature of workplace processes (including workflow, planning and control) and the related hazards;

formal and informal communication and consultation processes and key personnel related to communication;

language, literacy and cultural profile of the workplace; and

organisational culture as it impacts on the workplace.



As you work through the Activities, also include in your assessment portfolio any reports and memos asked for and any relevant documents you collect – such as a copy of a code of practice or part of one which enabled you to complete an Activity.

Required skills and attributes You will also need to show you have the necessary skills and attributes for this unit of competency. To do this, you should include in your assessment portfolio as much evidence as possible to show you can:

relate to people from a range of social, cultural, and ethnic backgrounds and physical and mental abilities;

communicate effectively with people at all levels of the organisation and with WHS and other specialists;

prepare reports for a range of target groups including the health and safety committee, health and safety representatives, managers and supervisors;

manage your own tasks within an agreed time frame;

employ effective consultation and negotiation skills;

analyse relevant WHS information and data, and make observations of workplace* tasks and interactions between people, their activities, equipment, environment and systems in order to meet requirements of WHS legislation;

use basic computer and information technology skills to access internal and external information and data on WHS; and

demonstrate attention to detail when making observations and recording outcomes.

Incident investigation − background information The following information is provided to assist you in understanding the overall approach that is adopted in this learning guide. This preliminary information will give you a broad picture of the component parts of an investigation* and how they will appear in this guide.



At the most basic level, there are three stages to the process of investigating incidents. These are: Stage One: Pre Investigation Stage Two: Investigation Stage Three: Post Investigation The activities undertaken in each phase and the corresponding competency elements within this learning guide are outlined on the following page.

Stage Activity Element of Competency

1: Pre investigation:

(a) the first response to an incident, prior to commencing the investigation, is the emergency response phase where any people who may have been injured are cared for

(b) securing the site ; (c) protecting evidence and (d) conducting notifications

and reporting to relevant agencies and others as appropriate.

The pre investigation stage is covered in Element 1.

2: Investigation:

(a) form an investigation

team; (b) collect information; and (c) analyse information.

Covered in Element 2. Covered in Element 3. Covered in Element 4.

3. Post investigation

(a) prepare findings; (b) compile report; and (c) take corrective actions.

Covered in Element 5.

Table 1: Overview of Investigation Stages

Severity of an incident

You will find that there are several references throughout this guide to the “severity” of an incident. The severity of the incident will usually determine the level of response, including the scale of an investigation which may be undertaken. For the purpose of this guide it is assumed that the nature of incidents to be investigated will be sufficiently serious and complex to warrant a detailed



investigation. WHS practitioners may from time to time be required to conduct detailed investigations. It may be helpful to be aware of the process applied by WHS regulators when assessing the severity of incidents. Keep in mind that this will vary from one jurisdiction to another, but a typical model applied by regulators is as follows: Category A Incidents − Fatalities and serious matters 1. Fatalities. 2. Serious matters of public concern. These include:

- high potential for a fatal incident; - serious injuries; - serious incidents which place a number of people at

risk; - repeat serious offences; and - matters of political or community sensitivity (eg,

asbestos). Category B Incidents − Breaches of Legislation All matters involving a serious breach of WHS legislation. Category C Incidents − Compliance investigations These matters generally arise from the suspected presence of particular hazards and possible breaches of legislation. Regulatory authorities will process information they receive from complaints or reports (notifications). They categorise the information using a model similar to that above and respond accordingly. Category A incidents will be actioned immediately and may involve a formal investigation. Category B and C incidents will be prioritised according to information and resource availability. They may not involve attendance by the regulator but if they do, they generally result in “on the spot” action such as issuing a notice requiring the PCBU to take action to control the risk.



Element 1: FACILITATE AN INITIAL ASSESSMENT OF THE SITUATION

The investigation of workplace incidents involves a logical sequence of actions designed to:

establish the facts;

determine the causes; and

develop corrective actions. Each of the elements of competency in this learning guide is directed towards these outcomes. This element of competency deals with the first stage of the investigation process. This involves an assessment of the situation to ensure that the area is safe and secured. Normally an incident investigation will not commence until the emergency response phase has been completed and the people involved cared for if required. In order to complete this first element of the competency unit successfully, you will need to show that you have met the following performance criteria: 1.1 Check area to ensure it is safe and that arrangements have already been made to meet initial needs of those involved in the incident. 1.2 Establish and maintain integrity of the site and personnel in accordance with legal requirements and to ensure objectivity of information collected. 1.3 Identify statutory and legal obligations and, if required, advise relevant government agencies. 1.4 Notify key persons within the organisation. 1.5 Determine factors affecting the complexity of the investigation. 1.6 Identify key stakeholders and interested parties, such as the coroner, police, WHS or other relevant regulatory agencies and notify as appropriate.



After completing this element of competency you will be able to respond to a workplace incident and assess the situation in an ordered and logical way. This action will lay the groundwork for the investigation. Remember the purpose of the investigation is to establish the causes of the incident and to develop recommendations for preventing similar incidents recurring. Your initial observations may be vital to achieving this and therefore you must view the scene thoroughly and objectively.

1.1 CHECK AREA TO ENSURE IT IS SAFE AND THAT ARRANGEMENTS HAVE BEEN MADE TO MEET INITIAL NEEDS OF THOSE INVOLVED IN THE INCIDENT A workplace incident can mean that any one or all of the following has occurred:

people have been injured or made unwell by a work activity or event;

people could have been injured or made unwell by a work activity or event. This is referred to as a “near miss”*; and

equipment has been damaged or could have been damaged and, as a consequence, people are exposed to the risk of harm.

Check the area and confirm people involved have been taken care of The first responsibility when responding to a workplace incident is to check the area and provide help where needed. The following approach should apply.



What to do in the first response and emergency phase

Assess the situation to ensure your own safety. You will be of little help to others if you are also injured. In some workplace incidents the number and nature of injuries has worsened because people with the best of intentions failed to assess existing hazards and potential risks properly.

Example In NSW a worker entering a confined space in an abattoir was overcome with toxic fumes. Two workers died in attempting to come to the first worker’s aid.

Once you are satisfied that the areas is safe, provide first aid if it is in your capability and summon help.

How do you make sure the area is safe?

The process of checking the area involves visually observing the scene and assessing the situation. Where possible you should also ask others in the area if there are any - hazards present they are aware of which may present a risk to health and safety. Things to look for include the following.

The presence of plant or equipment. Have people been hurt (or could have been hurt) because of the operation of any machinery? If so, and if practicable, people need to be moved away from operating machinery and the equipment turned off.

The presence of substances. Are any substances present and if so have these contributed to the incident? If this is the case, the risk of immediate/further exposure to the substance should be controlled as far as practicable, and people and the substances separated to minimise the risk of further injury.

The presence of particular hazards such as electricity or fire and explosion. These need to be identified quickly and measures put in place to ensure that they do not represent continuing risks to workers and others. If electricity is involved, ensure the supply is turned off before touching anything, including any apparent victims of the incident.



At the completion of the emergency response, it is important to record the names and if possible the contact details of the people who have been harmed or injured. A record should be kept as to where the people involved are going to be situated after the emergency phase is complete, such as if transported by ambulance, which hospital they were being transported to and their permanent home address. These records will ensure appropriate follow up action can be carried out and subsequently the investigators will be able to make contact with them to pursue their enquiries as necessary.

Summary To meet this performance criterion you will need to demonstrate that you have:

- assessed and responded to any risks to yourself and others;

- ensured injured people have been attended to; - identified and addressed immediate hazards and risks, and

- ensured names, addresses and contact details of those involved have been obtained

1.2 ESTABLISH AND MAINTAIN INTEGRITY OF THE SITE AND PERSONNEL IN ACCORDANCE WITH LEGAL REQUIREMENTS AND TO ENSURE OBJECTIVITY OF INFORMATION COLLECTED Once the area has been checked and the emergency response phase is complete, the investigation phase can begin. It is necessary to firstly confirm that the integrity of the site has been protected and safety of personnel, including yourself, is established and maintained. This requires that the site not only has to be safe, but should also be secured to avoid possible alterations to the scene. This must be done because:



The type of incident may be one that is subject to a legal requirement to notify the WHS authority. If so, an investigation conducted by the regulator may follow. The model Work Health and Safety (WHS) Act requires that a person conducting a business or undertaking must notify the regulator of any notifiable incidents that arise out of the conduct of the business or undertaking. A notifiable incident is an incident involving the death of a person, serious injury or illness of a person or a dangerous incident.

In the event of a notifiable incident, it is the responsibility of the person with management or control of the workplace to ensure, so far as is reasonably practicable, that the site (including any plant, substance, structure or thing associated with the incident) is not disturbed until an inspector arrives or otherwise directs. This does not prevent the person taking any action to assist an injured person, remove a deceased person, take action that is essential to make the site safe or to minimise the risk of a further notifiable incident occurring, or any action associated with a police investigation or action for which an inspector or the regulator has given permission. The primary purpose of incident notification is to enable the regulator to investigate serious incidences and potential contraventions of the model WHS Act as soon as possible.

In the case of fatalities, the scene of the incident usually falls under the jurisdiction of the State Coroner who will require that an investigation be conducted in anticipation of a future Coronial Inquest. Normally, the Coroners’ representatives at the site of the incident will be the Police.

There may be other regulatory authorities, such as the Australian Transportation Safety Bureau if the incident involves and aircraft or train, who may, depending on the circumstances, also have jurisdiction and wish to commence an investigation

Evidence must be preserved in order to ensure that the gathering of information is not complicated by unnecessary alterations to the scene. Retaining the incident scene as close as possible to what it was at the time of the incident helps the investigator to gain an understanding of the circumstances at the time of the event and minimises the chance that critical evidence which may lead to understanding causation becomes obliterated, removed, disturbed or otherwise unintentionally tampered with.



Secure the site In securing the site, the following actions need to be taken:

Close off the area. The area is to be physically barricaded or marked as a “no go” zone. This can be done using barriers or special purpose “hazard” tape. You need to make sure that you have not created any new hazards in this process. For example, by blocking off the area are you forcing people into an area which is also unsafe?

Relevant personnel are identified. Witnesses and others who may be able to assist in describing the events that led to the incident, or who may have any relevant information must be identified and their details recorded.

Evidence is protected. Ensure that any items of plant, substances or work procedures are secured. This is done to prevent evidence from being removed or altered. Where relevant it may be necessary to identify samples of equipment and substances that could have a bearing on the investigation. However, it is important that such evidence is not disturbed:

o Until it has been fully photographed in situ; and o where a formal investigation is to be conducted by

a regulatory authority, until the investigating officer in charge of that investigation has given approval for such samples to be collected.

It is necessary to note here that if the samples being collected may be later submitted as evidence in a Court case, proof of the continuity of evidence must be maintained from the accident scene, through all processing and handling stages, until it is presented into evidence in Court. In other words, it will be necessary to demonstrate beyond reasonable doubt, that the samples taken from the scene are the same ones presented in the Court.

Conditions are observed and noted. This may include a notation of any obvious damage to plant, equipment or premises as well as underlying environmental conditions such as temperature, wind, dust or odours.



Remember: Site integrity is a preliminary action. Keeping the site free of alteration will assist the investigation process. If the site conditions can be preserved as closely as possible to the conditions that prevailed at the time of the incident, the investigation team will be better positioned to understand what occurred.

1.3 IDENTIFY STATUTORY AND LEGAL OBLIGATIONS AND, IF REQUIRED, ADVISE RELEVANT GOVERNMENT AGENCIES

You need to establish which laws apply to the workplace where the incident occurred. For example, if the incident occurs on a mine site, specific health and safety laws may apply which will vary depending on the jurisdiction. The first step is to identify the jurisdiction.

Identify the jurisdiction In order to find out the WHS and other legal requirements applying to an organisation, including following an incident, you need to identify whether the organisation's workplace in question is covered by state, territory or Commonwealth WHS legislation. If it is not a Commonwealth government organisation or does not fall under Commonwealth WHS law for seafarers, offshore workers, then you can assume it will be covered by state-based WHS legislation. However, in New South Wales, Queensland or Western Australia you will need to identify if it is a mining or non-mining workplace. If it is a mine, separate legislative provisions will apply. Once you have done this, you can identify the particular legislation (eg WHS Act or Mine Safety Act) that applies to the workplace. Legislative instruments can be obtained in hard copy or via the Internet (see the relevant links given earlier in the Further Information section). The legislation establishes the parameters within which workplaces operate.



As a WHS practitioner, it is expected that you will have access to copies of relevant health and safety legislation. Part of the required knowledge for this unit is an understanding of WHS legislation in Australia. This includes an understanding that the regulatory framework consists of an Act, the Regulations and codes of practice. You also require an understanding of the fundamental duty of care principles, which are embodied in WHS legislation throughout Australia. All jurisdictions provide information and guidance on duty of care requirements as well as hazard-specific information and you should access this information as a preliminary step in the investigation process.

Notifying the authorities The Model legislation requires that certain injuries/diseases and incidents need to be notified to a regulatory authority. Those requiring notification tend to be of a more serious nature and where these occur the regulatory authority may undertake its own investigation, which will be conducted by an inspector of the authority. To assist in determining what type of incident must be notified, ‘serious injury or illness’ and ‘dangerous incident’ are defined in the model WHS Act. A serious injury or illness is one that requires a person to have: medical treatment within 48 hours of exposure to a substance, immediate treatment as an in-patient in a hospital, or immediate treatment for a serious injury or illness such as a serious head injury, a serious burn or a spinal injury and a number of other injuries listed in the model WHS Act. Importantly, it does not matter whether a person actually received the treatment referred to in this definition, just that the injury or illness could reasonably be considered to warrant such treatment. A dangerous incident is an incident in a workplace that exposes a worker or any other person to a serious risk to their health or safety emanating from an immediate or imminent exposure to a number of risks. These risks include an uncontrolled escape, spillage or leakage of a substance, an electric shock, a fall from a height or the collapse of a structure. As noted earlier, there are legal obligations to ensure the integrity of the scene. In these cases, the incident scene must not be altered or changed (other than to protect human life) pending an investigation by the regulatory authority.



You need to check the legislative requirements for the notification of incidents and identify the incident site preservation provisions in the jurisdiction that applies to your particular workplace.

If a serious incident occurs, resulting in the loss of life, the police must also be notified. The reason for this is that any fatal accident will be the subject of a coronial inquiry. This falls within the domain of the police. Notifying the police is in addition to notifying the WHS authority. The nature of the incident may be such that it is also necessary to notify other government agencies. Environment protection agencies may need to be involved if hazardous or toxic substances are released into the atmosphere or waterways. You can expect that the regulator will investigate the more serious workplace incidents. When assisting the regulatory authorities in conducting an investigation you need to be aware of the powers of inspectors.

Powers of an inspector WHS inspectors have very wide-ranging powers and can enter any workplace at any reasonable time for the purposes of conducting an inspection. In the course of a regulatory authority conducting an investigation, you are legally required to cooperate with the inspector such as by ensuring that all relevant facts are provided to the inspector. There are heavy penalties for failing to cooperate with an inspector.



Summary In commencing your investigation you need to be clear about the legal obligations with respect to reporting and notifying. These are outlined as follows: Establish legislative jurisdiction. Identify WHO you need to report to ie, the WHS regulator, the mining industry regulator, a commonwealth authority, and the Coroner, usually via the Police, if a fatality has occurred. Notify the regulator where required. Be clear about WHAT you are required to do - check the relevant legislation. However, as a rule of thumb, if it is a serious incident, providing prompt notification to the regulatory authority is a legal requirement. Cooperate fully with any official investigation. Contact relevant agencies. In certain situations you may need to contact other agencies such as the police, emergency services and/or environmental agencies.

1.4 NOTIFY KEY PERSONS WITHIN THE ORGANISATION The process of notifying people within an organisation will depend upon the nature of the incident being investigated. The reporting chain will largely be a function of the significance of the incident. It is useful in this context to consider what incidents need to be investigated.

What should be investigated? Organisational policy should require that all incidents including significant near misses be investigated. The investigation should commence as soon as possible after the incident occurs.



Relatively minor incidents such as a person tripping in a cluttered walkway may be investigated and resolved quickly within the immediate work area, involving workplace health and safety representatives and supervisors.

Who needs to be notified? The immediate supervisor or line manager should investigate each incident. Accordingly, these people need to be involved very early in the process. The exact reporting line will vary on a case-by-case basis and the organisation’s procedures should clarify this. However, those who should be notified of a workplace incident: are:

Supervisors ie, those people with responsibility for the work area involved.

Health and safety representatives and/or safety committees. Workplace safety representative should be advised as soon as possible, so they may participate in the investigations.

WHS Professionals. Some organisations will employ WHS Professionals, or your may be in that role. Often that person will be responsible for leading complex in-house investigations. Where this is the case, the WHS Professional should be informed promptly.

Senior managers. As noted above, depending upon the severity of the incident, senior managers will need to be advised.

Organisational legal advisers. In cases where people have been seriously injured and/or if regulatory authorities have been notified, it may be necessary to inform the organisation’s legal advisers. However, this may be a decision retained by senior management who may notify the company’s legal counsel once they themselves have been notified.

Workgroup members. These people may be part of a work team or work group and although they may not have been directly affected by the incident, it may impact on their work routine and they do need to be informed about the occurrence.




Employee assistance personnel. In situations where the incident has resulted in traumatic injuries and/or people have been or have the potential to be distressed by the incident, any employee assistance personnel should also be notified.

External contractors or specialists. Incidents may involve external contractors either directly or indirectly. If the incident involves the staff of a contractor/s, the contractor/s will need to be notified as soon as possible. If the contractors are suppliers of equipment or services that was either involved in the incident or requires the expertise of the contractor, they may also need to be notified.

Trade union representatives. In West Australia, if any worker involved in an accident at a mine is a member of a trade union, then a representative of that trade union is entitled to examine the place where the accident occurred. Accordingly, in those cases, a representative of the relevant trade union must be notified2 The Model WHS Act provides authorised union officials with a right of entry, for specific reasons, to workplaces where there are ‘relevant workers’. A ‘relevant worker’ is a worker who is a member, or eligible to be a member of the union which the permit holder represents, whose industrial interests the relevant union is entitled to represent and who works at that workplace. A work health and safety entry permit holder is not required to give prior notice when entering a workplace to enquire into a suspected contravention of the model WHS Act.

1.5 DETERMINE FACTORS AFFECTING THE COMPLEXITY OF THE INVESTIGATION Incidents may range from being quite straightforward occurrences, where the causes are obvious and the outcomes minimal, to very complex events involving a number of parties and a range of issues. As part of a team you will be required to identify and address particular factors that may influence the complexity of the investigation. It is helpful to group these factors into three broad categories:

2 DOCEP WA 2006, Guideline: Accident and incident reporting, http://www.dmp.wa.gov.au/documents/Guidelines/MSH_G_AccidentIncidentReporting.pdf


the incident scene, including the nature of the hazards and risks involved;

the people; and

legal and administrative issues.

The incident scene In examining the scene of the incident consider:

Location. The location of the incident may have a bearing on the complexity of the investigation. This is particularly so if the incident has occurred in a geographically remote area or one which has limited or particularly difficult access. Access to emergency services and by investigators will be limited and will require a higher level of planning and coordination. Environmental conditions such as terrain, temperature and wind may be related factors that impose limitations on the investigation process. When considering “location” you should not only consider isolated locations. Densely populated areas, with high volumes of people and/or plant and equipment passing through an incident site will add their own complications.

Secondary hazards. Are there any secondary hazards arising from the incident? This requires an immediate assessment by the investigator to ensure that the incident has not created additional hazards which put people at risk. One high profile example was the Air New Zealand DC-10 accident site on Mount Erebus in Antartica, where the site was located in a remote hostile environment which included crevasses in the ice within the accident site. Perhaps a more common example is the release of chemicals which may expose people to hazardous chemicals or toxic fumes, or perhaps machinery which has been rendered unsafe by an incident. Secondary hazards will require additional control measures and as such can add an extra and more difficult dimension to the investigation process.



Type of hazards. What is the nature of hazards that has caused the incident? In this case it is appropriate to think of physical hazards arising from the operation of equipment, the use of substances or work activities. However, human factors issues such as fatigue and psycho-social issues such as violence, harassment, or stress that present particular challenges to WHS professionals and demand special skills sets in the investigation. Depending on these considerations, the skill sets required may be beyond the capacity of any single investigator. By way of example, an accident occurring late in a shift may be linked to fatigue, which may be a consequence of work scheduling or the imposition of excessively tight deadlines. In other words, there may be a number of interrelated issues that need to be considered. Case Study Three provides a workplace scenario of these issues.

Production schedules. What is the impact of the incident on business operations and production? The investigation process needs to consider whether technical disruptions or loss of personnel, if any, will disturb the operations of the business. Advice on any anticipated disruption must be provided to senior management at an early phase of the investigation.

The people By their very nature, all incidents in the workplace will involve people, either directly or indirectly. Accordingly, human factors need to be considered and an assessment made of their role in the incident or to the underlying conditions contributing to the incident. Human factors are those which arise out of a persons’ interaction with the workplace systems, machines, equipment and environment, including all the organisational issues such as management structure, job design, rostering etc




An underpinning precept of a human factors approach to investigation is that humans are fallible and make errors, in simple terms errors of perception, errors of decision-making and errors of action or inaction. Accordingly, workplace systems should be designed to take these fallibilities into account. However, they frequently are not considered adequately.3 4 5 Amongst the human factors which need to be considered are: Medical or physiological factors, such as:

Influence of alcohol or drugs;

Dehydration;

Heat stress or cold;

Fatigue; and

Illness. Sensory Perceptual factors, such as:

Misjudged something eg distance, speed, movement, angle, height, weight, time etc;

False perceptions eg due to impaired visual acuity, poor light, glare, optical illusion etc; and

Spacial disorientation eg vertigo, acceleration and g-force related illusions.

