This can also be delivered as a virtual in-company course. Contact us for more details. Contact Email courses icheme. After graduating from Imperial College in with a degree in chemical engineering, Nigel worked as a process engineer for two firms of design contractors Stone and Webster and Davy Powergas and later worked for Shell Expro. In , he joined BP where he worked for the next 22 years.
His career with BP included exploration and field development, production operations offshore in Forties and onshore in the Forties Pipeline System , internal audit and health, safety and environment. After taking early retirement from BP, Nigel set up his own consultancy. He has provided a range of services to clients including process engineering, audit, process safety and occupational safety.
There may still be gaps in your understanding of the sequence of events that resulted in the incident. You may need to re-interview some witnesses or look for other data to fill these gaps in your knowledge. This is not extra work: it is a draft for part of the final report. Each conclusion should be checked to see if:. The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar incidents.
Recommendations should:. For example, you have determined that a blind corner contributed to an incident. Rather than just recommending "eliminate blind corners" it would be better to suggest:. Never make recommendations about disciplining a person or persons who may have been at fault. This action would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future investigations. In the unlikely event that you have not been able to determine the causes of an incident with complete certainty, you probably still have uncovered weaknesses within the process, or management system.
It is appropriate that recommendations be made to correct these deficiencies. The prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of the incident that you have so include all relevant details, including photographs and diagrams. If doubt exists about any particular part of the event, say so.
The reasons for your conclusions should be stated and followed by your recommendations. Do not include extra material that is not required for a full understanding of the incident and its causes such as photographs that are not relevant and parts of the investigation that led you nowhere.
The measure of a good report is quality, not quantity. Always communicate your findings and recommendations with workers, supervisors and management. Present your information 'in context' so everyone understands how the incident occurred and the actions needed to put in place to prevent it from happening again. Some organizations may use pre-determined forms or checklists. However, use these documents with caution as they may be limiting in some cases.
Always provide all of the information needed to help others understand the causes of the event, and why the recommendations are important. A difficulty that has bothered many investigators is the idea that one does not want to lay blame.
However, when a thorough worksite investigation reveals that some person or persons among management, supervisor, and the workers were apparently at fault, then this fact should be pointed out. The intention here is to remedy the situation, not to discipline an individual. Failing to point out human failings that contributed to an incident will not only downgrade the quality of the investigation, it will also allow future incidents to happen from similar causes because they have not been addressed.
However never make recommendations about disciplining anyone who may be at fault. Any disciplinary steps should be done within the normal personnel procedures. Management is responsible for acting on the recommendations in the investigation report. The health and safety committee or representative, if present, can monitor the progress of these actions.
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Reasons to investigate a workplace incident include: most importantly, to find out the cause of incidents and to prevent similar incidents in the future to fulfill any legal requirements to determine the cost of an incident to determine compliance with applicable regulations e. Most importantly, these steps can be used to investigate any situation e.
Ideally, an investigation would be conducted by someone or a group of people who are: experienced in incident causation models, experienced in investigative techniques, knowledgeable of any legal or organizational requirements, knowledgeable in occupational health and safety fundamentals, knowledgeable in the work processes, procedures, persons, and industrial relations environment for that particular situation, able to use interview and other person-to-person techniques effectively such as mediation or conflict resolution , knowledgeable of requirements for documents, records, and data collection; and able to analyze the data gathered to determine findings and reach recommendations.
Members of the team can include: employees with knowledge of the work supervisor of the area or work safety officer health and safety committee union representative, if applicable employees with experience in investigations "outside" experts representative from local government or police Note: In some cases, other authorities may have jurisdiction, such as if a serious injury or fatality occurred.
For example, an "investigation" which concludes that an incident was due to worker carelessness, and goes no further, fails to find answers to several important questions such as: Was the worker distracted?
If yes, why was the worker distracted? Was a safe work procedure being followed? If not, why not? Were safety devices in order? Was the worker trained? First: Report the incident occurrence to a designated person within the organization. Provide first aid and medical care to injured person s and prevent further injuries or damage. The incident investigation team would perform the following general steps: Scene management and scene assessment secure the scene, make sure it is safe for investigators to do their job.
Witness management provide support, limit interaction with other witnesses, interview. Investigate the incident, collect data. Analyze the data, identify the root causes. Report the findings and recommendations. The organization would then: Develop a plan for corrective action. Implement the plan. Evaluate the effectiveness of the corrective action.
Make changes for continual improvement. Figure 1: Incident Categories Task Here the actual work procedure being used at the time of the incident is explored. Members of the investigation team will look for answers to questions such as: Was a safe work procedure used?
Had conditions changed to make the normal procedure unsafe? Were the appropriate tools and materials available? Were they used? Were safety devices working properly? Was lockout used when necessary? For most of these questions, an important follow-up question is "If not, why not? What caused it to fail? Was the machinery poorly designed? Were hazardous products involved? Were they clearly identified? Was a less hazardous alternative product possible and available?
Was the raw material substandard in some way? Should personal protective equipment PPE have been used? Bookings must be made at the same time to receive the discount. Upcoming dates Date To be confirmed. Location UK — register your interest.
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