Loss of attention, such as:

Inattention to critical detail;

Task fixated at the exclusion of other demands;

Task or cognitive overload;

Not adequately trained on equipment or task; and

Reverted to old habits. Loss of situational awareness, such as:

False awareness of situation;

Failed to anticipate changing conditions

Failure of attention;

Failure to respond to communication or warning; and

Distraction by other task, activity or action.

3 Reason J. (1990), Human Error, Cambridge University Press, Cambridge 4 Reason J. (1997), Managing the Risks of Organisational Accidents, Ashgate, Surry 5 Reason J. (2008), The Human Contribution: Unsafe Acts, Accidents and Heroic recoveries, Ashgate, Farnham



The investigation of incidents where human error is a factor must go beyond the errors themselves and delve into the reasons those errors took place. Most often the errors will stem from organisational factors6 7 8, such as:

Inadequate design of equipment or workplace;

Degraded operation of equipment;

Inadequate workplace conditions such as poor lighting;

Poorly developed procedures;

Lack of effective training;

Inadequate supervision;

Poor communication of information from company, supervisors or others;

Language and literacy issues;

Conflicting or unrealistic organisational goals, such a production targets and other demands; and

Poor workplace culture. Investigation of incidents which involve a significant human error component may require a human factors specialist to be involved in the enquiries. Language, literacy and culture. In addition to being potential causal factors in an incident, language, literacy and/or cultural considerations may also be complicating factors when incident investigations are taking place in many workplaces. Language differences and the language competency levels of the various parties need to be evaluated. You may require the assistance of an interpreter to deal with the immediate situation and when interviewing the various parties. Literacy issues may also present an issue in investigations, especially when enquiring into procedural or systems issues where a persons’ understanding of written policies and procedures.

6 Woods D., Dekker S., Cook R., Johannesen L., Sarter N. (2011), Behind Human Error, 2nd Ed, Ashgate, Farnham 7 Dekker S. (2006), The Field Guide to Understanding Human Error, Ashgate, Farnham 8 Ciavarelli D., Sather T. (2001), Human Factors Checklist, An Aircraft Accident Investigation Tool, US Navy School of Aviation Safety, Monterey, https://www.netc.navy.mil/nascweb/sas/files/hfchklst.pdf


Although it is sometimes very difficult to identify and prevent, care should be taken to ensure interpreters do not answer questions on behalf of the person being interviewed. This can lead to false evidence being assumed, false causation assumptions and ultimately inappropriate or ineffective corrective actions being recommended. Cultural issues can have a significant adverse impact on the conduct of incident investigations. In some cultures, figures of authority, such as police and other officials, may not be trusted especially if there is a perception that blame may be apportioned. It is possible that individuals from such cultures will perceive the investigation in that light and be reluctant to divulge information to the investigators. In such cases it can useful to involve, as an observer, a trusted representative of the community or culture of the individual to help address any perceptions of threat held by the individual/s being interviewed.

Conflicts of interest. There may also be potential conflicts of interest when conducting investigations. For example, it would not be appropriate to include a supervisor who has been responsible for the development of work schedules and rosters, in an investigation where fatigue is a potential factor in the incident. The individual may deliberately or inadvertently, divert enquiries away from the fatigue or rostering issue. This is dealt with in more detail at 2.2, but as an investigator you need to be mindful of any potential for a conflict of interest.

Legal and administrative issues Notification requirements. What are the notification

obligations? Section 1.3 of this Guide outlined a number of legal requirements in relation to notifying government agencies. This includes the “who?”, “how?” and “when?” in relation to notification obligations. The involvement of regulatory authorities may add to the complexity of the investigation because:



o There may be more than one investigation being

conducted and that will often necessitate, where possible, arrangements being made to share evidence between the investigations, although often legal constraints on other investigations conducted by regulatory agencies make this particularly problematic.

o Of legal implications and the need for the PCBU to take prompt and effective action, which will be scrutinised by the regulator. The legal issues will include any potential civil or criminal matters that could arise from the incident.

Sensitive issues. There may also be issues which are particularly sensitive. Serious incidents may generate a level of public and political interest. When assessing an accident scene you need to be mindful of any such interest that may arise and ensure that senior management or others are suitably informed and briefed. An example here is any incident involving asbestos. Asbestos related incidents are often highly charged and more often than not draw the attention of trade unions and in the case of significant exposures generating considerable media and public interest. . This will influence the complexity of the investigation because:

(a) there may be a higher level of scrutiny of the investigation,

the methods applied, people involved and the outcomes; and

(b) the nature of the incident may warrant an independent investigation using technical experts.

Employment relationships. An investigation may also be complicated by the nature of the employment relationship. Among other things, there has been a rise in sub-contracting and the use of agency labour as the labour market becomes increasingly deregulated. There has also been an increase in casualisation, part time work and short-term employment. In commencing your investigation, you need to establish the employment relationship clearly and in particular the use of any sub-contractors or other parties that may have been brought into the workplace.



Legal Professional Privilege. Legal professional privilege may also affect the way an investigation is conducted. Following a serious incident, it is often the case that the company involved will seek to have the company’s internal investigation offered some protection under the conditions of Legal Professional Privilege. In doing so the company will often direct its legal counsel to commission the investigation on its behalf. The complexity of the investigation will almost certainly increase in such cases as there can be a direct conflict of interest between the usual aim of the accident investigation to identify causal factors and corrective actions to prevent recurrence and the lawyers aim to limit the investigations’ impact on any future litigation which has been foreseen and to which the legal professional privilege applies. In high profile cases, it is not unusual for the investigators to be required to sign confidentiality agreements before being allowed to view the evidence, to further protect the information to the incident from being made public during or after the investigation takes place.

1.6 IDENTIFY STAKEHOLDERS AND INTERESTED PARTIES, AND NOTIFY AS APPROPRIATE You will have gathered from the information outlined above that there are a number of parties or groups of people who have an interest in incidents that may occur in the workplace. It is important to identify quickly who may be considered to be a stakeholder and/or where there is an interest in the investigation process which you are about to undertake. It is also important to clarify who has responsibility for notifying certain groups. The investigation team will have a direct line of communication with management and will keep management informed of issues arising from the investigation. However, in some situations it is more appropriate for senior management or a delegated person to take the lead with notifying certain parties. The following list provides some guidance on who should be notified and by whom.



Notification by the investigation team Managers and those in control of the workplace. As the

people responsible for workplace safety and ensuring that corrective actions have been taken to minimise the possibility of re-occurrence, managers and those in control of the workplace will have a very close interest in the investigation process. Remember that notification at this point is to advise relevant/interested parties that the incident has occurred. This is most likely a procedural matter (see 2.1). However, a nominated person at the scene of the incident (and this could well be you) will need to contact relevant members of the management team. The severity of the incident will determine how high up the management chain you should go.

Government agencies and trade unions. Notification to Government agencies has been mentioned in some detail above. The organisation may have a policy in relation to contact with trade unions and this may need to be referred to senior management for advice.

Work colleagues and work groups. Other work groups within the organisation may also need to be notified. This is particularly so where the work activities have been disrupted. In severe cases it may be necessary to activate counselling and support procedures.

Sub-contractors. If the incident involved the activities of sub-contractors or installers, it is important to ensure that these groups are informed appropriately.

Designers, manufacturers, suppliers and importers. WHS legislation throughout Australia assigns duties of care responsibilities to designers, manufacturers, suppliers and importers. Where an incident has occurred involving plant or substances, it may be necessary to identify the responsible party ie, supplier, manufacturer etc, and appraise them of the situation. If the incident is directly related to the integrity or safety of the product, these groups have a specific interest in the incident and may be subject in certain circumstances to investigation by the relevant WHS regulatory authority. Although any conflicts of interest will need to be identified and carefully managed, it is possible that the designers, manufacturers, suppliers or importers have specialist



knowledge about their product, plant, equipment or material that is necessary to establish the facts around causation. For example, in aviation accidents, it is not unusual for representatives of the aircraft, engine and subsystems manufacturers, as well as the operating airline, to be directly involved in the investigations. Otherwise the investigation may not have access to the expertise necessary to identify all the causal factors.

Notification by management Following initial notification and preliminary briefing by yourself or other members of the investigation team, management should initiate action to ensure that other interested parties are notified. This will include:

The workers and their families. This is the most obvious group with an interest in the investigations process. The workers are those most directly affected by a workplace incident. Depending on the severity of the incident, family members may need to be notified. Should a serious accident occur, family members should be notified as soon as is possible. In the event of a fatality, Police will usually assume this role, but it is often beneficial if a senior member of the organisation involved should also make contact in person with or soon after the Police notification. Procedures must be in place to ensure that these matters are managed sensitively and appropriately.

Other PCBUs including employer groups and associations. These groups have a role to play in ensuring that similar accidents do not occur in other workplaces. Accordingly, they will have an interest in the investigation process and any additional control measures that may need to be applied by like PCBUs. Usually, in the first instance, the task of notifying these parties will fall on the regulatory agencies or perhaps the designers, manufacturers, suppliers and importers of the machinery, plant or equipment involved.



The community. In some situations the work activity and the community are intertwined. This is particularly so in mining activities or regional areas where a community is dependent upon a large PCBU. In these situations the community will have a very close interest in any incident where members of the community are involved. Effective and proactive flow of information is important, both in a business sense and an ethical sense. In these cases, it will generally be the responsibility of a senior member of the management team to keep the community informed.

Insurance companies. Injuries that may require medical attention and/or cause people to be absent from work may involve a workers’ compensation claim. Also, an incident may have an impact on insurance policies held by the company which may impact on whether or not certain risks are covered under the policies. In these situations, insurance companies will have an interest in the incident, will need to be notified and provided with the relevant details.

As a WHS professional it is recommended that you develop a Contact Schedule. This schedule will identify all relevant personnel who will often need to be contacted or notified in the event of an incident. It will contain relevant contact details and organisational protocols ie, who is responsible for contacting various parties. You may also want to develop a checklist to support the schedule. This can serve as a record for ensuring the nominated parties are contacted at the time of an incident.

Competency check for Element 1 Key issues for each performance criterion in Element 1 are as follows. 1.1 Check area to ensure it is safe and confirm that arrangements have been made to meet initial needs of those involved in the incident:

Ensure that the area is safe and that injured people have been cared for.



1.2 Establish and maintain integrity of the site and personnel in accordance with legal requirements and to ensure objectivity of information collected:

Identify any secondary hazards, seal off the area if possible, and preserve all evidence.

1.3 Identify statutory and legal obligations and, if required, advise relevant government agencies:

Identify notification requirements and contact relevant government agencies and others as required by law.

1.4 Notify key persons within the organisation:

Contact relevant personnel as soon as possible and ensure that they remain fully informed about the incident and the investigation.

1.5 Determine factors affecting the complexity of the investigation:

Assess particular issues related to the incident eg, technical issues, geographic isolation, employment arrangements (contractors/casual workers), people (eg, human factors issues and language problems etc) and the legal situation (eg, other investigatory agencies and notification requirements), to determine if there are any factors that may complicate the investigation. Relevant personnel within the organisation may need to be notified and advised of any matters that may impact on the progress of the investigation.

1.6 Identify stakeholders and interested parties, and notify as

appropriate:

Establish interested parties and determine notification requirements and priorities ie, who should be contacted and in what order and by whom?



Case Study 1

Fatalities and serious injuries at a mine site

You are a WHS manager to a Dutch mining company operating a number of gold mines throughout Australia. As the WHS manager you are responsible for the development of WHS policies and procedures, WHS training and the investigation of any incidents. You report to the General Manager Australia, located in Perth. The General Manager reports directly to the Chief Executive Officer in Amsterdam. The mine is located in an isolated area, approximately 25km from the nearest settlement and 190km from the nearest airport and hospital facilities. The mine currently has a permanent staff of 85 workers. There is a contract construction company with 11 staff on the site erecting a storage facility. You are on site conducting training. At 12.10 pm, in the course of your training session you are alerted to an incident which has just occurred. A building under construction on the mine site (located about 300m from the mine entrance) has collapsed. Two workers have been fatally injured and a further three workers have sustained injuries, which at this stage are unknown. It would appear that one of the fatalities involves a worker of the mining company who happened to be on the construction site at the time. The other workers are workers of the contractor. The building was being erected to store mining equipment. Early reports suggest that concrete slabs, used to construct the building using the tilt-up method of construction, became unstable and fell, precipitating the collapse. The slabs brought down power lines, temporarily cutting power to the mine operation. Auxiliary generators are being activated to restore power to the mine.



Senior staff at the mine includes the site supervisor and mine engineer. You have a delegated authority to investigate incidents. To progress your understanding of Element 1 “Facilitate the Initial Assessment of the Situation”, complete these tasks: 1. Further to your initial telephone contact with the General Manager you have been requested to prepare a briefing paper/report (1-2 pages) detailing your assessment of the situation. In particular you will:

describe immediate actions that were taken at the scene; and

outline the various legal obligations in relation to this incident. This will include advice as to what legislation applies and why. It will also provide advice on any reporting requirements that must be met.

2. As an attachment to your report include advice to your Manager as to who will have an interest in this incident and if there will be any issues of concern to particular stakeholders.

Key issues

The following issues have been provided to prompt your thinking (and research) about this case study. You are not required to provide answers to the questions below but, by considering the questions, you may be better positioned to respond to the tasks above.

Site integrity and the safety of others (a) Are there any secondary hazards? (Note the cut to power and

the possibility of further instability of tilt-ups). (b) How is first aid facilitated?



Jurisdictional issues (a) Does the general WHS legislation apply or does mines

legislation also apply? (b) Does the fact that the incident is a construction activity on a

mine site, rather than a mining activity, influence jurisdiction? (c) What notification requirements will apply and what are the

responsibilities for not disturbing the incident scene? How do you do this if you are trying to help others?

Interested parties (a) Will the health and safety representatives/committee be

interested? (b) Will the incident be of interest to the community? If so what

contact protocols may apply?




Activity 1

Keep a copy of this Activity for your Assessment Portfolio. By completing the following activities you will demonstrate that you have:

ensured the safety of the site and others;

secured the site;

identified and met relevant statutory obligations;

notified appropriate personnel; and

identified issues which will add to the complexity of an investigation.

You can use Case Study 1 to provide the background for the completion of these activities or alternatively you can relate these activities to a situation of your own choosing. 1. As the first member of an investigation team at the scene of a

workplace incident involving injured people and damaged equipment, outline your first actions.

2. Why is site security important and how might you achieve this?

3. How would you establish the legal obligations that will apply?

Outline the key legislative instruments and information publications that will apply in your jurisdiction in Case Study 1.

4. Who do you notify and why?

5. From your initial observations, what factors could make this a

complicated investigation?


Element 2: PARTICIPATE IN THE ESTABLISHMENT OF AN INVESTIGATION PROCESS

This element continues the pre-planning for the investigation. It deals with:

who should be involved in the investigation team;

the scope of the investigation; and

the resources needed to conduct the investigation. It is always helpful to check on any organisational policies and procedures which may be in place. A pre-existing policy may stipulate who is to be involved and who is to lead the investigation. This will assist you in your role in participating in the planning of the investigation by saving time in setting up the investigation team. Not surprisingly, accessing policies and procedures is one of the performance criteria that you will need to meet for this element. In order to complete the second element of the competency unit successfully, you will have to show that you have satisfied the following performance criteria: 2.1 Access and understand organisational policies and procedures for incident investigation. 2.2 Convene investigation team appropriate to the level of the investigation. 2.3 Define scope of the investigation taking account of legislative requirements. 2.4 Facilitate involvement of interested parties in accordance with legislative requirements. 2.5 Identify and source resources required to conduct the investigation, including the need for expert advice, if required. 2.6 Identify and address barriers to investigation.



2.7 Ensure action plans and time lines are developed by the investigation team In Element 1, you learned how to assist in assessing an incident scene and notifying relevant personnel. Element 2 takes you to the next step and involves setting up the framework for the investigation. In other words, in the first element you secured the scene to protect the scene and ensure the safety of workers and investigators and notified relevant personnel. In this element you define the investigation team and its activities.

2.1 ACCESS AND UNDERSTAND ORGANISATIONAL POLICIES AND PROCEDURES FOR INCIDENT INVESTIGATION In preparation for the investigation you will need to access any existing policies and procedures that may be relevant to the investigation. It may be the case that an organisation has an established policy for incident investigation. Most large organisations will have such a policy and it is likely that the policy will clearly spell out the procedures to be undertaken, including who is to be contacted, who is to be involved and the relevant reporting obligations.

Why are policies and procedures important? It is important to know that such documentation exists and the investigation team has access to this material, because it can provide the framework and the authority for the investigation. The policy may also include organisational protocols relating to legislative obligations; for example, who should contact regulatory authorities and the associated communication processes.



In addition to a policy relating to incident investigation, other organisational policies and procedures will no doubt be helpful in investigating an incident. These may range from policies and procedures on issues such as emergency procedures and first aid, to safe operating procedures for work activities, specific risk management procedures. These are referred to in more detail below. Policies and procedures provide the investigation team with an insight into the standards that have been established by the organisation. They can provide invaluable information about the organisation’s expectations about how work is to be undertaken and thereby provide a benchmark to determine the level of compliance. The absence of relevant policies and procedures may indicate inadequacies in the organisation’s management system and may be causal factors in the incident.

What policies and procedures may be relevant? As noted above, the first policy/procedure you should consider is the organisation’s Investigation policy/procedure. Its title will vary on a case-by-case basis but may be simply called something like “Incident Reporting and Investigation Procedure”. This document may provide important background information including legislative provisions, reporting requirements and investigation standard investigation methods and techniques. Policies and procedures addressing a range of workplace issues may need to be considered. These include:

WHS Risk Management, including job safety analyses, safe work method statements.

Incident and Hazard Reporting and corrective action.

Training Contractor Management (this policy is important in defining the roles of contractor’s vis-à-vis safety and compliance).

Purchasing, Change management.

First Aid, Emergency Response.

Risk Management including perhaps fatigue risk management, Hazardous Substances Management, Plant Operation and Maintenance and Work Procedures, Standard Operating Procedures or safe Operating Procedures (covering a range of work activities).



In developing policies and procedures, an organisation establishes an expectation that that they will be followed. Your investigation will determine if this is the case, or indeed if the policies and procedures themselves were a causal factor, such as if they were inadequate for the intended application or outcome..

Where will you find policies and procedures? The size of the organisation may influence where this documentation is stored. It is naturally desirable for organisational policy and procedures to have as wide a distribution as possible and therefore this material should ideally be available electronically through the organisation’s Intranet, where appropriate. However, this level of sophistication may be beyond the capacity of some organisations and in these situations more traditional sources need to be explored. The following is a guide to where the documentation may be accessed:

Manager’s office

Supervisors’ files

Human Resources department

Work Health and Safety Officer

Intranet.

Larger, well-resourced organisations are also likely to have document registration and tracking procedures in place. These will include specific details about document owners, and issue and revision dates and details. This can be an additional indicator of the organisation’s quality management systems for maintaining policies and procedures. Smaller organisations may not have documented investigation procedures in place. In these situations, the performance criteria outlined in this element will assist you in establishing an investigation process that is commensurate with the nature of the incident and the resources of the organisation.



Continuous improvement As with all management practices, it is essential that existing policies and procedures are reviewed to ensure that they remain current and relevant. The investigation may provide an opportunity to review and evaluate the procedures and, if necessary, to recommend their revision. When the investigation is completed and the team is preparing its report, it is prudent to highlight any deficiencies with current practice and to recommend how it may be improved. However, in the course of the investigation, any documentation relating to investigation procedures should be observed.

Summary When you are preparing to participate in an investigation process, it is important that you ask:

Is there an incident investigation policy or procedure?

Where is it?

Does the policy/procedure identify who is to be involved in the investigation?

Does it afford sufficient authority to the investigation team to conduct the investigation?

Does the policy/procedure incorporate specific methods that are to be followed in conducting an investigation?

What other policies and procedures are available?

Are these policies and procedures known and understood by supervisors and workers?

You must as part of the initial phase of the investigation, determine if a policy is in place and familiarise yourself with the requirements of the policy.



2.2 CONVENE INVESTIGATION TEAM APPROPRIATE TO THE LEVEL OF THE INVESTIGATION Section 2.1 above, highlights the importance of accessing policies and procedures where such information exists. In particular, an investigation policy may establish who is to be involved in the investigation team. Where this is the case, the policy will usually be cast in general terms and will refer to position titles such as “supervisor” and “team coordinator”, rather than people by name. Accordingly, the investigation team leader may have some discretion in putting the team together. This section will assist you in identifying team members that will be appropriate to the investigation. In convening the investigation team, one of the most important considerations is to match the relevant skills and expertise of the people available with the type of incident that has occurred.

In most situations the investigation team should include people who are familiar with the tasks and the work environment. Normally, the line manager or immediate supervisor will be involved in the investigation because they are best positioned to inform the team about the work processes related to the incident. While the immediate supervisors or managers can add value to the investigation process, you will need to be mindful of the potential for a conflict of interest, as stated previously. Decision makers should not be in a position where they are evaluating their own decisions. Therefore, officers should not be included in an investigation team if there is a perception that there may bring a biased view to the investigation.

Other organisational personnel who could contribute to the investigation will include:

health and safety representatives/ committee members;

WHS advisers/managers;

occupational nurse/first aid officer;

site manager;



technical staff, such as in-house engineers and equipment or materials suppliers; and

technical specialists, such as human factors specialists, representatives of the plant or equipment manufacturers etc.

There are no hard and fast rules about who should be included in the investigation team. This will be determined on a case-by-case basis; however, the constitution and size of the team will be influenced by:

seriousness/severity of the incident;

technical expertise required; and

incident sensitivity eg, an incident that is of particular interest to stakeholders may have a bearing on who is involved.

Let us now consider these aspects.

Seriousness/Severity Incidents that have resulted in serious harm or injury to workers may require an investigation team with numerous people involved. Once again there is no rule about how many people should be in a team, but investigations involving multiple issues may require extra resources to spread the workload and bring additional expertise to the process. Larger teams require careful planning and management to ensure that all team members are productively and suitably engaged.

Technical expertise Where an incident involves equipment, substances and/or sophisticated production techniques, the investigation team will need to include people with the relevant technical expertise. This could include people with formal engineering or technical qualifications, human factors specialists, medical or pathology experts, or people who by virtue of their experience are well suited to advise on technical matters. Qualified personnel will be invaluable in interpreting technical specifications and identifying faults or failures in the production system.



In many cases the technical experts should be available within an organisation and will generally be those people who have been directly involved in the technical development aspects of the work activity. In some cases, especially in large complex investigations, technical experts that are external to the organisation may need to be sourced to participate in the investigation team. This will no doubt need to be approved and resourced by management and some effort needs to be directed at identifying the exact nature of expertise that is required.

Incident sensitivity As part of the investigation team you will need to appraise any sensitivity associated with the incident or any interest that various parties may have in what has occurred. Refer to sections 1.5 and 1.6 to refresh your thinking about this. Where an incident is of a particularly sensitive nature, the investigation team should include someone who is able to contribute to addressing those matters. For example, it may be helpful to include a work colleague of a similar cultural background to that of injured workers.

Health and safety representatives The nature of the incident may necessitate the involvement of a member of the health and safety committee as well as the health and safety representative. Keep in mind that health and safety representatives are a central feature of safety management systems and therefore play a role in the investigation of incidents.




Under the Model WHS Act9 being enacted in all Australian States and Territories, health and safety representatives are entitled to:

represent the workers in matters relating to work health and safety;

investigate complaints from workers relating to work health and safety;

enquire anything that could be a risk to workers’ health and safety, inspect the workplace;

accompany a WHS inspector during an inspection of the workplace; and

with the consent of the worker involved, be present at any interview concerning work health and safety. /or any formal in-house investigations.

To ensure these legal rights of health and safety representatives are not breached, one approach which has been found to ensure all duties and obligations are met, is to involve health and safety representatives in the investigation team. This approach brings the health and safety representatives practical experience to the investigation and provides the health and safety representatives with an opportunity for learning and experience concerning investigation methods and analytical techniques and depending on the circumstances, exposure to the broader principles of health and safety management. In this context they can also become advocates at the workplace level for securing the implementation of any resulting recommendations for action.

Participant skills In convening the investigation team, it is important to ensure that the people involved have the appropriate skills to contribute to the task. These skills include:

9 SafeWork Australia (92011), Model Work Health and Safety Act revised draft 23 June 2011, http://safeworkaustralia.gov.au/AboutSafeWorkAustralia/WhatWeDo/Publications/Pages/model-work-health-safety-act-23-June-2011.aspx


Incident investigation techniques including gathering witness evidence via interviews (this is covered in more detail in section 3.4). Ideally, team participants will have received some formal training in investigation techniques. Where this is not the case, team members may need help, mentoring or coaching to ensure their value to the investigation is realised.

Technical skills of the work processes, equipment and workplace layout. It has already been explained that including specialists in the team can be crucial to understanding the technical factors that may have contributed to the incident.

Investigative skills, including an ability to observe and note details, take photographs, sketch maps and write reports. These issues will be considered in more detail in section 3.5.

Summary The investigation team should include people with a combination of skills, experience and expertise relevant to the incident. Additionally, it should include health and safety representatives from the workgroup where the incident took place and where appropriate, representatives of other stakeholders. Convening the team is an important element of the strategic planning for the investigation. Giving careful consideration to the composition of the team at this phase can make a significant contribution to the quality and credibility of the investigation.

2.3 DEFINE SCOPE OF THE INVESTIGATION TAKING ACCOUNT OF LEGISLATIVE REQUIREMENTS The “scope” of the investigation refers to:

how detailed an investigation should be;

the resources to be allocated to the investigation; and

the range of the investigation ie, what it will cover and how far reaching the investigation will be.



We have seen from the previous performance criteria that serious incidents may require the involvement of a number of people in the investigation, including technical experts, workplace specialists, and health and safety representatives and so on. Significant occurrences will require a far more detailed investigation than minor events. Incidents that involve seriously injured workers or could have potentially injured workers seriously will demand a substantial investigative effort. In addition to the number of people to be involved, these incidents may require a detailed examination of production processes including work systems, plant design, operator training records and maintenance records. In some instances, it might be necessary to reproduce or simulate the conditions at the time of the incident, especially in the case of fires, explosions or other incidents where some of the evidence is consumed or destroyed in the incident or the sequence of events before or after the incident. This will take some time and will therefore be a cost to the organisation. With this in mind, a key activity in preparing the investigation is to define its scope by projecting what is involved and how long it may take.

Examples: 1. The explosion at the Esso gas plant at Longford in Victoria in September 1998, required an extensive independent investigation. In fact, the Victorian Government appointed a Royal Commission to enquire into the incident and which took more than seven months. In this case the Commission’s investigation team involved numerous technical experts and specialised personnel.

2. At the other end of the scale, the investigation of an incident involving a worker bumping their head on an overhead cupboard could be conducted by a line manager/supervisor in conjunction with a health and safety representative. This type of investigation can be conducted within a very short space of time but should still follow the basic processes outlined in this competency.



In addition to the seriousness of the incident, the scope of the investigation will be influenced by:

regulatory requirements;

technical issues such as plant and equipment failure; and

production disruption.

Regulatory requirements Most jurisdictions specify serious occurrences that must be notified to the authority. A notifiable incident is an incident involving the death of a person, serious injury or illness of a person or a dangerous incident. A serious injury or illness is one that requires a person to have:

medical treatment within 48 hours of exposure to a substance

immediate treatment as an in-patient in a hospital, or

immediate treatment for a serious injury or illness such as a serious head injury, a serious burn or a spinal injury and a number of other injuries listed in the model WHS Act.

Importantly, it does not matter whether a person actually received the treatment referred to in this definition, just that the injury or illness could reasonably be considered to warrant such treatment. A dangerous incident is an incident in a workplace that exposes a worker or any other person to a serious risk to their health or safety emanating from an immediate or imminent exposure to a number of risks. These risks include an uncontrolled escape, spillage or leakage of a substance, an electric shock, a fall from a height or the collapse of a structure. Therefore, for any reportable incident the regulatory authority may initiate an investigation. As a result, any reportable incident may be a signal for the need to undertake a significant investigation. These situations will obviously require more effort than a relatively straightforward incident.



Technical issues Incidents involving plant, substances, technologically advanced equipment and/or sophisticated production systems will invariably require a more detailed investigation. A failure in a complex operational system will usually require greater effort to establish the source of the problem. This is one of those complicating factors identified in section 1.5. For this section you need to make an informed assessment as to how the complication will influence the scope of the investigation.

Summary The following questions will provide some assistance in determining the scope of the investigation:

Was there serious injuries or could there have been serious injuries

Does the incident involve major damage to plant, equipment and/or work processes?

Is the damage severe?

Do operational and maintenance records need to be accessed?

Will job experts and technical expertise be required to assist?

If the answer is “yes” to these questions, the level of detail required for the investigation will begin to increase.

2.4 FACILITATE INVOLVEMENT OF INTERESTED PARTIES IN ACCORDANCE WITH LEGISLATIVE REQUIREMENTS The involvement of interested parties may be:

direct − participating in the investigation team; or

indirect − being informed and/or providing input into the investigation process.

In determining who should be involved, the first thing to do is to ensure that any legal requirements are observed.



In Element 1 you identified relevant statutory and legal obligations, stakeholders and interested parties. In this section you take the next step to involve an interested party where there is a legal requirement to do so. The key considerations in undertaking this step are:

What are the legislative requirements in relation to involving other parties?

Who are those parties?

How do you “involve” them?

What are the legislative requirements? In sections 1.1 and 2.3 it was noted that Australian safety legislation prescribes notification of certain incidents to the relevant regulatory authority. In sections 1.1 and 1.6 it was also noted that other parties such as the police or environmental authorities may have a responsibility to respond to and investigate workplace incidents. This information provides the basis for identifying the legislative requirements for involving other parties. Essentially, the legislative requirements will be found in WHS legislation, or in legislation for specific workplaces such as mines, petroleum refineries, maritime or aviation operations. The severity of the incident is a key factor for notification requirements. If the incident is such that people are seriously or fatally injured and after the emergency services have been contacted, other relevant agencies, such as the applicable WHS regulatory authority should be notified.

Who needs to be involved? The following parties may also have a legal authority to be involved in the investigation. Remember, being involved does not necessarily mean being an active participant in the investigation team. It can mean an indirect role such as an observer or part of an independent investigation.



Also, workplace incidents have a tendency to attract widespread attention with many seeking to be associated with the enquiry for ego, kudos or other motivations. It is important that the investigation team consists only of those with a legislative right to be involved, those who add skills, experience, knowledge, specialist input, or other benefits to the investigation. Generally, the larger the investigation team, the more difficult it is to manage, the more the investigation may ultimately cost and ultimately adversely affect the timeliness of its deliberations, analyses, conclusions and recommendations.

WHS/Mines Inspectors

You will recall that in the previous performance criteria the statutory obligations to notify the relevant WHS authority were referred to. In those situations it is quite likely that an inspector of the WHS authority or the mines authority will be involved. You will doubtless have little say in this matter and it is important to cooperate fully where Government agencies are involved.

Health and safety representatives

As previously covered, the involvement of suitably qualified health and safety representatives is very important and can be considered as a legal requirement if there is any aspect of the incident or investigation that impacts on the health and safety of workers, which they almost always do. The Model WHS legislation has incorporated provisions requiring the active participation of health and safety representatives in issues that impact on the safety of workers. In many cases, this would extend to ensuring that health and safety representatives are involved investigations. Against this background, there is an unambiguous expectation that health and safety representatives be suitably involved in any investigation that is undertaken by the PCBU.

Trade union representatives

The Model WHS Act provides authorised union officials with a right of entry, for specific reasons, to workplaces where there are ‘relevant workers’. A work health and safety entry permit holder is not required to give prior notice when entering a workplace to enquire into a suspected contravention of the model WHS Act.



Other workplace parties While there are no statutory provisions relating to the involvement of parties other than those noted above, it is good management practice to consider involving a range of other people, if there is benefit to the investigation. The nature of this involvement may be little more than a communication process to ensure that relevant people remain “connected” to the investigation process. These parties can include but are not limited to the following.

Senior Management

Depending upon the severity of the incident, the General Manager/CEO or a senior management representative may have a direct interest in the investigation process and will want to be informed of investigation activities regularly. This may involve establishing regular meetings with the team or team leader to get updates on progress. The potential challenge for the investigation team is to ensure that the management remains at ‘arms length’ from the investigation process and not seen to influence the investigation findings. However, the involvement of senior management can be vital in securing needed resources and ensuring that the team has the appropriate authority to conduct the investigation.

Co-workers

The direct involvement of any co-workers may be helpful in understanding work processes and work culture. However, any such involvement needs to be considered in the context of the incident, giving careful weight to the circumstances and the likely contribution of any co-worker. This issue aside, it is a good idea to ensure that workers remain informed, so far as is possible concerning any impacts the investigation might have on the workplace. The health and safety representative may provide the conduit for this information.



2.5 IDENTIFY AND SOURCE RESOURCES REQUIRED TO CONDUCT THE INVESTIGATION, INCLUDING THE NEED FOR EXPERT ADVICE, IF REQUIRED This performance criteria deals with the resources that are needed to conduct the investigation effectively. In any investigation some commitment of human, financial and capital (equipment) resources is needed. In this section you will learn about the decision-making processes that you will need to undertake to ensure that the investigation team has the necessary resources to conduct the investigation.

Human resources The most significant resource commitment will be the involvement of relevant personnel in the investigation team. The investigation may need to involve technical experts from within the organisation if available; if they are not available internally it may be necessary to engage external technical experts. Expert technical advice may be required in the following circumstances:

In the case of serious incidents resulting in serious or fatal injuries (or the potential for serious injuries), acquiring outside specialists might be preferred in order to ensure the independence of the investigation. This will have cost implications for the organisation and will need to be approved by senior management.

Where there is significant product or property damage (or the potential for product or property damage), or complex machinery or processes are involved, technical experts may be needed. These could include people with engineering or chemical qualifications and expertise, along with process experts familiar with the work activities and techniques being undertaken.



In either case, specialist human factors investigation expertise may need to be sought, either internally or externally, to ensure the underpinning reasons for errors, omissions and organisational factors which led to the incident can be investigated and included in the deliberations of the team.

You will also need to determine the number of people in the investigation team. You will normally involve the line manager, a person involved in the work processes, a health and safety representative and a person from another business unit.

Equipment People involved in the investigation may require some or all of the following pieces of equipment:

Communications equipment such as mobile and/or satellite phone.

First aid kit.

Notepad and pen.

Digital camera(preferably with date recording facility).

35mm film camera, if the photographs are intended for submission as evidence in Court.

Movie camera, which can be useful to provide persons who do not attend the scene, such as in the case of people involved in subsequent court cases, with an overall perception of the nature of the scene.

Rolls of barrier tape.

Tape measure.

Compass.

Torches with fresh batteries.

Evidence bags and collection containers, labels and tags.

In addition, the following items have been found to be useful investigation resources, depending on the circumstances:

Laptop computer with internet connection.

Portable GPS devise.

Simple tool set with screw drivers, spanners, allen keys etc.



You will recall from section 1.1 that it is important to ensure the safety of those at the scene and those that come onto the scene. This will include those people undertaking the investigation. Team members will need to be provided with appropriate items of personal protective equipment. This will vary from case-to-case but may include:

hi-viz vests;

eye protection;

hearing protection;

appropriate footwear;

Protective clothing; and

breathing apparatus or gas detectors.

Financial resources Conducting an investigation will carry a cost. In some situations the cost may be significant. Therefore, it is important that in identifying the scope of the investigation an estimate of the resources required and their associated cost should be made and sufficient funds made available to ensure that the investigation can be completed satisfactorily. Costs can be categorised as direct costs and indirect costs. The direct costs will include:

wages and salaries of staff involved, including the cost of engaging technical specialists;

equipment hire, transport and accommodation for the investigators, if applicable; and

testing of plant, equipment systems & materials.

Indirect costs include:

workers’ compensation costs;

legal costs; and

diversion of resources − people taken “off line” to conduct the investigation.



There are also costs associated with the incident which to some degree are independent of the investigation, such as:

cost of replacing damaged plant or equipment; and

production costs ie, loss of production arising from the incident, although these may increase if the investigation is lengthy and production cannot be resumed.

It is therefore vital that the investigation be conducted in as cost-effective and efficient manner as possible.

Adequate Facilities for the Investigation It is often necessary to arrange an appropriate room or other facility for the investigation team to use to deliberate and discuss aspects of the investigation. This will usually include white boards and other display boards, so that issues, concepts and analyses may be posted to aid discussion, understanding and evolution of thinking amongst the team members. Accordingly, the facility needs to have the capability to be locked and kept secure from interference or inadvertent release of information. As such, it may be necessary to cover windows in the facility to ensure displayed items are not subject to scrutiny by others outside the investigation. Access to the facility should be restricted to team members, unless arrangements have been made and appropriate precautions taken to cover sensitive or confidential information. A log should be kept of all evidence brought into the facility and no evidence should be removed from the facility without being logged and approved by the investigation team leader. At remote accident sites, tents or marquees would be appropriate to satisfy the need, although it may be necessary to arrange a security guard to prevent unauthorised access or removal of evidence from the facility.



2.6 IDENTIFY AND ADDRESS BARRIERS TO INVESTIGATION This performance criterion is related to section 1.5, “Factors affecting the complexity of the investigation” in that some barriers to conducting the investigation may also complicate it. You should refer to section 1.5 to refresh your memory about those factors. In this section you will identify potential barriers to undertaking the investigation. You will be required to demonstrate measures that can be adopted to address those barriers. The barriers to an investigation may arise from three interrelated sources: the people, the incident and the work environment.

People People can pose a barrier to conducting an investigation in the following ways.

Attitudes

You may encounter a situation where worker and/or management attitudes become an obstacle to the investigation. People may be reluctant to collaborate with the investigation team for fear of being implicated or blamed. Their reluctance may also stem from a desire to protect others, including work colleagues. Attitudinal issues are often difficult to manage and the approach that you take will depend on the particular circumstances in the workplace. In situations where workers are unwilling to cooperate for fear of blame, it is most important to reinforce the position that the purpose of the investigation is to ensure that the incident does not happen again and that the issues that led to the incident are corrected and improved. Remember: The investigation is not about blaming people or seeking to find that someone was at fault.



The inclusion of a worker representative, a safety and health representative and/or a co-worker can often go some way to putting people at ease about the investigation process. Also, the development of fair and transparent policies and procedures relating to the investigation process can help. If people are well informed about what to expect and why an investigation is necessary they will be more likely to assist in the process.

Language and cultural issues

If the workforce is made up of people for whom English is not their first language, communication may be difficult and may present a problem in obtaining eyewitness accounts or statements about what happened. If language is identified as a barrier, it may be necessary to engage the services of an accredited interpreter to ensure that witness statements can be accurately recorded. Fellow workers may be able to interpret during conversations; however, you should be cautious about adopting this approach. It is quite possible that you end up with the “go between’s” view rather than an accurate record of what occurred. This is why an accredited interpreter service should be considered as a preferred option. Cultural issues may also be a potential barrier. These can take a variety of forms, ranging from a reluctance to speak to people in authority to cultural differences at the work scene. Some cultures may be reluctant to assist in an investigation because of a fear of formal investigation processes and a desire to avoid the scrutiny of “authority” figures. There may also be a situation of cultural tension between various groups within the workplace. Addressing these situations will require a planned approach recognising the sensitivities that surround the situation. The involvement of fellow workers or if need be, community leaders, can be a useful strategy to assist in encouraging the required level of cooperation. For example, Aboriginal elders may help to address issues of concern to Aboriginal workers.



It is important to note that if you become aware of any unforeseen tensions or reluctance to participate on the part of an interviewee or other participant, the process should be halted and the matter reviewed. Ethics preclude forcing the issue with a reluctant participant and the investigation outcomes will no doubt be adversely affected by such action.

Political and community stakeholder sensitivity

Certain workplace issues may attract the interest of political and community groups. Asbestos has been mentioned previously. The construction sector is a highly unionised workforce where trade union officials may express views about an incident to the media. Workplace incidents involving young or inexperienced workers will also generate community and stakeholder interest. Naturally, the more serious the incident the more sensitive it is likely to be. The following example of the death of a young construction worker in NSW highlights the need to be sensitive to political and community sentiment regarding workplace incidents.

In October 2003, a 16-year old construction worker fell 15 metres to his death at a construction site in Sydney. It was his third day of working for a major construction company. This incident had a significant public profile and resulted in a sustained industrial and political campaign by the Construction Forestry Mining and Energy Union (CFMEU) in NSW. The campaign was directed at changing OHS laws to include provisions for industrial manslaughter for employers guilty of blatant breaches of safety laws which result in serious injuries. Although this provision has not yet been included in the statutes, the health and safety laws have since changed to substantially increase penalties for non-compliance with health and safety legislation.

In situations where an incident may invoke political and community sensitivity, it is important to understand who the stakeholders are and the particular interest they have. Communication programs are vital in these situations. Interest groups need to be well informed about the processes that are in place to minimise an incident occurring.



Where a major incident does occur, the media will often seek details and updates in the public interest. There needs to be a systematic program in place to provide them with accurate and ongoing information on what happened, what caused the incident and what the organisation is doing about it. In cases of political sensitivity, the regulatory authority will no doubt seek information from the PCBU in order to keep the political stakeholders informed appropriately.

The incident The investigation process may be constrained by a number of factors surrounding the incident.

Time

The length of time that elapses between the incident occurring and an investigation commencing can have a significant impact upon the outcome. The longer the delay the more difficult will be the investigation. Physical evidence could be lost or misplaced; witnesses may no longer be available, witness recollections will be less reliable, given that people may forget critical details or their memory could become influenced by the views of others. It is essential that an incident be notified to relevant personnel within an organisation as soon as possible and the investigation process commence as soon as practicable thereafter. Of course, the more pre-planning and preparation arrangements carried out in advance of the incident, such as pre-existing investigation procedures, the shorter will be the delay in commencing the investigation.

Resources and economic impact

The resources available to conduct the investigation may also become a barrier. The most obvious limitation is access to technical specialists, particularly if these are not available within an organisation. Further to this, the allocation of staff to an investigation team will generally divert these people from other routine production activities. This is a difficult choice for management and one that may be resisted. This is especially an issue in smaller organisations where staff involvement in an incident investigation could impact on productivity.



These are real issues that need to be managed carefully. Organisational policies and procedures can be of assistance here. Developing a planned response, which identifies the resources that will be deployed to an investigation and agreed to by senior management, can avoid disputes about who should be involved. In the case of smaller organisations, the resource commitment will be commensurate to the size of the organisation. However, it may mean that in situations where the investigation team is quite small you will have a more substantial role or workload in the investigation process.

Legal restrictions

An internal investigation may be delayed by the need to observe particular legal requirements. By way of example, an investigation being conducted by a regulatory authority will take precedence over investigations initiated by the organisation. Internal processes may need to be scheduled to accommodate any such external investigation. This does not mean that the investigation is on hold; rather the process of the investigation is scheduled in such a way as to not interfere with any other investigation or activity. Where there are legal barriers, it is important to identify the scope of those limitations and where possible undertake activities, such as research and data collection, which can occur in parallel with and not interfere with the legal issues. Note that information gathered in an investigation conducted by a regulatory authority may also be available to contribute to an internal inquiry.

Testing equipment, technical design information and research data

The availability of specific equipment or data may present an obstacle to the timely investigation of an incident. For example, an air-monitoring device may be required to measure the presence of particular gases. Such equipment may not be readily at hand. Proactive measures to identify equipment needs and data that relates to workplace activities will naturally reduce delays in the investigation. However, this is of little help where such material is unavailable. Where possible, equipment may be able to be sourced quickly from suppliers or other PCBUs or it may be necessary to contract in a service provider.



Suppliers, designers and manufacturers will keep details about the technical specifications for plant and chemicals and should be contacted for relevant information. In incidents involving chemicals you will need to refer to Safety Data Sheets (SDS). PCBUs are legally required to maintain a register of hazardous chemicals used in the workplace, to obtain a SDS from the supplier of the chemical and ensure the SDS information is available in the workplace for reference by those workers using or otherwise potentially exposed to the chemicals. If chemicals are involved in the incident or work process involved, you need to be able to access the relevant SDS copies in the workplace and be aware of the method for obtaining SDSs from the manufacturers and suppliers. Employer associations, regulatory authorities or Internet searches may be useful avenues in seeking specific data. By way of example, regulatory authorities provide a significant amount of guidance material and information products on technically based issues, such as working with electricity or particular items of plant. You will need to access relevant information to assist in the investigation process.

The environment Environmental factors related to the scene of the incident can also create some barriers to the investigation. This is particularly so in the following situations.

Geographic location and/or accessibility

Many workplaces may be isolated or geographically remote from other parts of the organisation. Mine sites and oil rigs are good examples where the geographic location of an incident may create a barrier to an investigation, both in terms of the time taken to get to the site and the accessibility of the site itself. In these situations, the investigation policy and procedures, where they exist, must make allowances for access to the site by the various participants involved in the investigation.



Where a worksite, or the site of the incident is geographically isolated, there is a greater imperative to ensure that investigation procedures include appropriate consideration of such issues as the safety and field support of the investigation teams well as effective emergency response arrangements. These may be an extension of the emergency response arrangements in place for the workers, but need to take into consideration the needs of the investigators which may involve potential exposures to additional hazards or substances generated or resulting from the incident.

Changes to the incident scene

As noted at section 1.2, it is important to seal off the area where the incident has occurred. The purpose is to preserve the integrity of the site in order to assist the investigators in understanding the environment in which the incident occurred. However, in some situations this is not practicable or is not achieved. Commercial imperatives to maintain productivity and workflows mean that there will sometimes be pressure for work activities to resume as soon as possible after the incident has occurred. It is important not to rush unduly the investigation processes. This situation of course heightens the risk that mistakes may be made in the investigation and key evidence may be lost. The impact of changes to the incident scene are best minimised by a timely response to the incident and actively initiating the investigation process. This should be a matter of organisational priority and investigative action should be given the necessary priority.

Where for whatever reason, the incident scene is corrupted or altered; the investigation team may need to reconstruct the scene as closely as possible to that where the incident occurred. This may be established by the use of sketches, photographs and diagrams and the use of recorded statements of individuals.



Investigators should be certain that all the necessary evidence has been obtained from an accident scene, before handing over control of the site to another party, such as handing affected plant back to operations or maintenance departments. There is no going back from that decision. Once the site and/or the plant and equipment involved in an incident have been subject to rehabilitation, refurbishment, maintenance or other actions to return to pre-incident status, it is most likely that any evidence of the earlier incident will be lost.

2.7 ENSURE ACTION PLANS AND TIME LINES ARE DEVELOPED BY THE INVESTIGATION TEAM In this section you will learn that a key component in scheduling the investigation is to develop an action plan and time-line for the conduct of the investigation. We saw in section 2.2 that the establishment of an investigation team requires identifying who will be involved. Decisions are based on, among other things, the nature of the incident and the level of expertise available. In section 2.3 issues that can assist in defining the scope of the investigation were examined. Developing an action plan and time frame for the investigation are fundamental to the planning process. This activity demands leadership and naturally, in the context of the investigation process, the role of the team leader will be paramount. This point is made because the team leader should have the authority, support, experience and investigative skills to shape a plan of action and the time-line within which that action will occur. However, the essence of good leadership is to involve others effectively. Consultation is pivotal to successful outcomes and the development of an action plan must involve all investigation team members.



As a WHS professional you may be in situations where you are the team leader. Notwithstanding this, as a participant in the investigation of incidents your contribution to the development of an action plan for the investigation will be equally important. Accordingly, you need to be aware of what is to be included in an action plan.

Action plans An action plan sets out, in a structured way, who is doing what and when that should occur. This provides a physical record of what is expected so that the team members are in no doubt about their role. An action plan:

Identifies the team leader and team members and clearly establishes communication and reporting lines, so that all team members are clear on their role and reporting responsibilities.

Prioritises the investigation, taking care to address urgent matters in an organised and systematic way. Those matters, which if delayed, have the potential to compromise the investigation, will be actioned first. By way of example, this will include an inspection of the scene and the gathering of evidence before the scene can be altered. The collection of eyewitness accounts and statements from people involved will also be high on the action list to ensure that information is gathered while it remains fresh in people’s minds.

Identifies expert assistance that may be required.

Assigns tasks to particular individuals in the team to ensure that:

o all team members are involved appropriately in the investigation process; and

o the plan harnesses the skills of the team and each team member is comfortable with their assigned tasks.

Defines the time-line for the investigation. This will be achieved by nominating the time frame for each task assigned and estimating the total time for the investigation; commencing at the date of the incident and concluding with the completion of the final report.



Sample action plan template

Incident: Date:

Location details and contacts:

Investigation Team:

Issue Action required Person responsible Time frame Status

1. Site inspection. 2. Records 3. Etc

photographs J. Smith 1 June Completed

Table 2: Sample Action Plan

Workplans In addition to the development of an action plan, which outlines the broad approach to be taken for the investigation, it is useful to develop a workplan to provide a more detailed plan for particular tasks. The workplan is essentially the methodology for achieving tasks outlined in the action plan. Each action item should be supported with a workplan which will assist team members in undertaking their investigation tasks. For example, the action plan will include conducting interviews to obtain eyewitness reports. The workplan will provide a schedule of when those interviews will occur, who will be involved, how the information will be recorded and where the interviews will be undertaken. Each team member should develop a workplan for the tasks that they will undertake. It may be helpful to prepare a template document for the team to ensure consistency. A briefing for all team members on the application of the action plan will also assist members in preparing for their tasks. The action plan is a formal document which will form part of the records of the investigation process.



Competency check for Element 2

Key issues for each performance criterion in Element 2 are as follows.

2.1 Access and understand organisational policies and procedures for incident investigation:

Identify and access all relevant policies and procedures.

Review documentation to benchmark operational standards and organisational compliance with policies and

procedures. 2.2 Convene an investigation team appropriate to the level of the investigation:

Set up the investigation team incorporating skills and expertise to facilitate the investigation. This will involve a combination of people familiar with work activities and people with technical/specialist expertise.

2.3 Define scope of the investigation taking account of legislative requirements:

The depth and breadth of the investigation is defined, including the resources required and the time to be taken.

Legislative requirements relating to notification and involvement of regulatory authorities are given priority consideration.

2.4 Facilitate involvement of interested parties in accordance with legislative requirements:

All interested parties are appropriately informed about the investigation and involved to the extent required, especially where legislation requires it.



2.5 Identify and source resources required to conduct the investigation, including the need for expert advice, if required:

The investigation team is appropriately resourced with personnel, equipment and budget.

2.6 Identify and address barriers to investigation:

The range of barriers arising from the incident, people involved, and the environment have been suitably identified and addressed as part of the investigation plan.

2.7 Ensure action plans and time lines are developed by the investigation team:

An action plan for the investigation has been completed and all team members are clear on their roles and the time frame for completing set tasks.



Case Study 2

Incident report − Anna Chan

You are engaged as a WHS advisor to a medium-sized construction firm. You report to a management team consisting of the General Manager, Construction Manager and Site Supervisor. You are responsible for reviewing all incident reports and, where appropriate, coordinating incident investigations. The company’s accident investigation policy states that a formal investigation will be undertaken where the incident:

results in injury or significant damage to plant;

results in time off work or a workers’ compensation claim; or

is otherwise assessed as a significant occurrence.

In your weekly review of incidents you note that one of the company’s temporary staff, Anna Chan, has lodged an incident report. The facts of the incident (as reported) are as follows. The plumbing contractor approached Anna complaining that he had not been paid. When she advised that she had not seen his paperwork, the contractor became aggressive and abusive. He kicked over a chair and threatened Anna with violence if she did not arrange his payment. He also shouted and swore at her, making racial comments. Anna reported the incident to her supervisor (the Construction Manager) but was told that the construction industry is a “rough game” and she had to accept that people get a little “hot under the collar”. When Anna approached the employment agency that had arranged her contract, she was told that the construction company was an important client and she needed to “get on with it” and not cause any trouble otherwise she might lose the position.



Anna has been employed on a temporary basis through a labour hire firm to process invoices and prepare payments for contractors. Anna has recently left college and has been with the firm for three weeks. Anna’s English is not of a high standard but she has considerable experience in book-keeping and accounting practices. There have been no concerns about the quality of her work or her diligence. Anna is considerably distressed by the incident to the point where she feels unwell when coming to work.

Tasks

To progress your understanding of Element 2 “Establish an investigation process”, complete the following tasks:

1. Explain why this incident warrants an investigation (you may

refer to the Act, regulations, codes of practice or other guidance material).

2. You have been asked to investigate this issue. Make a list of

company policies or documentation that may assist in this investigation. Explain why such documentation would be of assistance.

3. The Construction Manager continues to dismiss the incident.

How would you respond? 4. Prepare a draft action plan and time-line for the investigation.

The information in the action plan will include: - who has been included in the investigation team; - the expected scope of the investigation; and - the resources required to conduct a full investigation.

5. Provide a brief explanation of why you have included the

people nominated above in the investigation team. The following issues have been provided to prompt your thinking (and research) about this case study. You are not required to provide answers to the questions raised below, but in considering the questions you may be better positioned to respond to the tasks above.



Issues

1. Consider policies relating to harassment, violence, bullying. How can these be used and what do you do if they do not exist?

2. Does the regulatory authority need to be involved? Why or

why not? 3. In setting up the investigation team, is there a potential for

conflict of interest? 4. Is there a role for the health and safety representative or

committee members? 5. In Element One complicating factors were considered. The

following factors are of interest in this case study:

(a) Contract employment. (b) Language issues. (c) Experience of the worker. (d) Supervision. (e) Existence of company policies and/or compliance with

policies/procedures. (f) Workplace stress generated by psycho-social hazards.



Activity 2

Keep a copy of this Activity for your Assessment Portfolio.

The following activities can draw upon the information contained in Case Study 2 or you can relate these activities to a situation of your own choosing.

1) Make a list of the organisational policies and procedures that

will be relevant to the investigation of a WHS incident.

2) How would you go about accessing these documents and why are they important?

3) Who would you include in the investigation team and why?

4) What factors will influence the scope of an investigation?

5) Who do you consider would be an interested party in the

investigation of a WHS incident of this type and why? How might these parties be involved in the investigation process?

6) Make a list of the potential barriers to conducting an

investigation and outline how you would address these barriers.



Element 3: COLLECT INFORMATION AND DATA FOR ANALYSIS

This element is the ‘nuts and bolts’ of the investigation process. It is where as an investigator you ‘roll up your sleeves’ and collect the relevant information and data needed to establish the cause(s) of the incident. In this element you will learn how to:

identify the different types of information relevant to the investigation;

collect relevant data and information;

secure evidence; and

involve team members in this process. In order to complete this element successfully you will have to show that you have satisfied the following performance criteria: 3.1 Identify and access sources of information and data. 3.2 Inspect incident site, equipment and other evidence. 3.3 Facilitate information and data gathered by others. 3.4 Take and record interview statements, photographs, measurements and documentary evidence, taking account of objectivity, confidentiality and legal implications. 3.5 Appropriately secure the site, evidence and all necessary documentation. 3.6 Appropriately involve members of the investigation team.



3.1 IDENTIFY AND ACCESS SOURCES OF INFORMATION AND DATA This section will assist you to identify the types of information and data that will be helpful to the investigation and where you can obtain that information. As stated previously, an investigation is a systematic collection and analysis of the facts relating to an incident. The facts of the incident are underpinned by a range of critical information and data, which relate to:

documentation;

personnel;

plant/substances; and

the physical work environment and work processes.

Documentation Documentary evidence includes any document containing writing, printing, drawings, graphs or photographs etc, that are relevant to the investigation. These include policies and procedures, operating manuals, maintenance manuals, accident and injury records, training records, plant and chemical registers, reports, risk analyses and other company records. Some of the more common types of documentary evidence are detailed below.

Policies and procedures

Policies and procedures are a vital source of information because they outline how work activities and processes are to be undertaken. In this way, policies and procedures set the benchmark as to how things should have happened. You will recall that in section 2.1 a number of key organisational policies and procedures were identified, where they may be kept and how these can be accessed. You may want to review that section now to refresh your memory.



Incident and injury records and reports

Keeping a register of incidents and injuries is part of the duty of care. Generally, it is also established under workers’ compensation legislation as part of the requirement to notify insurers about workplace accidents. The incident and injury register can be an invaluable source of information to the investigation team. It provides evidence of any previous events or occurrences that may be related to the incident. In this way it might be possible to establish a history of incidents leading up to the current one. If the incident/injury register establishes a history of incidents, it is evidence of a systemic failure to take any decisive action to control obvious risks.

Training records

One of the key features of an investigation process is to enquire about the training that has been provided to workers involved in the incident. In fact, often one of the key questions to be asked when investigating an accident is likely to be “What training and supervision did the worker receive?” The failure to provide adequate instruction, training and supervision is one of the most commonly utilised provisions in WHS prosecutions.

Training is a critical issue because, if people were injured because they failed to do something or did it in the wrong way, the obvious question is “Were they given instruction and direction on how to do the task?” The training records will provide your investigation team with this information and are a primary source of information. If records are not available it is an indicator: (a) that no training has been provided and/or (b) of poor record keeping. Such a situation would be highlighted in the team’s final report.

Personnel records

Usually, the personnel records are maintained by the human resources section of the organisation and they should be accessed through that area. These records may provide relevant information. You will see in Case Study 3, that the injured worker is over 50 years of age and has pre-existing injuries. While it is difficult to quantify the extent to which these contributed to the incident reported in the case study, they are certainly factors that need to be considered.



When accessing personnel records you need to be mindful of confidentiality and privacy issues. Any matter contained in the files that is not directly relevant to the investigation must remain confidential and should not be included in any reporting process or communicated to other people. This issue is covered in section 3.4.

Equipment/maintenance records

These records provide information about equipment or substances that may have been involved in the incident. This may include information relating to the purchase of the equipment, manufacturer/supplier details, and maintenance records and operational/user specifications. This information will assist in assessing the operational limits of the equipment and ensuring that the equipment and/or substance was being used within the parameters defined by the manufacturer/supplier.

Personnel People are a primary source of information. Who better to provide information about an incident than those directly involved? Relevant information sources include:

injured persons;

witnesses to the incident;

people who were not witnesses but who were present or in the near vicinity and/or who know something about the job or the incident;

supervisors/managers;

health and safety representatives/committee members;

technical experts;

maintenance or repair personnel;

Representatives of manufacturers or suppliers; and

any other relevant personnel including trainers, first aid officers, other worker representatives.

Targeting the right people and interviewing them is a start. However, getting the right information means asking the right questions.



It is also important, where possible, to verify witness evidence with other evidence from the investigation as witness perceptions are also subject to the human factors limitations described in Section 1.5 above. This is covered in more detail in section 3.4.

Equipment and substances We referred earlier to the information that can be obtained from operational manuals provided by the supplier or manufacturer of equipment. It may also be necessary to commission an independent review of the operation of plant, equipment or vehicles involved in an incident. For example, where a vehicle collision occurs and there is evidence that the brakes may have been faulty, it would be desirable to have an independent mechanic check the brake configuration and operation rather than the workshop that had been responsible for servicing the vehicle prior to the incident. Chemical registers and SDS information will be critical to developing an understanding of chemical involvement in incident causation. However, it may also be necessary to involve an industrial chemist, industrial hygienist or toxicologist where complex chemical processes and associated plant are involved.

Work environment/work process While an examination of information and data for plant and equipment is important, it is only part of the story. It is also important to see how the particular operation fits into the broader work environment. For example, a piece of machinery might be fully maintained and operational. However, if the workplace has inadequate lighting the use of the machinery may be hazardous. Similarly, the process taking place at the time of the incident needs to be investigated. This may involve:

determining the number of people in the work area at the time;

assessing the workspace to check whether the work area was restricted or cluttered;

determining if the person involved was working alone; and

checking on the attendance of supervisors.



How you take the information gathered from documents, personnel, equipment and the work environment and processes and use that as evidence to inform the investigation is covered in more detail in section 3.4.

3.2 INSPECT INCIDENT SITE, EQUIPMENT AND OTHER EVIDENCE The purpose of inspecting the incident site and examining the equipment that may have been involved is to establish an accurate “picture” of the incident scene or the tasks that were being carried out at the time of the incident. In compiling your evidence, it is important that the team describes the incident scene in as much detail and as accurately as possible. This is because:

the scene may change over time and the real reasons for the incident may become blurred as the scene is altered;

our memory of specifics can fade and even distort over time; and

Others, such as management, who have not had exposure to the scene, will rely upon your description of the incident scene in your final report. Therefore, the incident scene must be described accurately in order to support any recommendations for corrective action. It is useful to sketch the scene to show relationships of the key features of the site and location of any wreckage or other relevant artefacts. As stated previously, photographs and video footage of the scene are also invaluable for this purpose.

How to inspect The inspection of the site will involve the physical presence of the investigation team at the scene of the incident.



For evidence purposes, you will need to make direct observations about anything you see, feel, smell and/or hear that may be relevant at the time of the inspection. This should include descriptions/records of the accident scene and the tasks being carried out and should include measurements, diagrams and general observations. This aspect is covered in more detail in section 3.4. It is important to keep a record of your inspection, including information about inspection methods and observations. This can be prepared as a formal document eg, “Inspection Report”. Keep in mind that the inspection report should contain only information gathered from your direct observations. The information collected must not contain subjective opinions or statements. The inspection report should also include any observations about changes that appear to have been made to the scene since the incident occurred. The inspection report will sit alongside other information and data that you have gathered, such as maintenance records and work schedules that you will analyse later to help establish causative factors.

What incident information is needed? The site inspection will establish and record basic facts including:

date, time and location (also include when you were contacted and by whom);

names of injured people, other persons involved in the incident, witnesses and people who were first on the scene;

condition of plant and equipment and the presence of any substances;

the layout of the incident scene; and

prevailing conditions in the work environment such as light, temperature, etc. It is useful to also conduct one of your site inspections at the same time of day when the incident occurred. For example, if the incident occurred on the night shift, inspection at the same time of day will ensure you make accurate observation of lighting conditions. This is particularly relevant to incident scenes outdoors, where other environment conditions such as sun glare can be a transient issue.



Table 3.1 Inspection report template The following example of the structure of an Inspection Report is provided as a guide to the type of information and layout that you may want to adopt in your own investigation activities. 1. Following receipt of notification of the incident, I visited the work shed

of…………………………………. 2. I met with ……… I advised …… that an investigation team had been

set up consisting of myself and …… and that we were to inspect the scene of the incident. In undertaking the inspection I was accompanied by…….

3. The work shed is a corrugated iron building located at the north west

corner of the depot situated at ……………. 4. In the southern corner of the work shed there is an elevated ramp

used to inspect the equipment. Sketch map A, shows the location of the ramp area. The site of the incident is marked.

5. The ramp is approx 1.4m above the floor surface and is accessed by

stairs leading on to ………Photographs were taken of the stair area and the surrounding workshop.

6. A steel wheel brace was lying on the floor approx 1.5m from the base

of the stairs. Blood was evident on the floor, with a trail of blood extending 600mm from x to y.

7. At the time of the inspection there is no handrail on either the stairs or the elevated area.

8. The work area was clean and uncluttered. There were no other

hazards obvious at the time of the inspection. 9. Maintenance records were located at…………… 10. Shift information was available in the work shed office and

documents were complete and up-to-date. 11. There were no other staff present in the shed at the time of the

inspection. 12. The floor area approx 10m surrounding the incident scene was clear

and free of obstacles. 13. The inspection was completed at……



Inspecting the scene − what to look for The incident scene and equipment used are valuable sources of information. Your investigation will require you to examine any machinery, equipment or substance relevant to the investigation. In particular you need to:

look for signs of obvious damage to machinery or parts of machinery (check to see if parts are broken, bent, damaged, scratched, burnt or out of place);

look for signs of previous damage or worn equipment;

check fluid levels to ensure that the correct type and amount has been used;

check for any guarding or barricades that is or should be in place;

check that the correct tool or item of plant was being used for the task;

check to see if any substances were present and if there was any unintended release of substances; and

check the work environment, for example lighting, ventilation and general housekeeping.

3.3 FACILITATE INFORMATION AND DATA GATHERED BY OTHERS Earlier in this guide, a number of different groups who will have an interest or need to be directly involved in an investigation were considered. It is possible that some of these groups will gather information that may be important to the team’s investigation. These parties may be external to the organisation such as the police or internal such as work colleagues who were first on the scene.



This section will assist you to identify and access the information that may have been gathered by various parties. Remember this section is only considering information that may have been gathered by others and that is of direct relevance to your investigation. It does not attempt to repeat the primary information sources to be accessed by the investigation team (see section 3.1).

Regulatory authorities As noted in section 1.3, there may be a statutory obligation to notify various regulatory authorities of the incident. In serious cases, such as deaths and explosions, both the police and the WHS regulatory authority may be involved.

Police

In the event that the police are involved, their first response will be to provide arrangements for the safety of others and to secure the area. The police may conduct preliminary enquiries. However, in most work-related incidents they will defer a full investigation of the incident to WHS inspectors of the regulatory authority. In the case of a fatality, the Police will usually be the Coroners’ representatives and will conduct an investigation on the Coroners’ behalf. Notwithstanding this, the police may be able to provide the investigation team with some key facts to assist your investigation. This is particularly the case in situations where the police are either the first on the scene or are in attendance prior to any internal investigation. For example, the police may be alerted to a workplace fatality by a member of the public, by an ambulance officer or from another source. It is quite possible in these situations that the police will be at the scene before any organisational personnel.

WHS/Mines inspectors

In serious workplace incidents a WHS inspector of the relevant regulatory authority may be in attendance and have initiated an investigation. It is possible that you and/or nominated personnel will be asked to assist the inspector in gathering the information and this may be of some help in your own investigation.



It is unlikely that the inspector will provide you with information he or she has gathered until their investigation is completed or until a coronial inquiry has been conducted. Even then, if it is a matter involving a serious breach of WHS legislation and is likely to proceed to prosecution, there will be a significant delay in you receiving information from the regulatory authorities about evidence gathered in the course of their investigation. In such cases, it is usually necessary for the internal investigation team to conduct their own enquiries which may duplicate the action of the Inspector, but this will almost always be preferable to waiting on the chance relevant information will be forthcoming from the Inspector’s investigation.

Other regulatory authorities

Other regulatory authorities which may also provide information include medical services such as ambulance officers or treating doctors. These services may be able to provide a preliminary medical assessment of any injured workers. This information may be of assistance to you in understanding the extent of injuries incurred. Environmental agencies may need to be involved if, for example, there is a release of chemicals into the environment. This information may include site/spill measurements, etc, which can assist the investigation.

Other sources Other parties may be able to provide information that will assist with the investigation.

Those first on the scene

It is possible that anyone who was in the vicinity of the incident when it occurred or was in attendance immediately after the incident may have gathered relevant information. While the observations of these people will be established through the collection of witness statements, it is also possible that they may have taken items of plant or equipment or moved various belongings or tools of relevance to the investigation. It is important to access these people as soon as possible after the incident to obtain relevant information and any physical evidence they may have gathered.



Health and safety representatives/committees

Health and safety representatives are closely involved in monitoring and contributing to health and safety conditions in the workplace. Therefore, they can provide valuable information on a range of issues including pervious WHS issues, control measures and WHS management systems that may have a bearing on the incident.

Maintenance and repair staff

Records of any maintenance activity, conducted by either internal maintenance crew or contractors can provide important details about the operational performance of particular items of plant.

Organisational staff

Relevant personnel including the human resources manager, other WHS advisers/managers, supervisors, etc, can all provide useful information and need to be considered when you are gathering factual information.

3.4 TAKE AND RECORD STATEMENTS, PHOTOGRAPHS, MEASUREMENTS AND DOCUMENTARY EVIDENCE, TAKING ACCOUNT OF OBJECTIVITY, CONFIDENTIALITY AND LEGAL IMPLICATIONS In earlier sections the processes involved in inspecting the site and the relevant parties to the investigation were considered. It is now time to consider the protocols and processes involved in physically collecting the evidence. This section will work progressively through each of the key elements of the investigation, which are:



conducting interviews (including interviewing techniques);

taking photographs, measurements and samples; and

gathering documentary evidence.

Interviews and statements In section 3.3 it was noted that the “people” are a crucial source of information. The mechanism for accessing that information is by interview. Interviewing is the process of talking to people and listening to what they say in order to find out what happened. The interview process includes:

planning the interview;

interviewing the injured worker/s;

interviewing witnesses (includes eyewitnesses, co-workers, maintenance staff, others);

interviewing supervisors; and

interviewing managers.

Planning interviews

The investigation team will need to identify who will be interviewed and who will conduct the interviews. In some situations it may be only one person who conducts the interviews and there are obvious benefits if this should be the case. However, some incidents may be more complex involving numerous parties and in these situations you may need to share the interview load.

As part of the team you need to recognise that everyone interviewed may offer different perspectives and information about the incident. Therefore, you may need to decide before each interview any specific information you may wish to obtain from a particular witness. For example, the interview of the maintenance officer will be quite different to that for the first aid officer. Therefore, prior to the interview the investigation team should:

define the objectives of each interview; and

prepare a list of questions.



When should interviews be conducted?

Interviews must be conducted as soon as possible after the incident has occurred, while events are still fresh in people’s minds.

Where should interviews be conducted?

Where possible, interviews should be conducted in a private environment, free of noise and visual distractions. Depending on the incident, interviews may also take place at:

the workplace;

hospital;

location of the incident; or

private home (subject to the concurrence of the interviewee and approval by management).

Regardless of where the interview is conducted, care should be taken to create a private environment to prevent other parties listening in or interrupting.

Other persons attending interviews

There may be circumstances where it is appropriate to involve other parties in the interview. For example, you may need to include an interpreter in the interview. Some workers may also request an observer such as a specific health and safety representative, work colleague or a trade union representative. These are reasonable requests and should be supported.

Documenting interviews

The interview should be documented and the facts carefully recorded. This is particularly important where: (a) the incident is serious eg, where people have been injured or

there was the potential for people to have been seriously injured;

(b) people involved in the incident make allegations or

contradictory comments about what occurred; and/or



(c) witnesses have conflicting recollections of the incident or events leading up to the incident or resulting from the incident.

It is important that the interview process be fair and impartial and that the interview be recorded accurately. It is advisable to not make an electronic recording of the interviews, since this will often inhibit the interviewee and may adversely affect the fidelity of the information related in the interview. In most cases you will make notes of pertinent points provided by the interviewee. A relaxed and casual atmosphere can assist and the following principles will also contribute to gathering useful information from interviews.

Interview principles

Be a good listener

As well as asking the right questions, the interviewer also needs listening skills and to display appropriate non-verbal behaviour. This involves carefully following what a speaker is saying. The responses of the interviewee may open up new areas for questioning or they may make pre-planned questions irrelevant. Skilful listening requires you to suspend judgment about interviewees and their views. Preconceived prejudices or stereotyping can lead to a situation where you ‘hear’ what you expect to hear rather than what is actually being said.

Ask the right questions

Like listening, the ability to ask the right questions is a skill that can be improved over time with careful practice and application. It is helpful in commencing an interview to ask the person to explain in their own words what happened. This helps you to obtain an overall picture of the incident and may also serve to put the interviewee at ease. You may not want to interrupt the interviewee with further questions at this point, but rather to allow the interviewee to finish their observations.



The interview should be clear and concise and should gather all relevant information. This may involve bringing the interviewee back to the question by discouraging digressions and longwinded answers. Be careful to identify any omissions, errors or contradictions emerging from the interview and to resolve these with the interviewee.

Be familiar with technical terms and jargon

You will need to familiarise yourself with any technical terms or jargon and the names of people who may be connected with the incident. Where necessary you may need to clarify these matters in the course of the interview, ensuring that where first names are used the interviewee is asked to provide the full name of the person and if possible the person’s job title.

Never suggest possible answers

During an interview situations may arise where interviewees will say things that may be ambiguous or confusing. In these cases you may need to repeat a question or rephrase a response. You should always check any interpretation that you have made to confirm that it is an accurate reflection of the incident.

Remember: The interview is not about assigning blame. It is important to put people at ease about this. You need to reassure the people involved that the objective of the exercise is to find out what happened to prevent a similar incident occurring again. You will need to be particularly sensitive if you are talking to a person who was injured in the incident or who witnessed a traumatic incident.



Quality questioning techniques

Each question should start with one of the following words: “who?”, “what?”, “when?”, “where?”, “how?” and “why?” For example, “Where did the injury occur?” These are “open questions” which will not result in a yes/no answer.

Ask one question at a time and wait for the answer to be completed before continuing.

Allow a short pause after an interviewee’s response. Ask concise questions using simple, easy-to-understand language.

Where technical terms or jargon are used, ask the interviewee to explain what they mean. For example, “You mentioned that the bus driver was changing the ‘desto’ when the accident occurred. What is a ‘desto’?”

Questions to be avoided There are certain types of questions that should be avoided when conducting an interview.

Leading questions

These are questions that lead the interviewee to provide a particular response. The following are examples of leading questions. More appropriate questions are provided in brackets: a) You saw Peter near the machinery didn’t you? (Who did you

see near the machinery?) b) Were you concerned that the supervisor was absent at the

time? (Where was the supervisor at the time?)



Double-barrelled questions

A double-barrelled question is where more than one question is asked in a single sentence. This is confusing for interviewees and will often result in poor responses. This type of questioning is to be avoided. Examples of double-barrelled questions are: a) What is your role in the company and how long have you been

doing this? (Best presented as two questions.) b) What action has the company taken to prevent this incident

from happening again and do you agree with it? (This is a confusing question and presupposes that action has been taken and seeks an opinion.)

Questions that reveal attitude, opinion or is accusatory

You should always avoid questions that express your particular views or attitudes about the incident or related matters. For example, you would not ask: “I know that we have had trouble with Dave in the past but….” “You have been the safety rep on this site for some time, what had you done to prevent the unsafe practice which led to the incident? Equally you should not give any indication about your uncertainty or lack of knowledge about a situation. For example, you would not begin a question with: “This is probably not important but….”

Interview difficulties In the course of interviewing people, difficult situations may arise. These difficult situations may be created by those who feel they are being blamed or by those seeking to blame others. In some cases, the interviewee may become hostile or angry. In these situations selective questioning can steer the interview away from sensitive issues.



Each situation must be managed on its merits but your approach is important. You should:

stay calm;

stick to the facts;

put the interviewee at ease – assure them you are not there to blame anyone, rather to prevent the incident from recurring;

do not take sides; and

in situations where the interviewee is likely to be aggressive involve more than one team members in the interview,

It is most important to seek to validate the accounts of witnesses with other evidence from the scene or other accounts of the event. As previously suggested, witnesses also suffer from all the human factors weaknesses detailed in Section 1.5 above and validation from other sources will greatly strengthen the accuracy of the witness account of the incident and other evidence collected from the witness. Witnesses also naturally try to make sense of what they observed heard or otherwise experienced and do so by comparing what they saw, heard or experienced with their previous experiences. This can lead to a rationalisation of their experience which may affect the account you obtain during the interview. This is another reason why interviews should be conducted as soon as possible following an incident and why there is benefit in validating interviewee accounts with data from other sources.

Photographs, measurements and samples

Photographs

Section 2.5 provided some detail of the resources required to conduct an investigation. It was noted in that section that essential equipment includes a camera, preferably a digital one. Except in the most unusual circumstances, investigation scenes must be thoroughly photographed. Photographs provide a visual record of the scene, enhancing your observations and mental reconstruction of events.



Photographs help you to:

record the details of a scene or items which are susceptible to change or disturbance; and

provide an accurate record of a scene for future analysis. With these things in mind you should take as many photographs of the scene as possible to ensure that you capture everything that may be of assistance in the course of your investigation. When taking photographs:

attempt to obtain an overall picture of the scene, taking several photographs from different angles, both close up and wide angle views;

photograph the ground surface, indicating the general condition and slope;

photograph individual items that may be relevant to the investigation eg, barriers, guards, markings, PPE, signage;

photograph plant and equipment involved in the accident;

place an object such as a ruler against the item to be photographed to indicate dimensions or provide perspective; and

do not include people (unrelated to the incident) in the photograph.

It is important to record:

the incident that the photo relates to;

the name of the person taking the photo;

the date and time that the photo was taken (most cameras have a date and time facility and this will need to be set accurately);

a notation as to the location where each photograph was taken;

a brief description indicating what the photograph is showing; and

the orientation of where the photograph was taken from eg, northern corner of the building two metres to the south of the incident site).



The front surface of the photographs should not be marked in any way. Any notation or comments should be written on the back of the photographs.

Sketches and measurements

Measurements, diagrams and sketches at the scene of the incident provide an overall perspective of people and machinery in relation to the incident. Sketches can be drawn freehand into the notebook being used to record your observations of the scene. Sketches should represent as accurate as possible projection of the item, feature, scene or map being drawn. This can be assisted by including a scale and orientation on the sketch. The scale can be calculated by taking a measurement of the area and using a simple conversion for representation on the sketch. For example, if the area is 10m in length, a simple scale might be 1cm = 1m. The orientation can be shown on the sketch by using a compass rose and indicating north. Sketches should be dimensionally accurate, and the location of moveable objects indicated from two fixed locations. This can be achieved by:

taking two measurements at right angles to adjoining walls or other fixed locations;

taking two measurements on either side of the object to other fixed locations; and

selecting two fixed locations as points of reference and taking measurements from the object in question to the points of reference.

When you are recording dimensions, millimetres are used for measurements up to 999mm. For measurements of one metre and greater, metres are used as the unit of measurement. For fluid measurements use millilitres up to 999ml and litres thereafter. All measurements should be metric, except where industry or workplace norms dictate otherwise. For example, the aviation industry internationally still measure altitude in feet and speed in knots (nautical mile per hour).



Samples

A sample is any substance or other material that is collected from the scene of an incident. It can be in the form of a liquid, gas or solid including powder, pellets or dust. When collecting samples it is important to avoid damaging or contaminating the sample because it may provide valuable evidence. When participating in the process of collecting samples you must ensure that all team members are using appropriate personal protective equipment including masks, protective eyewear, gloves, etc. In some cases, samples will be collected for analysis by specialist agencies or testing laboratories. These agencies may have specific requirements in relation to the way in which the sample is collected and presented. When taking samples:

make sure you take enough of the substance for the type of analysis or examination to be undertaken;

ensure that in collecting the sample you do not damage other evidence;

divide the sample into two separate parts and seal each part in a suitable container and label each container;

keep a separate record of the samples taken and the arrangements for testing;

keep at least one of the samples and store this securely. The other sample may be sent to the testing laboratory; and

each sample must include your name, the time and date that the sample was taken, location of where the sample was taken, the sample number and a brief description.

To satisfy continuity of evidence requirements when samples may be used subsequently in a court case, it is useful to photograph the sample being taken, including the label on the container in which the sample is placed. This will help validate that the sample taken was the same one presented as evidence in the court.



Documentary evidence Documentary evidence includes any document that is relevant to the investigation. This includes work procedures, operating manuals, company records, training records, plant and chemical registers, drawings, specifications and other documents discussed earlier in section 3.1. It is important to keep a log of documentary evidence collected which includes the date the document was obtained, who or where it was obtained from, a brief description of the document and its relevance to the investigation. Confidentiality, privacy and legal implications

In collecting evidence, the team must have regard to a range of issues that have implications for the final outcomes of the investigation, including the acceptance of the report. In the course of the investigation you may collect information about particular individuals that is of a private or personal nature. The investigation team must give due regard to privacy considerations in the collection and reporting of any such information. Any information not directly relevant to the incident (such as the person’s employment history) must remain confidential and should not to be included in any report unless relevant to establish causation. Personal details are not to be discussed with other individuals such as co-workers or supervisors.

If you are engaged as an external contractor to assist with the investigation you need also to be mindful of corporate confidentiality. Trade secrets and confidential information that relates to the organisation’s business must be protected from disclosure to competitors. Information relating to production techniques, production schedules, volumes and so on, are matters that many organisations will prefer to keep confidential. You may be asked to sign a confidentiality agreement to ensure that any sensitive information gathered in the course of your investigation is not provided to competitors or otherwise released.



Notwithstanding the need to maintain the confidentiality of certain information, you may of course be obliged to provide relevant information to regulatory authorities. As noted in section 1.3, it is important to provide all necessary assistance and cooperation to any investigation that is being conducted by a WHS inspector of a regulatory authority. This is also a legal requirement.

Summary Methods for gathering information and evidence are summarised in the following table.

Source How to access

Documentation Training records Work schedules Operating procedures Injury/accident records

People Interviews Questioning Discussions

Plant/substances Visual inspection Tests Operating manuals Chemicals registers (SDS)

Work environment/process Visual inspections Photographs Sketch maps and floor plans

Table 3.2 Information and evidence

3.5 APPROPRIATELY SECURE SITE, EVIDENCE AND ALL NECESSARY DOCUMENTATION This section covers those measures that are necessary to ensure that the site and evidence collected is secure from loss, theft or contamination.



You will recall in section 1.3, that some jurisdictions have provisions which allow an inspector to quarantine a site for a limited period while an investigation is being conducted. Notwithstanding these statutory requirements, the investigation team needs to take appropriate measures to ensure that the site, any evidence and relevant documentation is secured appropriately. This will require the following measures.

Authority The investigation team is to be vested with sufficient authority to secure the incident scene and any relevant equipment. Organisational policies and procedures (referred to in section 2.1) may assign the investigation team or a nominated person within the team with the appropriate delegation to secure any area, material or evidence required to undertake the investigation.

Storage Any evidence collected must be kept in a safe, secure location. For smaller, portable items including documents, photographs, witness statements, small pieces of equipment and samples, a specific storage area may need to be allocated. This could be a room that has been set aside for the purpose of the investigation as described previously, or it may be lockable cupboards or filing cabinets. The storage area must be capable of being locked to ensure that access to the storage area is by approved personnel only. Depending upon the sensitivity of the investigation, it would be appropriate to keep a log to record who has accessed the secure area and when that access occurred. Where documents have been transcribed electronically, access to the database must be strictly controlled. In some situations, damaged plant may need to be removed and stored in another location while under investigation. Off-site storage will require special arrangements and management approval should be sought. In either case measures must be taken to prevent general access to the equipment.



3.6 APPROPRIATELY INVOLVE MEMBERS OF THE INVESTIGATION TEAM As outlined in section 3.2, a key feature of the investigation process is the establishment of the investigation team. The credibility of the investigation process depends upon the active participation of all team members. The role of the team leader is vital. The team leader, in consultation with other team members, will need to formulate an action plan which allocates tasks and responsibilities to various team members. In developing the action plan the following principles should be kept in mind.

Allocate tasks according to the experience and expertise of team members. For example, one team member may have technical skills with a high level understanding of the operation of plant and equipment. This person should be given the task of examining and reporting on damaged plant.

Do not prejudge a team member’s skills or knowledge. Take the time to consult with the members of the team to explore and utilise their particular strengths.

Ensure that all team members are fully involved and not simply used for a period as a token gesture of inclusion. Similarly, be careful not to marginalise any team member by assigning them minor or menial tasks. This is particularly the case with a health and safety representative or other worker representative.

Ensure you do not inadvertently discriminate against a team member on the basis of gender, race or disability. Indeed, these can be vital attributes to an investigation team. For example, in a workplace where there is large number of non-English speaking workers, it will be helpful to include an non English speaking background worker on the team.

Use the investigation as an opportunity to mentor and develop people’s skills by “buddying” less experienced members with more experienced members.

Hold regular team meetings, maybe twice daily during the initial field investigation phase, to exchange information and update members on progress.



Ensure that all reports and documentation include the names of the team members and acknowledge their role in the investigation activity.

Following the completion of evidence collection Once all relevant evidence has been collected it may be appropriate to release the incident scene and for work activities to resume. The following tasks should be completed by the organisation’s management prior to any resumption of work in an area that has been the subject of an investigation.

Ensure all immediate hazards have been identified and risks controlled to prevent a re-occurrence of the incident (longer-term control strategies will emerge from the investigative process − this is considered in the next Element).

Review the scene and ensure that the area is clean and clear of obstacles.

Remove any barriers that were put in place in the course of the investigation.

Repair or replace any damaged equipment.

Confirm that all mandatory reporting has been completed.

Confirm that all relevant evidence from the scene has been collected and releasing the scene will not adversely affect the investigation.

Advise and secure approval of senior management to release the scene.

Competency check for Element 3 Key issues for each performance criterion in Element 3 are as follows. 3.1 Identify and access sources of information and data:

Draw relevant information from all sources. This will include background information such as legislation, personnel records, training records, accident and incident reports, maintenance records. It will also include direct sources of information drawn from interviewing witnesses and site inspections.



3.2 Inspect incident site, equipment and other evidence:

Physically inspect the site and accurately record all observations.

3.3 Facilitate information and data gathered by others:

Access data and information that may have been collected by regulatory authorities, co-workers, contractors or other personnel.

3.4 Take and record statements, photographs, measurements

and documentary evidence, taking account of objectivity, confidentiality and legal implications:

Progress your investigation by systematically building a record of the scene through interviews with eyewitnesses and others. Interview skills and questioning techniques underpin effective analysis of events.

This is supported by photographs, sketches and measurements, ensuring that all activities are undertaken objectively and accord with confidentiality requirements, and do not present unexpected legal implications for the organisation.

3.5 Appropriately secure site, evidence and all necessary documentation:

Protect evidence gathered by ensuring that there is a record of all material gathered in the course of the investigation and that it is secured to prevent any interference or contamination. This includes the facility used by the investigation team for its deliberations etc.

3.6 Appropriately involve members of the investigation team:

Ensure that all members of the investigation are fully and meaningfully utilised and that an active process of consultation is in place to afford team members an opportunity to provide input into the action plan and investigation activities.



Case Study 3

Transport workshop incident

You are engaged as a WHS advisor to a large transport company. The company has a permanent workforce of 100 workers consisting of drivers, maintenance staff and administrative staff. The company operates from a single site consisting of a workshop, depot sheds and an administration area. You are responsible for coordinating incident investigations and report directly to the General Manager. One evening you are contacted at 11.45pm by Mike Taylor, the Workshop Manager and advised that there has been an accident. The facts of the incident are as follows:

The incident

At 11.05 pm, a truck driver, Steve Peterson entered the workshop prior to commencing his night shift. As per company policy Steve looked around the workshop to check on the night mechanic, Jim Atkins. This policy had been instituted as a preventative measure because the night mechanic works alone. Steve found Jim Atkins lying face up on the pit floor with his head propped on the handrail post of the stairs leading up from the pit. Jim’s head was bloodied and, although conscious, he appeared dazed and possibly in shock. He was unable to recall how the accident had occurred. A truck with its wheel removed was found on top of the gantry platform where the night mechanic services trucks. A large wheel brace was also found nearby. A pool of blood was found in the pit, approximately 1.4metres beneath this gantry platform. There was smeared blood leading from this point to the foot of the pit stairs where Jim was found.



Steve Peterson sought the assistance of another truck driver and bandaged Jim’s head while an ambulance was called. Steve assisted the ambulance crew in treating Jim. Steve also rang the Workshop Manager, Mike Taylor, to advise of the incident. Subsequent to the incident a day driver, Gary Williams, advised that at the end of his shift (approximately 10.45pm), he had spoken to Jim who looked weary but was otherwise fine. Jim has been employed by the company for 12 years. He is 51 years old, overweight and is the regular night mechanic by choice. A review of the company’s Register of Injuries reveals that Jim has suffered two previous work-related injuries. On one occasion he suffered a “twisted knee” from slipping down the stairs beside the gantry platform in the workshop. On the other occasion his leg was badly swollen when a wheel brace he was stamping on to loosen a nut slipped and hit his leg.

Your task

To progress your understanding of Element 3 “Collect information and data analysis”, complete the following tasks. The General Manager has asked that you brief her on how you propose to go about this investigation. Prepare a two-page summary which outlines:

1. a proposed investigation team and how they may contribute to

the investigation;

2. the type of information that may assist in this investigation;

3. an inspection plan, covering what you will inspect and the processes that you will apply in undertaking the inspection; and

4. an interview plan, including who you need to interview.

The following issues have been provided to prompt your thinking (and research) about this case study. You are not required to respond or provide answers to the questions below; but in considering these questions you may be better positioned to respond to the tasks above.



Issues

1. Documentation

(a) Why might previous accident and injury records be useful in this case?

(b) Consider the work schedule, keeping in mind that hard tasks were undertaken at the end of the shift.

2. Inspection

(a) Should the area be photographed and/or should a sketch map be made? Why might this need to be done quickly?

3. Witness statements

(a) Who should be interviewed and why? (b) Where will these interviews occur and why? (c) What would you do if a person refuses to be interviewed?

4. Investigation Team

(a) Which tasks might you allocate to particular team members? Why?

(b) Should the health and safety representative or member of the health and safety committee be involved? What role might they play?




Activity 3

Keep a copy of this Activity for your Assessment Portfolio. Consider the information provided throughout Element 3 and undertake the following activities. 1. Identify three important sources of information that are critical

to the conduct of an investigation. You may refer to an actual investigation that you have been involved with or you may base your response on the information provided at Case Study 3. Indicate how you would access this information

2. What other parties may be able to provide information that will assist in your investigation?

3. Based on an incident of your own choosing (either from personal experience or research), prepare a summary of the methods you would adopt to inspect the scene and gather relevant evidence.

4. How can you ensure that evidence and other documentation gathered in the course of the investigation is secured appropriately?

5. What steps will you take to ensure that all team members are suitably involved in the investigation?


Element 4: ANALYSE INFORMATION AND DATA GATHERED TO IDENTIFY IMMEDIATE AND UNDERLYING CAUSES AND PRACTICAL PREVENTION MEASURES

The previous Element focused on collecting the information and data needed for the investigation. The next step in the investigation process involves organising and analysing this information to identify the causes of the incident and to develop corrective actions to prevent any re-occurrence. This is the crucial step of working out what went wrong and what needs to be done to correct it. In developing this approach you will need to:

examine the sequence of events that occurred before, during and after the incident;

analyse all the information and data gathered in the course of the investigation; and

establish the immediate and underlying causes of the incident.

In order to complete this Element, you need to demonstrate that you have analysed all of the relevant facts carefully to get to the root causes of the incident and all the related causal factors leading to the incident. This involves satisfying the following performance criteria: 4.1 Ensure the investigation team understands and identifies the conceptual basis for the analysis. 4.2 Construct time line of events leading up to incident. 4.3 Research causative event/s. 4.4 Identify conditions and circumstances that contribute to the causative event/s. 4.5 Identify intervention points on the time line for prevention. 4.6 Identify strategies to prevent the re-occurrence of the incident.



4.1 ENSURE THE INVESTIGATION TEAM UNDERSTANDS AND IDENTIFIES THE CONCEPTUAL BASIS FOR THE ANALYSIS You will recall that the investigation plan needs to identify the team members who will be responsible for examining particular elements of the information gathered. It is equally important that the team members understand how this information is to be analysed. This is often overlooked by investigation teams. Yet it is a critical part of the process. The conceptual basis provides the structure for the investigation, prevents the team from going off on tangents and is vital to determining the root causes of the incident.

Prior to analysing the evidence that has been collected it is therefore vital that the team leader organise a team meeting to provide clear guidance on the “conceptual basis” for the investigation. The conceptual basis of the investigation comprises four key principles, vital to determining the cause of the incident. These are:

being objective and open-minded;

avoiding blame;

focusing on systemic failures; and

asking “Why?” and “How?” rather than “What?”

Objectivity and open-mindedness Objectivity is fundamental to achieving a fair and balanced report of the incident. Often the seemingly obvious “cause” of the incident is not what really happened. Team members should be advised not to bring preconceived views or attitudes about the incident to the investigation process, but rather to keep an open mind until all the evidence is examined. In analysing the evidence, team members need to be advised to stick to the facts rather than offer opinions or judgements. This can require a degree of discipline given that human nature tends to focus on the obvious and on reaching a quick conclusion.



Do not focus on individual behaviour As a WHS practitioner involved in the investigation of incidents, you will encounter situations where various people refer to the “stupidity” of others in undertaking certain actions. Their view will be that the accident was the individual’s fault because they were careless, inattentive or “stupid”. This is not a sound basis for an investigation. As - discussed previously, an incident is usually the result of a failure in the interaction between people, plant or materials, the work process and/or the work environment. In other words, incidents result from a failure in the work systems rather than a failure by individuals. By focusing solely on human behaviour, factors central to determining the underlying causes of the incident will be overlooked. For example, did the person’s allegedly “careless” behaviour emanate from fatigue, a lack of training, inexperience, poor task design, inadequate working environment etc? Apportioning blame would not only be inappropriate, but would make people less cooperative with the investigation process and may even cloud the underlying causes of the incident; for example by people providing false or misleading testimony or by hiding documents crucial to the investigation. In analysing information about the incident, care needs to be taken to record the central facts without apportioning blame, for example:

“a man fell off a ladder” rather than a “man fell off the ladder because he was not concentrating”; and

“a person was hit by the forklift truck” rather than “the person was hit by the forklift truck because she was not watching where she was going”.



Systemic failures The principle of focusing on the system rather than the individual has a long history in WHS practice. Laws and courts in Australia have also reinforced this notion. WHS legislation requires PCBUs to maintain a safe system of work. In interpreting these provisions the courts have determined that such systems should take into account the errors and omissions that individuals may make. For example, in Ferraloro v Preston Timber Ltd (1982) 42 ALR 627 the court determined that, in developing safety systems: “The employer is bound to have regard to a risk that injury may occur because of some inattention or misjudgement by the worker performing his allotted task.” Focusing solely on human behaviour will not only overlook factors crucial to determining the cause of the incident, but is fundamentally flawed in that it is impossible to intervene effectively to ensure the people are no longer fallible to normal human weaknesses. Also, it ignores one of the key conceptual bases for WHS law in Australia. Remember, the focus of the investigation is not on individual behaviour but rather relates to the work system as a whole. The individual is only a part of the total work system and an error or omission of an individual which leads to an incident, is a failure of the system and the system is where effective remedial action will lie. The investigation team needs to be mindful of these underlying principles.

Ask “Why?” and “How?” rather than “What?” We noted above the importance of examining the system of work rather than its individual components. Certainly the individual component (ie, the direct and possibly most obvious cause of the incident) maybe a starting point. However, to track back through the system of work requires a more structured analysis based on continually asking why an event occurred or how a particular thing might have happened.



Consider the scenario of a worker injured when her fingers were caught in an unguarded machine. Asking “what?” focuses the investigation on the injury and may lead to simplistic conclusions such as (a) the machine was not guarded and this is the cause of the accident or (b) the worker was stupid to put her hand where it would get caught. Both cases ignore the fundamental issue of “why” the machine was unguarded. How could the system of work allow such a thing to occur? It is clearly an analysis of the system of work that underpins a successful resolution of the issue. The questioning techniques outlined in section 4.3 will assist the investigation team to focus on the system of work rather than individual actions which form part of that system.

4.2 CONSTRUCT TIME LINE OF EVENTS LEADING UP TO INCIDENT Once team members understand the conceptual basis of the investigation it is time to begin organising the facts and data in a way that will assist the team to analyse the incident. This will involve developing an ordered sequence of the events that led up to the incident. A useful tool here is to actually draw a time-line. As noted in section 4.1, often assumptions can cloud the reasons behind an incident and what seems “obvious” is not the case at all. A time-line will help to construct a sequence of events from the evidence to determine the likely immediate cause of the incident in an impartial and objective manner. Take the case of a mechanic, Bob, found unconscious near the mechanic’s pit of a long haulage trucking company. The time-line could look something like this:



1. Mechanic Bob Jones commences shift 11am. Provided with list of jobs for the shift.

2. 4pm Bob complains of headache to supervisor Dan Long. 3. 6.45pm Bob seen by Dan Long hosing truck rego no. MYD

234. 4. 7 pm Supervisor Dan Long leaves for the day. 5. 8 pm day driver Phil Brown farewells Bob at the end of his shift.

Bob seen ascending mechanic’s gantry next to truck rego no. GHT 229.

6. 8.45 pm Chris Charlton discovers Bob lying unconscious in mechanic pit at foot of gantry with wheel brace in hand.

Table 4.1: Sample Time-line of events When time-lines are combined with work activities and physical evidence on site, a “picture” or possible sequence of events begins to emerge. For example in the case above, mechanics at the workshop were provided with a list of work activities to be performed during the shift. Workers crossed these activities off as they were completed. This and the physical evidence at the site suggest that injured mechanic Bob was checking the wheels on truck GHT 229 between 8.00 and 8.45pm at the time of the incident. Note that at this stage the relevant evidence and facts are being assembled in an objective way to help the possible causes of the accident to emerge. In most cases the end point of the time-line will be the time of the incident. From this point the investigation team needs to work back to include any evidence gathered that may be relevant to the investigation. It is important that the investigation extends back in time as far as is required. While the time-line for the example above extends only to the day of the incident this is not always the case and time-lines in major or complex cases may extend back days and even weeks, months or years from the date of the accident. If the investigation is charged with also enquiring into the emergency response phase of the incident, the time line may extend beyond the incident itself and plot all the events and issues existing post incident.



4.3 INVESTIGATE CAUSAL FACTORS In this section you will learn about analysing the events or conditions highlighted by your time-line to determine the causal factors leading to the incident.

Direct causes The direct causes of an incident are the factors that are directly responsible for the incident. They generally occur immediately prior to the incident; with immediate effect. Direct causes are sometimes quite straightforward and in many cases they will be apparent immediately. For example, in the example provided in section 4.2, a direct cause of the incident could be grease on the gantry which caused the worker to slip and fall from the gantry into the mechanics’ pit. Establishing the direct causes provides a starting point for researching the incident to establish the underlying causal or contributing factors that led to the event.

Contributing factors However, to uncover the underlying contributing factors, sometimes referred to as “root” causes of the incident, we need to dig deeper, looking “backward” for the reasons “why” those direct causal factors existed, by considering such issues as any latent system or organisational failures, errors or omissions maybe right back to the design stage of the plant equipment and systems involved, factors which could have existed for a significant time before the incident took place. Incident causation can often be very complex and are usually based on multiple contributing factors. To ensure all possible incident causes have been identified, a structure or methodology for the analysis is needed.




While a number of different models of incident investigation methods are available, one of the more common tools used is the “Root Cause” or “Why Tree” analysis10 11. This methodology is based on the notion that each causal factor is linked to others. The method involves a systematic examination of the incident and uses a repetition of the question “why?” a sufficient number of times to ensure all relevant underlying causal conditions and circumstances are identified. In this way a logical representation of the incident is constructed as in the following simple example.

Example: “Why Tree” Root Cause Analysis Undertaking a “Why Tree” root cause analysis involves the following steps: 1. The starting point for the analysis is the incident (eg, the

vehicle colliding with a worker) and the direct causes of the incident (eg, “Loss of control of the vehicle” and “Poor road and footpath design”) ). You should refer to the time-line you developed in section 4.2 when constructing your “why tree”.

2. After each “why?” question is asked, potential contributing

factors are documented. Note that there may be more than one potential contributing factor for each question. For example, the loss of vehicle control in the example above, could have been caused by one or more of the following factors (speeding, road surface, faulty vehicle, etc). You will need to document all possible factors since all may be relevant to uncovering all causes of the incident.

10 Williams P. (2001), Techniques for root cause analysis, Baylor University Medical Centre, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292997/ 11 NASA (2003), Root Cause Analysis, NASA Office of Safety & Mission Assurance, http://www.hq.nasa.gov/office/codeq/rca/rootcauseppt.pdf


3. The process of continually asking “why?” may raise questions for which you do not have information (eg, was the vehicle faulty?). This may involve further investigation or additional information. Accordingly, it may not be possible to complete this process in one session and the team may need to revisit the analysis a number of times as more facts are known and more questions raised.

4. As you develop the tree, decisions will need to be taken as to

the relevance of potential causes. The facts obtained from the investigation will determine which factors remain part of the causation tree and which are rejected as irrelevant. For example, in an investigation of a forklift incident, one branch of your causation tree may suggest the forklift may have malfunctioned. However, maintenance records may demonstrate that it was well maintained and therefore can be rejected from the causation tree.

Note: Where there is a lack of evidence to support or reject a potential causal factor, the investigation should continue to explore the option until it is either proven or disproven as being causative to the incident.

5. You need to be specific when documenting the causal factors,

otherwise corrective actions will be difficult to develop later. For example, a comment like “management did not implement a system” helps no one and is too vague to generate an appropriate corrective action. You should stipulate what the system features were exactly that management failed to implement...what system features the absence of which caused the incident to occur.

6. When you think the tree is complete, review all your

investigation evidence and all the “why tree” factors, including those you have previously rejected, to ensure you have not missed anything.



4.4 IDENTIFY CONDITIONS AND CIRCUMSTANCES THAT CONTRIBUTED TO THE DIRECT CAUSES OF THE INCIDENT The last section focused on researching the various causative factors that led to the incident. It was seen that the investigation needs to dig deeper than the immediate causes of the incident to identify the underlying contributing factors, the conditions and circumstances that gave rise to the immediate causes and ultimately to the incident. This section outlines some of the potential factors that could be considered when assessing conditions and circumstances which might have contributed to failures in the system of WHS management that could have led to the incident.

Conditions Conditions refer to the attributes of the work activity which are in place permanently. This includes the type of equipment used, the layout of the work area, and work practices and processes that are applied in the normal course of the work. For example, in the case of the injured mechanic referred to in section 4.2, the conditions may include:

Plant, equipment, such as the gantry, a manual wheel brace the layout of the work area, such as working on an elevated gantry; and

work procedures and practices; such as rostering and working alone procedures.

It can be seen that the conditions associated with the work activity may have had a bearing on causation of the incident. Your investigation should examine all the conditions that led to all the direct causes of the - incident.



In the above example in which Bob was found unconscious on the floor of the mechanics pit, some of the conditions mentioned are:

he fell off the gantry − the gantry is a condition ie, workplace layout;

he was changing the wheel using a manual wheel brace − the wheel brace is a condition ie, workplace equipment;

Bob used his foot for leverage, his foot slipped and he fell backwards off the platform − this is a condition ie, a work practice; and

he performed the task late at night when he was tired − this is also a condition ie, work process.

By applying the root tree analysis to these conditions you will begin to uncover the underlying causes. For example:

Why was there no fall barrier on the gantry?

Why was Bob using his foot on the wheel brace?

Why was he doing this task late in the shift?

Circumstances Circumstances refer to situations that are not part of the normal work activity. These may be short-term situations, for example, changing weather conditions or the absence of key staff. Equally, they may be matters which on the surface could seemingly be unrelated to the incident. For example, a person may have a pre-existing injury. While the injury has hitherto not been a problem and would appear to be unrelated to the incident, there may be an underlying relationship. In our example of the injured mechanic, contributing circumstances could have been:

one of the mechanics called in sick and Bob was required to work overtime to cover the extra work;

Bob had previously injured both legs and suffers physical weakness which may have resulted in less stability; or

Grease had been spilled and transferred to the gantry and wheel brace on the mechanics shoes.



It is important to identify all circumstances that potentially have some part to play in the event. The purpose of analysing workplace conditions and circumstances is to move beyond the direct causes of the incident and to identify failures in the organisation, working environment and systems of work. Working through the example above you start to recognize failures in the WHS management system as being the “root causes” of the incident. The management system failures to:

identify hazards eg, the elevated gantry, working long hours, performing tasks when tired, using inappropriate equipment and work practices; and

implement effective control measures such as fall protection, adequate training, effective procedures, rostering arrangements, supervision, appropriate work schedules, and so on.

As previously noted, the work system comprises a number of interrelated elements: people, plant and materials, the work processes and the work environment. In grouping contributing conditions and circumstances these elements provide a useful framework for identifying relevant factors, organising our information in a logical sequence and to determine causative factors. This process is illustrated below.



System/Element Condition/Circumstance Possible Failures

People

Technique used to change wheel (condition) Working extra shift to cover absent mechanic (circumstance). Pre existing injury (circumstance)

Training/instruction/supervision. Workplace planning Instruction/ supervision.

Plant and Materials Old equipment – manual wheel brace (condition). Elevated gantry (condition).

Purchasing Workplace design

Work Process Schedules of work – long shifts (condition) Performing manual handling tasks late in the shift (condition)

Job design Job design

Work Environment No barrier on gantry

Workplace design

Table 4.3: Incident Causes and System failures

Approaching the analysis in this way will begin to identify the failures in the work system and will also help determine possible control options. The development of control options arising from your analysis is dealt with next.

4.5 IDENTIFY INTERVENTION POINTS ON THE TIME LINE FOR PREVENTION We saw in section 4.2 that the development of a time-line is a crucial step in analysing the information that has been collected as part of the investigation. It also provides an opportunity to determine where and when the organisations’ management systems can be modified or improved.



Using the previous example timeline, the evidence has pointed to a number of events in the lead-up to the incident:

1. Mechanic Bob Jones commences shift at 11am. Provided with

a list of jobs for the shift. 2. 4pm Bob complains of headache to supervisor Dan Long. 3. 6.45pm Bob seen by Dan Long hosing truck rego no. MYD

234. 4. 7pm Supervisor Dan Long leaves for the day. 5. 8pm day driver Phil Brown farewells Bob at the end of his shift.

Bob seen ascending mechanic’s gantry next to truck rego no. GHT 229.

6. 8.45pm Chris Charlton discovers Kevin lying unconscious in mechanic pit at foot of gantry with wheel brace in hand.

Sample Time-line

These include:

mechanic commences shift;

mechanic provided with list of activities;

mechanic hoses truck (light work);

shift supervisor leaves, mechanic left alone; and

Bob changes wheels on truck (heavy work).

From this list of activities, a number of intervention points are suggested, for example:

the timing and length of the mechanic’s shift;

the sequence of work (light duties performed first, heavy duties performed later);

the lack of mechanical devices to reduce the exerted force when changing wheels; and

the worker’s lack of supervision during the latter part of the shift.

It should be noted that these are only suggested intervention points in the development of controls. Their utility will depend upon the range of contributing factors and the underlying conditions and circumstances identified during the root cause analysis of the investigation (see section 4.3).



There is a further consideration here. While it is important to determine at which stage in the process controls can be introduced, it is also important to determine whether the corrective actions are practicable and will have the desired effect. In formulating strategies to prevent a re-occurrence it is therefore important to examine all possible corrective actions in terms of the following.

Will the corrective action be effective? There is no point in recommending a course of action that will have limited practical effect or could potentially introduce new hazards.

Are the corrective actions feasible?

How long will the measures take to implement?

How much will they cost?

Will they affect productivity?

This process of determining corrective action is illustrated in the next section. In conclusion, once all the intervention points have been identified, you should ensure that must identify and prescribe a potential corrective action addressing each of the causal factors, conditions and circumstances that you have previously identified in your investigation and why-tree analysis.

4.6 IDENTIFY STRATEGIES TO PREVENT THE RE-OCCURRENCE OF THE INCIDENT Once the underlying causes of the incident have been identified it is necessary to identify the corrective actions required to prevent the incident occurring again. This will incorporate changes to the management systems and involve specific actions such as changes to:



training;

policies and procedures;

health and safety inspections;

equipment (new or design modifications); and

work schedules.

The process of developing corrective actions requires a strategic approach. This is fundamental to the success of the investigation process. This strategic approach should adhere to the following principles:

Develop corrective actions for each condition and circumstance Following the process in the previous sections, you will have identified a number of causal conditions and circumstances that relate to the direct causes of an incident. Your corrective actions will need to address all of these matters. In determining corrective actions for each causal factor you should first consider any legislative requirements which need to be met and then consider a range of interventions which might address the causal factor using the hierarchy of hazard control. There may be multiple possible corrective actions for some causal factors. They will no doubt differ in level of regulatory compliance, effectiveness, cost and ease of implementation. In the final analysis, you should recommend that which you determine to be most effective and reliable method to address the particular causal factor. Note: When making incident investigation corrective action recommendations, you should avoid wherever possible recommending corrective actions that are themselves investigations. For example, when making a recommendation for introduction of a travel restraint system to prevent the recurrence of a fall from a roof, avoid making a recommendation such as “Company X should explore the introduction of a travel restraint system to....” This would effectively surrender to another investigation and investigator your responsibility to find an appropriate corrective action for a causal factor in the incident you were commissioned investigate. Unless you have been constrained from carrying out those enquiries within the scope of your investigation, maybe due to financial or time limits, you should



explore the matter within the corrective action phase of your own investigation and then make specific recommendations (eg in this example you should investigate appropriate travel restraint systems and recommend something like “Company A should introduce an ABC travel restraint system with XYZ features, or similar” to address the causal factor.

Examine the legislation The starting point for identifying appropriate controls will be the relevant WHS legislation. The legislation needs to be examined to determine if any specific control measures relating to a particular causal factors are outlined in the legislation or in guidance material provided by the regulatory authority. For example, in the forklift incident case study described below, legislation requires statutory licensing for operators and a range of design measures (eg, movement alarms) for the forklift truck itself; and further information on control measures is available in the form of guidance information. Your Why Tree analysis should have identified if these features were in any way causal to the incident being investigated and if so then the corrective actions recommended will need to ensure the subsequent legislative compliance of the forklift.

Determine the most appropriate action using the Hierarchy of Control Not every condition or circumstance will have a legislated control measure and a range of different controls (for example as outlined in a code of practice, standard or other guidance information) may be possible for each cause of the incident. In such cases it is important that the various options be identified and the most effective controls implemented. Here a risk management approach can assist. This involves attempting to, firstly, eliminate the hazard, but if this is impracticable (because of suitability, availability, cost, etc) then working through a “hierarchy” to arrive at the most effective control to a problem. The “hierarchy of control” process is enshrined in the WHS regulations and in codes of practice and guidance material and is illustrated in the table below. Note that if the particular hazard



cannot be eliminated, you need to work through the control options outlined in the Table to arrive at the most effective control. You should be aware that personal protective equipment (PPE) is considered the least effective form of control because it:

simply provides the worker with a protective barrier to mitigate the impact of the hazard, rather than controlling the hazard at its source;

relies on the person to ensure it is worn or used as was intended by the PPE manufacturer;

has design limits and effectiveness limitations beyond which the expected protection may not exist; and

introduces additional hazards and considerations, such as limiting the persons perception capability; and

may engender a false sense of security which is not proportional to the actual level of protection afforded.

Hierarchy Control Examples

1 Substitution Replacing hazardous piece of plant. Substituting large boxes with small boxes of supplies. Substituting cleaning product with less hazardous product.

2 Isolation Spray booth, abrasive blasting chamber. Electronic swipe-card to prevent client access. Protective screens for taxi/bus drivers. Locating dangerous machine away from staff.

3 Engineering Machine guarding. Stands and glare screens for computers. Trolleys/hoists for manual handling. Movement alarms/flashing lights for forklift trucks.

4 Administration Two or more staff present to serve clients. Warning signs. Job rotation. Safe work procedures. Training.

5 Personal Protective Equipment

Hard hats. Rubber gloves for kitchenette. Safety boots. Ear muffs, ear plugs. Sun block, sun hats.

M

O

S

T

E

F

F E C T I V E

L E A S T

Table 4.4: The Hierarchy of Controls



Ensure that the control will not introduce new hazards

When considering control options it is important to avoid introducing any new hazards into the workplace, without them being thoroughly assessed and effectively controlled. . For example, if an incident involved a worker’s limb being trapped in a piece of plant it is important that, if new plant is to be purchased, the operation of the new plant must not introduce new hazards such as excessive noise levels.

Examine how the control fits into the broader management system

When assessing the effectiveness of a particular control measure the impact of the control on the broader system of work needs to be considered: How will the control measure actually fit into the system of work? Will a new operating process and procedure need to be developed to accommodate it? A pertinent issue in this context is cost. How expensive will it be to implement each control? In certain circumstances the investigation team may need to undertake a cost-benefit analysis to demonstrate to management the merit of one control option over another.

Assign responsibility to specific people and set dates In determining possible control options, the investigation team needs also to consider how these actions will be implemented. This may involve recommending each control against clear lines of responsibility and suggested deadlines. This process needs to be open and transparent so that all members of the organisation will know what is to be done, who might be responsible and when it needs to be completed. If you are contracted as an external specialist to participate in the investigation you may not be in a position to assign responsibilities and time frames. Where this is the case, the determination of responsible parties can be included as a separate recommendation for management. This aspect is considered further in the next Element.



Incorporate the recommendations in an investigation report

When the investigation team has agreed on the detail of the corrective actions, it is time to prepare the investigation report, which is the subject of the next Element.

Competency check for Element 4 Key issues for each performance criterion in Element 4 are as follows. 4.1 Ensure the investigation team understands and identifies the conceptual basis for the analysis:

The team applies a systematic and consistent approach to analysing the information and data gathered. This approach focuses on WHS systems and establishing why a particular event occurred rather than who may have been responsible.

4.2 Construct time line of events leading up to incident:

The analysis of information will trace the history of the incident via a time-line to identifying key events that may have some role in the incident.

4.3 Investigate causal factors:

The direct causes of an incident provide the starting point for the investigation and are the primary links with the contributory factors. These direct causes need to be analysed thoroughly to identify the underlying or “root” cause/s of the incident. “Why tree”root cause analysis is a useful incident analysis tool.



4.4 Identify conditions and circumstances that contribute to the causative event:

The investigation must examine the work systems and processes that are a feature of the work activity in conjunction with any short-term or isolated events which may have contributed to the incident.

4.5 Identify intervention points on the time line for prevention:

The causes of the incident are examined to analyse possible solutions. These solutions are cross checked to ensure they will be feasible and effective and will not introduce new hazards into the worksite.

4.6 Identify strategies to prevent the re-occurrence of the incident:

The identification of the strategic course of action to be included in the final investigation report. This will include recommendations to be implemented to prevent future

occurrences.



Case Study 4

Forklift collided with worker in loading dock area

You have been engaged by the safety manager of a major warehousing organisation to coordinate the investigation of a serious incident. You go to the warehouse the day after the incident has occurred and have an opportunity to have a look around and meet with people who were present at the time. A forklift truck has collided with a worker in the vicinity of the loading dock area. The injuries are quite serious with latest reports indicating that the worker’s leg may need to be amputated. The details of the incident remain sketchy but it appears that the worker walked into the path of the forklift as it travelled out of one of the aisles between the racking systems. The forklift was carrying two fully-loaded pallets of grocery items with the load being carried at around waist height. You are advised that the warehouse has been modernised with a new layout and infrastructure, commencing the previous week. New rack systems have been installed and traffic areas established. You notice that the pedestrian access markings, which applied to the old layout, are still on the floor and are now covered substantially by rows of racks. There is no signage on the racks; however, there is a sketch map of the new floor plan on the staff notice board in the dock area. The sketch map has clearly marked directions for traffic flow and includes instructions on “no walk” areas.



The forklift operator is a relatively new worker. He has been on the job for four weeks. He was not injured in the incident but was clearly upset and distressed. He is away from work today. His supervisor notes that he appears to be a reasonable worker. The supervisor advises that the busy schedule in the warehouse has meant that the forklift operator’s induction has been delayed but is expected to occur before the end of the month, when all the warehouse workers will be briefed on new operating procedures that apply to the revised layout. You observe that the forklift which was involved in the incident is being driven by another operator. The machine seems to be quite old and you notice that there is fluid leaking around the rim of the right front wheel. The supervisor tells you; “The worker was careless. It was his own fault that he was hit by the forklift. Despite being told on numerous occasions about the dangers of working near moving equipment, he wasn’t watching and walked straight into the forklift as it turned out of the rack lane. It’s the same with most of these workers here. They have very poor English and they just don’t listen to me.” While you are inspecting the passageway where the incident occurred, one of the injured man’s co-workers calls you aside, out of view of the supervisor. He claims that the accident happened because the forklift was driving too fast. He says that speeding is commonplace in the warehouse because they have such tight deadlines to load the trucks and move them out. He does not want you to tell anyone that he has told you this for fear of losing his job. You have established an investigation team consisting of key personnel within the organisation. You are concerned about the comments of some team members who have suggested that one or more individuals are to blame for the incident. You see this as an opportunity to draw the team together to ensure that all team members have an understanding of this phase of the investigation. You coordinate a team workshop and for this purpose prepare a briefing paper for the team.



Task

The briefing paper is to be approximately two pages and will outline:

the importance of being open minded and objective;

questioning techniques based on “why?” and “how?” rather than “what?”; and

focusing on work systems rather than individual behaviours.

Issues

The following issues have been provided to prompt your thinking (and research) about this case study. You are not required to respond to the matters below; they merely serve to guide your thinking about the processes involved in analysing information. Consider:

1. The concept of “fault” which is being promoted in the

workplace. The supervisor blames the worker; the workers blame the forklift operator and the work schedules. A challenge for an investigation team is to work through this notion without alienating the workplace. You will need to consider how you will do this.

2. Contributing factors such as:

(a) the changed workplace – new layout, old markings; (b) worker induction (too busy to provide to the forklift operator who will be briefed along with other workers about new procedures at the end of the month); (c) training and instruction to workers (new schedule on notice board but nothing else); (d) faulty equipment; (e) inappropriate operation; (f) inexperienced worker; (g) lack of supervision; (h) work schedule; and (i) language barriers.

3. Other issues such as legislative requirements eg, notification

and incident site preservation. How would you respond to these?



Activity 4

Keep a copy of this Activity for your Assessment Portfolio. The following activities are based on the incident reported in Case Study 4; alternatively you can relate these activities to a situation of your own choosing. 1. Write a report to the health and safety committee explaining

the approach that will be taken for analysing the information that has been collected. Your report will need to emphasise a “no blame” approach, and provide a rationale for this.

2. Explain what is meant by “direct causes”, and give examples.

3. What are conditions and circumstances, and give examples of

how these may have contributed to an incident? You can use Case Study 4 to demonstrate this or you can use a situation of your own choosing.

4. Develop a time-line for the incident presented in Case Study 4

and identify appropriate points of intervention along the time-line that will prevent the incident from recurring.

5. Outline strategies that may be adopted to prevent a re-

occurrence of the incident outlined in Case Study 4.



Element 5: COMPILE AN INVESTIGATION REPORT

You have now reached the stage of the investigation where it is time to draw all of your methods, findings, analyses and recommendations together as part of a Final Report. This section describes how you can compile the investigation report to ensure that all relevant issues have been addressed and the information is presented in an organised and objective way. After completing this section you will need to demonstrate that you can prepare an investigation report which is concise, relevant and objective and meets the needs of the organisation to improve health and safety outcomes. Among other things you will consider who the target audience ie, who will get the report and for what purpose. In order to complete this element of the competency unit successfully you will have to show that you have satisfied the following performance criteria: 5.1 Document results of analysis in a format to suit the required target audience and legal requirements. 5.2 Phrase report in objective terms and cite evidence and reasons for conclusions. 5.3 Include recommendations for prevention in report. 5.4 Disseminate relevant information and data to key personnel, stakeholders and external agencies as appropriate, following appropriate authorisation. 5.5 Use findings from the report to develop further prevention strategies



5.1 DOCUMENT RESULTS OF ANALYSIS IN A FORMAT TO SUIT THE REQUIRED TARGET AUDIENCE AND LEGAL REQUIREMENTS It is essential to document the findings of the investigation team in a way that suits the needs of the required audience and meets any legal obligations. The various groups interested in the report may have different needs and their interest in the report will be motivated by different reasons. For example, the Board of Directors will review the report from a different perspective to that of the workers or those involved in the incident. You need to be cognisant of these differences as well as the skills and capabilities of each group. However, in all cases the format of the report must be directed at providing sufficient information to improve safety outcomes and avoid a re-occurrence of the incident. This section demonstrates how you do this.

Who is your target audience? The target audience of the investigation report can vary and may include:

Health and safety committees and health and safety representatives;

senior management;

line management and operational staff; and

external authorities.

Each of these groups may have different perspectives and needs and it is important that the investigation report caters to those needs. Each group will now be discussed in turn.



Health and safety committees and representatives

As the primary WHS consultative means within an organisation, the health and safety committee and health and safety representatives will be key recipients of incident investigation report. When used effectively, the health and safety committee and health and safety representatives can advise management on key issues arising from the report. The health and safety committee and health and safety representatives will view the report from the perspective of “what action is needed now and over the longer term to ensure that workers are not exposed to undue risk?” Accordingly, the structure and language of the report will need to emphasise immediate and long-term action and may recommend a role for the committee in helping ensure that recommendations are appropriately put into place. The health and safety committee and health and safety representatives may monitor the implementation of the report and may offer views on the report and its various recommendations.

Senior management

In most cases the final report of the investigation will be prepared for the approval and/or endorsement of senior management of the organisation. The level of management involvement will depend upon the size of the organisation and the nature of the incident; however, it can be expected that the report will be brought to the attention of the General Manager/Chief Executive Officer. This may take place through a chain of command including production managers, line managers, and directors; however, ultimately the report will provide recommendations that require decisions at senior levels of the organisation.



With this in mind, the results of the investigation should be presented in a manner that will convince management that there is a problem and remedial action is necessary. This is likely to be achieved if the facts are presented in a way that identifies not only the causes of the incident but also demonstrates how the proposed solutions will be the most effective in preventing incident recurrence. As noted in the previous Element, this may involve providing a cost-benefit analysis demonstrating the relative merits of the proposed solution against other possible alternatives. It will also be important to define and explain any legal obligations which may arise from the incident. Senior management will need to be given clear advice on what is required to comply with legal standards. Naturally, this advice must be evidence-based and recommendations will need to be substantiated from the information gathered through the course of the investigation.

Line management and staff

In some cases line management and staff will also receive a copy of the report. In many cases this will consist of a summary of findings rather than the detailed report (see section 5.4). In view of this it is important that the report be written in a language and style that will be understood by a wide audience. Technical terms and jargon should be avoided. Subjective statements and opinions must also be excluded.

External agencies

In certain situations the report will be of interest to external agencies such as the WHS regulator, the police and perhaps the coroner. While this will generally be in relation to very serious incidents, it is important that reports and documentation are of a high standard and structured with the possibility of external review in mind.



It is possible that the investigation report will be filed in court proceedings, either as evidence of what occurred or as an indication of what action the organisation has taken in response to the incident. The report therefore needs to contain all necessary detail including information relating to statements obtained and information gathered. As noted, the report needs to be objective and factually based. The next section describes how this can be achieved.

5.2 WRITE REPORT OBJECTIVELY, CITE THE EVIDENCE AND REASONS FOR CONCLUSIONS This section will focus on the structure and content of the report. The level of background detail included in the report will vary between organisations and incidents. However, all reports should contain at least:

the sequence of events leading up to the incident;

description of all the causal factors of the incident; and

recommendations for preventing a re-occurrence.

This section will examine these issues in more detail.

Report content Irrespective of who the audience is, a number of fundamental principles underpin the compilation of an investigation report. These are:

objectivity;

evidence-based; and

quality.



The report must be objective, that is it should focus on the principal function of the investigation; your findings, conclusions and recommendations regarding the causes of the incident in question and the prevention of its recurrence. It should report the facts and avoid the opinions and personal views of team members. In developing the report, language that attributes blame or negligence to a person must be avoided. For example, phrases such as “Simon injured himself…” should not be used. It is more appropriate to say “Simon was injured after the forklift collided with the racks…..” The first phrase blames the injured person while the second phrase puts the event in a cause and effect context. The report should be based on supportable evidence which is accurate and has been analysed objectively. To ensure this, the report should make reference to the particular methods applied, evidence collected and information gathered in the course of the investigation. Beyond objectivity and being evidence-based, the report should be logical and readable. This relates to the structure and presentation of information in the report. This is outlined below.

Report structure At the beginning of this Element the essential information needed to be included in the report was outlined. In this section a model structure for the investigation report will be examined. This may be modified according to the nature and severity of the incident investigated.

1. Header or cover page

The report needs a cover page which contains preliminary information relating to the nature, place and date of the incident. For example: “Investigation of injuries to Simon Smith involved in Forklift Incident at (address) on 26 July 2004”.



2. Contents page

The report should be divided into clear sections following a logical sequence. The Contents page allows the reader to easily navigate the document. The contents page will vary on a case-by-case basis. The example below provides one method of presentation.

1. Introduction Background Scope of Investigation Investigation techniques

2. Incident details

Eyewitness reports Inspection/investigation observations Victim details Injury details

3. Causation

Sequence of events Direct causes Contributing factors Legislative obligations General observations

4. Corrective actions

5. Recommendations

3. Introduction

The introduction provides preliminary information relating to the investigation team and the investigation process. This section of the report will provide background information including the establishment of the investigation team, who the team is, and the scope (or boundaries of the investigation). It will also provide the reader with a description of the techniques and processes that have been applied in the course of the investigation. Processes include statements about visual inspections, the collection of information and data, taking photographs, interviewing witnesses and so on.

4. Incident details

The incident details section of the report will provide a description of what occurred and the information and evidence that was gathered in the course of the investigation.



This section will include details of what you saw, where you went, what you did, who you met and any interviews that were undertaken. Such information should be presented as a logical, chronological sequence of events covering:

date, time and place of the incident;

the nature of the incident and whether anyone was injured or could have been injured;

injury details if any, including a comment on the current state of the injured person;

the age and experience of the injured person (or others who may have been involved);

name of supervisors and/or eye-witnesses; and

investigation observations.

5. Causation

The investigation team’s conclusions on the causes of the incident need to be based on the key facts, incorporating information and data gathered in the course of the investigation. Remember - your conclusions need to be logical and objectively based. Chronological order and clarity are essential here. It is suggested that information on causation be presented in the following order:

outline the likely sequence of events providing a narrative of the time-line that led up to the incident;

explain any contributing factors related to the people involved, plant used, the working environment or the work processes;

establish the immediate or direct causes of the incident;

outline the legislative obligations that do or may arise from the incident. You will need to be aware of any specific legislative requirements relating to particular hazards as well as the overarching general duties that may be contained in the relevant WHS Act;

describe all causal factors your investigation revealed; the direct causes, contributing factors, conditions and circumstances, all the underlying causes behind the incident, which arose from the failure of the WHS management system; and



conclude with any general observations that the team may make in relation to the incident. This could include the level of cooperation given to the investigation team and/or to measures that have been undertaken by the PCBU to minimise or eliminate unsafe work practices.

Detailed information on causation is outlined in Element 4.

6. Corrective action

You will recall that in section 4.6 strategies to prevent re-occurrence of the incident were covered. The nature of these corrective strategies needs to be outlined in some detail in your report. The corrective actions must address each of the causal factors that contributed to the incident including identified deficiencies in the WHS management system. A possible approach is to commence your corrective actions with a description of the management system deficiencies and necessary changes, and outline the risk management processes that should be applied. You can then go on to provide specific recommendations in relation to control measures that may be necessary to address particular risks. Corrective actions should then be summarised in the report’s recommendations.

5.3 INCLUDE RECOMMENDATIONS FOR PREVENTION IN THE REPORT The recommendations of the report will require specific actions by management. Therefore, the recommendations need to outline clearly and concisely exactly what action is required. For example: “R1. Gantry platforms on the right hand side of the bay over the pit area be fenced in accordance with AS 1657, Fixed platforms, walkways, stairs and ladders – design, construction and installation.”



“R2. Regular inspections of the worksite (including workshop) be undertaken by the health and safety committee. These inspections should be undertaken at a time when work is being conducted to ensure that work processes as well as the physical work environment are observed.” Recommendations should be listed in order of priority, with urgent recommendations requiring immediate implementation listed first and other longer-term recommendations following. Each recommendation should be clearly and separately numbered and, where relevant, cross-referenced to an action plan which assigns responsibilities and time frames. Recommendations should also include follow-up action to ensure key recommendations are implemented.

5.4 DISSEMINATE RELEVANT INFORMATION AND DATA TO KEY PERSONNEL, STAKEHOLDERS AND EXTERNAL AGENCIES AS APPROPRIATE, FOLLOWING APPROPRIATE AUTHORISATION This section aims to ensure that organisational protocols in relation to reporting and information transfer are appropriately observed. Some organisations require that the General Manager/CEO sign all public documents and notices. It is important that the investigation team confirm company policy in relation to this.

Prior to approval Keep in mind the pivotal role of health and safety representatives in responding to the investigation of incidents. You will recall that in section 5.1 it was mentioned that the health and safety representative and/or committee would have a primary interest in the content of the report. Accordingly, the representatives and health and safety committee should be afforded an opportunity to consider the report prior to final management approval/endorsement.



This process may assist management in its evaluation and sign-off regarding the recommended corrective actions described in the report, given that the views of the health and safety representatives and health and safety committee will be known. Having the report reviewed by the health and safety representatives and health and safety committee also provides an opportunity for them to:

provide an opinion, independent of the investigation team, that the objectives of the investigation have been achieved;

offer a quality control check that the report is clear, understandable and there is a logical argument linking the investigation processes, the evidence, findings, conclusions and recommendations; and

test the reaction to recommendations of a sensitive nature, such as implications of poor management practices or other errors and omissions which may have been part of the causal sequences.

Against this background it may also be helpful (prior to submitting the report to the health and safety representatives and health and safety committee) to have the report reviewed by a person next in management seniority to those on the investigation team. This is not always possible but it can help the investigation team get a feel for management’s views on the report. Where the investigation has been conducted under legal professional privilege, it is not unusual for the lawyers who commissioned the investigation report to subject the report to detailed scrutiny prior to it being finalised. This can be a very effective quality control process ensuring that the finished report is very robust and will stand up well to third party scrutiny and criticism. However, care should be taken to ensure factors critical to the causation and corrective action argument are not lost or diminished in the process.



Approval The report should not be released without appropriate approval. In most cases senior management will provide approval for release of the final report. Responsibility for approval will usually rest with the most senior officer in the organisation, ie, the General Manager/CEO or a senior officer delegated by the CEO.

Dissemination Senior management will usually determine the scope of distribution of the report. This decision needs to be observed.

The interest of key personnel, stakeholders and external agencies has been considered in section 1.6. This does not mean that all these parties will be provided with a full report. In some cases it will not be appropriate to provide workers and colleagues with this level of detail (eg, where there is sensitive information about the nature of injuries sustained). Nevertheless, relevant people need to be provided with information and data emerging from the investigation. In these cases, a summary of the report rather than the full report may be disseminated. The summary should outline:

key findings including causes of the incident;

corrective actions and recommendations; and

implementation action and timetables.

The health and safety representatives and health and safety committee can contribute to the dissemination process and may have views on to whom the report should go and in what form. It can be expected that in the interests of an open consultative approach to health and safety, the health and safety representatives and health and safety committee should be provided with a full copy of the report. The information provided to interested parties should be in a non editable form, either hardcopy or locked pdf electronic file. It should be signed by the investigation team and co-signed by a senior manager or, where company policy requires it, by the General Manager or CEO.



Some organisations maintain a WHS intranet site. If approved, relevant information arising from the report may be included on this site as part of the organisation’s commitment to improve safety.

5.5 USE FINDINGS FROM THE REPORT TO DEVELOP FURTHER PREVENTION STRATEGIES This section deals with the action that may be necessary to give effect to the report findings. It is important to keep the context of the report in mind, ie, the primary purpose of the report is to ensure that the incident under investigation does not happen again and people can work in a safe and healthy environment. We have mentioned that the investigation will highlight deficiencies in the WHS management systems. If these deficiencies exist in one part of the organisation it is likely that they will be repeated in other parts. The investigation findings provide the catalyst for systematically managing health and safety by identifying deficiencies in the current WHS management system and proposing appropriate changes. There is therefore merit in applying the findings of the investigation to other work activities in the organisation to test the presence of broader systemic failures. Indeed, it is often useful to include a recommendation in the report aimed at ensuring the lessons from the incident investigation are applied elsewhere in the company or beyond. A systematic approach to managing safety in the workplace is the key issue and your report can provide a valuable tool as it has resulted from a systematic analysis of the management systems failures that led to the incident. It details a process and identifies causative factors, all of which can be used to change and enhance the overall WHS management system to correct failures in the current system of managing health and safety.



The final report should engender a holistic approach to managing safety. It is important that the report does not only focus on a hazard management approach but rather proposes improvements to the broader systems of WHS management, which address all identified deficiencies. These may include a quantum of issues such as training, policies and procedures, purchasing protocols, work scheduling and so on. Reviewing and monitoring management systems is also an essential component of an safety management system. Accordingly, within the program of actions arising from the report, the findings should include reference to the need for ongoing monitoring and review of effectiveness of corrective actions, with specific recommendations about when this should occur and where appropriate,, who is responsible for ensuring that it happens.

Competency check for Element 5 Key issues for each performance criterion in Element 5 are as follows. 5.1 Document results of analysis in a format to suit the required target audience and legal requirements:

Establish who is going to get the report and its intended use.

Report language and content is shaped according to the needs of the audience. Conciseness, clarity and fact are evident in your report.

5.2 Phrase report in objective terms and cite evidence and reasons for conclusions:

The report is based on an objective analysis of the facts.

Report findings and recommendations do not include subjective statements and are supported by evidence gathered in the course of the investigation.



5.3 Include recommendations for prevention in report:

The overriding objective of the investigation is to establish clear recommendations of corrective actions to prevent re-occurrence of the incident.

Recommendations must be expressed in precise terms rather than vague, general statements.

5.4 Disseminate relevant information and data to key personnel, stakeholders and external agencies as appropriate, following appropriate authorisation:

Identify and follow organisational protocols relating to the approval required to disseminate the report.

Establish any requirements relating to who the report will go to and in what form, ie, some parties may not require a full report.

Once approved, circulate the report (or report summary) to interested parties.

5.5 Use findings from the report to develop further prevention strategies:

The report is to provide the basis for adopting a systematic approach to managing safety in the workplace.

The report is to include recommendations to address the immediate factors which caused the incident, but should also incorporate broader prevention strategies which can be applied to the management systems across the organisation.



Case Study 5

Investigation report Locate and review a case study of an investigation. There are many examples available via the internet. Here are the references to some major incident reports which will be useful to compare how their investigators have approached the issue of effective investigation report writing: ATSB (2001), Investigation Report 199904538, Boeing 747-438, VH-OJH Bangkok Thailand 23 September 1999, Australian Transport Safety Bureau, http://www.atsb.gov.au/media/24447/aair199904538_001.pdf BP (2010), Deepwater Horizon Accident Investigation Report September 8, 2010, BP, http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/gom_response/STAGING/local_assets/downloads_pdfs/Deepwater_Horizon_Accident_Investigation_Report.pdf Eldon R. (1990), Accident Investigation Report, Dude Fire Incident, Multiple Firefighter Fatality, US Forest Service, http://www.fireleadership.gov/toolbox/staffride/downloads/lsr11/lsr11_investigation_report.pdf Mogford J. (2005), Fatal Accident Investigation Report, Isomerization Unit Explosion Final Report, Texas City, Texas USA, http://www.bp.com/liveassets/bp_internet/us/bp_us_english/STAGING/local_assets/downloads/t/final_report.pdf Newton Lord (2008), The Buncefield Incident 11 December 2005, The final report of the Major Incident Investigation Board, Buncefield Major Incident Investigation Board, http://www.buncefieldinvestigation.gov.uk/reports/


http://www.atsb.gov.au/media/24447/aair199904538_001.pdf

http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/gom_response/STAGING/local_assets/downloads_pdfs/Deepwater_Horizon_Accident_Investigation_Report.pdf



http://www.fireleadership.gov/toolbox/staffride/downloads/lsr11/lsr11_investigation_report.pdf

http://www.fireleadership.gov/toolbox/staffride/downloads/lsr11/lsr11_investigation_report.pdf

http://www.bp.com/liveassets/bp_internet/us/bp_us_english/STAGING/local_assets/downloads/t/final_report.pdf

http://www.bp.com/liveassets/bp_internet/us/bp_us_english/STAGING/local_assets/downloads/t/final_report.pdf

http://www.buncefieldinvestigation.gov.uk/reports/


Activity 5

Keep a copy of this Activity for your Assessment Portfolio.

Investigation final report

Choose any one of the Case Studies in this learning guide. Prepare a final report that draws together the information you have gathered and analysed and the findings of the investigation team. The report is to be constructed in accordance with the guidelines provided in Element 5. It will outline a number of recommendations to prevent further occurrences of the incident. The report will be provided to:

Executive Management team (General Manager/CEO, Production Manager, Human Resources Manager);

Board of Directors (where applicable);

Health and safety representatives and health and safety committee; and

workers and line managers.

Two additional investigations

Select two additional workplace incidents requiring a WHS investigation. These can be relatively straightforward incidents but should involve different situations, circumstances, scope and hazards to those involved in your above final report. Prepare a report which summarises the investigative process undertaken for each incident demonstrating that you have initially assessed the situation, established investigation processes and collected and analysed information. The report will also include recommendations for corrective actions and prevention. Explain to whom you would disseminate the information and why. Your selection of incidents may be fictitious, or can be based on your own workplace/experience. Alternatively, you may wish to select an actual incident reported on the web page of the WHS regulatory authority, eg, www.worksafe.wa.gov.au


http://www.worksafe.wa.gov.au/


On-line unit test questions

As a final Activity, check your understanding of participating in the investigation of incidents by answering the on-line test questions for the unit, which you can access at the SafetyLine Institute: www.safetyline.wa.gov.au/institute The test questions have been taken from the Readings and Resources for this unit as well as from this learning guide. Keep a copy of your student record in your Assessment Portfolio as evidence you have correctly answered the on-line test questions. Please note that you may be further questioned about the test questions during your Assessment Interview.




Integrated project

Keep a copy of this Project for your Assessment Portfolio. By completing the Activities, you have undertaken the actions necessary to ensure that you can participate actively and effectively in the investigation of incidents. While each Activity has to be individually identifiable for assessment purposes, you should also present them in a way that provides an integrated report for your workplace and demonstrates that you can participate in the investigation of incidents. This will also give you the opportunity to check that you have provided evidence that you have:

the required knowledge and understanding; and

the required skills and abilities, which are outlined in the Introduction to this unit.

You should ensure that you integrate evidence of the required knowledge and skills into your report.

Oral presentation In addition to the written report, you are required to present an oral report to a workgroup (or a simulated workgroup) on the incident investigation processes that you have applied and the outcomes. The presentation will include a concise description of the basic facts of the incidents, the information gathered and analysed and the findings of the investigation team. You may select the format and approach that you consider is most appropriate to the workgroup, but you should take account of the Project Review Checklist that will be used to assess you. While your report may not address every area contained in the checklist you may be called upon to answer questions, to demonstrate that you have attained the required knowledge and understanding.



ASSESSMENT

Assessment portfolio from learning guide For BSBOHS508B: Participate in the investigation of incidents. Note to participant Any documentation provided as evidence must be prepared by you to a satisfactory standard and be in accordance with workplace procedures. When collecting material for your assessment portfolio, please ensure that the confidentiality of colleagues, workers and other persons is protected, and block out any sensitive information. If you have any doubts regarding confidentiality issues, contact the organisation concerned. Participant’s name: _______________________________

Date: _______________________________

the box when you complete an activity from the Learning

Guide. Add the material from the activity to your assessment portfolio.

Activity 1

Activity 2

Activity 3

Activity 4

Activity 5




Assessment portfolio from learning guide (cont.)

On-line test questions

Integrated project and presentation

Note: Attach a copy of this document to your assessment portfolio, so that your assessor can see you have completed all the activities. Assessor’s signature:

Date:


Project review check-list For BSBOHS508B – Participate in the investigation of incidents. Participant’s name: _______________________________

Date: _______________________________

the box if the learner has completed the following:

Presented a written report detailing three incident investigations.

Gave a summary oral presentation to a workgroup (or a simulated workgroup), that demonstrates the investigation of incidents in a systematic manner. Ensure you cover the initial assessment of the situation, processes established, information collected and systematically analysed, recommendation for prevention and dissemination of information. You will also need to explain how the following knowledge underpins this process:

Roles and responsibilities under WHS legislation of PCBUs, including supervisors and contractors.

Requirements for reporting under WHS and other relevant legislation including notification and reporting of incidents. Rights of WHS inspectors.

Requirements for record keeping that address WHS, privacy and other legislation.

Structure and forms of legislation including regulations, codes of practice, associated standards and guidance material.

Requirements under hazard specific WHS legislation and Codes of Practice.

Standard industry controls for a range of hazards. Hierarchy of control and considerations for choosing between different control measures, such as possible inadequacies of particular control measures.

Methods of providing evidence of compliance with WHS legislation.

Principles and practices of systematic approaches to managing health and safety (WHS management systems).

Assessor’s Signature: _________________________________ Date: ___________________________



Third party (manager/mentor) report For BSBOHS508B – Participate in the investigation of incidents. Note to participant Where possible you should have a WHS practitioner as a mentor to assist in developing the practical skills in applying your knowledge. Your manager is also an important source of feedback on your competence, although from a different perspective.

The assessor will arrange to meet with you and your mentor, coach or manager to discuss completion of the third party report. The third party report will support integrated assessment of this unit.

The mentor, coach or manager is required to provide the Assessor with any relevant information. This report will be forwarded by the Assessor to the candidate for inclusion in their assessment portfolio.

The following is provided as the basis for a checklist for you and your mentor, coach or manager. Where you have both mentor and manager, separate forms should be completed.

The checklist has been designed to reflect the performance criteria and to collect information about your demonstration of competence in the workplace. The assessor may use additional questions to address any need for supplementary evidence to support your competence.

Checklist

Did the Candidate satisfactorily: Yes No

1.1 Check the area to ensure that it is safe and arrangements have been made to meet initial needs of those involved in the incident?

1. Facilitate initial assessment of situation

1.2 Establish and maintain the integrity of the site in accordance with legal requirements and ensure objectivity of information collected?




1.3 Identify statutory and legal obligations and, if required, advise relevant government agencies?

1.4 Notify key persons within the organisation?

1.5 Determine and note factors affecting the complexity of the investigation?

1.6 Identify and notify stakeholders and interested parties as appropriate?

Comments:

2.1 Access and know organisational policies and procedures for incident investigation?

2.2 Convene an investigation team appropriate to the level of the investigation?

2.3 Define the scope of the investigation taking account of legislative requirements?

2.4 Facilitate the involvement of interested parties in accordance with legislative requirements?

2.5 Identify and source resources required to conduct the investigation, including the need for expert advice (if required)?

2. Participate in the establishment of an investigation process

2.6 Identify and address barriers to investigation?




2.7 Develop action plans and time-lines for the investigation team?

Comments:

3.1 Identify and access sources of information and data?

3.2 Inspect the incident site, equipment and other evidence involved?

3.3 Facilitate the gathering of information and data/

3.4 Take and record statements, photographs, measurements and documentary evidence, taking account of objectivity, confidentiality and legal implications?

3.5 Appropriately secure the site, evidence and all necessary documentation?

3. Collect information and data for analysis

3.6 Appropriately involve members of the investigation team?

Comments:




4.1 Ensure that the conceptual basis for the analysis is identified and understood by the investigation team?

4.2 Construct a time-line of events leading up to the incident?

4.3 Investigate causal factors?

4.4 Identify contributory factors, conditions and circumstances that contributed to the direct causes of the incident?

4.5 Identify intervention points on the time-line, for prevention?

4. Analyse information and data gathered to identify immediate and underlying causes and practical prevention measures

4.6 Identify corrective actions to prevent the re-occurrence of the incident?

Comments:




5.1 Document results of analysis, in a format to suit the required target audiences and legal requirements?

5.2 Phrase the report in objective terms and cite evidence and reasons for conclusions?

5.3 Include recommendations for prevention in the report?

5.4 Disseminate relevant information and data to key personnel, stakeholders and external agencies as appropriate, following appropriate authorisation?

5. Compile investigation report

5.5 Use findings from the report to develop further prevention strategies?

Comments:



Comments: Further comments by assessor (if required)

Keep a record of the following:

Name of person completing checklist:

Background/ experience in topic (if any)

Date:

Relationship to person being assessed (tick)

Mentor/coach for

Months

Manager for

Months

Other Months

(explain)

Team Manager/Mentor’s Signature: _______________________

Assessor’s Signature: _____________________________

Date: ______________________________



Skills checklist For BSBOHS508B – Participate in the investigation of incidents

Candidate’s name

Assessor’s name

Work activity Investigate incidents

Unit of competency BSBOHS508B Participate in the investigation of incidents

Location

Instructions:

The candidate participates in the investigation of incidents (may be simulated). Where possible you should gather any evidence which supports your achievements of these skills. Evidence gathered should be kept in your assessment portfolio.

During the investigation of incidents did the candidate demonstrate or provide evidence of the following abilities:

Yes No

Relate to people from a range of social, cultural, and ethnic backgrounds and physical and mental abilities.

Communicate effectively with people at all levels of the organisation and with WHS and other specialists.

Prepare reports for a range of target groups including a health and safety committee, health and safety representatives, managers and supervisors.

Manage tasks within an agreed time frame.

Employ effective consultation and negotiation skills.

Analyse relevant WHS information and data, and make observations of workplace tasks and interactions between people, their activities, equipment, environment and systems in order to meet requirements of WHS legislation.

Communicate effectively with personnel at all levels of organisation.



During the investigation of incidents did the candidate demonstrate or provide evidence of the following abilities:

Yes No

Use basic computer and information technology skills to access internal and external information and data on WHS.

Demonstrate attention to detail when making observations and recording outcomes.

The candidate’s overall performance met the standard:

Yes No

Comments / observations:

Assessor’s signature

Candidate’s signature

Date of assessment



Interview questions For BSBOHS508B – Participate in the investigation of incidents. Note to participant The questions listed below cover the performance criteria for this unit and support your required knowledge and skills. The assessor can add to or modify these questions to suit the particular context.

Candidate’s name

Assessor’s name

Work activity Investigate incidents

Unit of competency BSBOHS508B - Participate in the investigation of incidents

Location

Instructions:

The candidate is required to provide verbal answers (using examples where possible) to the following questions that will be asked by the assessor. It is suggested that the interview should be a ‘conversation’. The interviewer should be prepared to insert his or her own questions to explore weaknesses, or other queries, that arise during the ‘conversation’.

Did the candidate satisfactorily answer the following questions:

Yes No

1. Outline the key steps in undertaking an investigation of a WHS incident.

2. What are the legislative challenges confronting an incident investigation?

3. When an incident has occurred who needs to be notified and why do these people need to be informed?

4. What are some of the key considerations in setting up an investigation team?

5. In relation to the investigation of an incident, what is meant by site integrity and why is it so important?




Yes No

6. Outline the key processes for gathering information and data relating to a workplace incident.

7. In gathering statements from witnesses who should be interviewed and when should these interviews occur?

8. What questioning techniques should be used in gathering information from witnesses?

9. Why is it important to take measurements and make sketch maps of the scene of an incident?

10. How do you protect the confidentiality of information gathered in the course of your investigation?

11. “A workplace incident is not the failing of an individual; it is a failing of the system.” What are your views on this?

12. What techniques can you employ to establish the root causes of an incident?

13. Why is objectivity critical in investigating a WHS incident?

14. What role can a health and safety representative and committee have in (a) assisting with an investigation; and (b) the review of the final report?

15. In preparing the final report, “objectivity and factual evidence” are the most important principles to be observed. Why is this?





Yes No

16. What do you think will be a key feature of the recommendations contained in a final report?

17. Who should get a copy of the final report and when can they receive it?

18. In what ways can investigation outcomes improve the WHS management system in a workplace? Give examples.

The candidate’s required knowledge was satisfactory:

Notes / Comments:

Assessor’s signature

Candidate’s signature

Date of assessment

work health and safety practitioner learning guide unit ... · bsbohs508b participate in the...

Documents