Your organization shall establish, implement and maintain a procedure(s) to record, investigate and analyse incidents in order to:

a) Determine underlying OH&S deficiencies and other factors that might be causing or contributing to the occurrence of incidents

b) Identify the need for corrective action

c) Identify opportunities for preventive action

d) Identify opportunities for continual improvement

e) Communicate the results of such investigations.

The investigations shall be performed in a timely manner.

Any identified need for corrective action shall be dealt with & the results of incident investigations shall be documented and maintained.

What the law requires

A ‘responsible person’ has the duty to report to the relevant enforcing authority any of the above scenarios, including deaths.

Introduction

Organizations should have effective procedures for reporting and evaluating/investigating accidents, incidents and non-conformance’s.

The prime purpose of the procedure(s) is to prevent further occurrence of the situation by identifying and
dealing with the root cause(s).

Furthermore, the procedures should allow detection, analysis and elimination of potential causes of non-conformities.

Typical inputs:

Procedures (in general)
Emergency plan
Hazard identification, risk assessment and risk control reports
OH&S Management System audit reports, including non-conformance reports
Accident, incident and/or hazard reports
Maintenance and service reports.

Process

The organization is required to prepare documented procedures to ensure that accidents, incidents and non-conformance’s are investigated, and corrective and/or preventive actions initiated.

Progress in the completion of corrective and preventive actions should be monitored, and the effectiveness of such actions reviewed.

1) Procedure

The procedures should include consideration of the following:

General:

Define the responsibilities and authority of the persons involved in implementing, reporting, investigating, follow-up and monitoring of corrective and preventive actions

Require that all non-conformance’s, accidents, incidents and hazards be reported

Apply to all personnel (i.e. employees, temporary workers, contractor personnel, visitors and any other person in the workplace)

Take into account property damage

Ensure that no employee suffers any hardship as a result of reporting a non-conformance, accident or incident;

Clearly define the course of action to be taken following non- conformances identified in the OH&S Management System.

Immediate action

Immediate action to be taken upon observation of non- conformance’s, accidents, incidents or hazards should be know to all parties.

The procedures should:

Define the process for notification

Where appropriate, include co-ordination with emergency plans and procedures

Define the scale of investigative effort in relation to the potential or actual harm (e.g. include management in the investigation for serious accidents).

Recording

Appropriate means should be used to record the factual information and the results of the immediate investigation and the subsequent detailed investigation.

The organization should ensure that the procedures are followed for:

Recording the details of the non-conformance, accident or hazard

Defining where the records are to be stored, and responsibility for the storage.
Investigation

The procedures should define how the investigation process should be handled.

The procedures should identify:

The type of events to be investigated (e.g. incidents that could have led to serious harm)

The purpose of investigations

Who is to investigate, the authority of the investigators, required qualifications (including line management when appropriate)

Identification of the root cause of non-conformance

Arrangements for witness interviews

Practical issues such as availability of cameras and storage of evidence

Investigation reporting arrangements including statutory reporting requirements.

Investigatory personnel should begin their preliminary analysis of the facts while further information is collected.

Data collection and analysis should continue until an adequate and sufficiently comprehensive explanation is obtained.

Corrective action

Corrective actions are actions taken to eliminate the root cause(s) of identified non-conformance’s, accidents or incidents, in order to prevent recurrence.

Examples of elements to be considered in establishing and maintaining corrective action procedures include:

Identification and implementation of corrective and preventive measures both for the short-term as well as long-term (this may also include the use of appropriate sources of information, such as advice from employees with OH&S expertise)

Evaluation of any impact on hazard identification and risk assessment results (and any need to update hazard
identification, risk assessment and risk control report(s))

Recording any required changes in procedures resulting from the corrective action or hazard identification, risk assessment and risk control

Application of risk controls, or modification of existing risk controls, to ensure that corrective actions are taken and that they are effective.

Preventive action

Examples of elements to be considered in establishing and maintaining preventive action procedures include:

Use of appropriate sources of information (trends in “no loss incidents”, OH&S Management System audit reports, records, updating of risk analyses, new information on hazardous materials, safety “walk-throughs”, advice from employees with OH&S expertise, etc.)

Identify any problems requiring preventive action

Initiate and implementing preventive action and application of controls to ensure that it is effective
Record any changes in procedures resulting from the preventive action and submit for approval.

Follow-up

Corrective or preventive action taken should be as permanent and effective as practicable. Checks should be made on the effectiveness of corrective/preventive action taken.

Outstanding/overdue actions should be reported to top management at the earliest opportunity.

2) Non-conformance, accident and incident analysis

Identified causes of non-conformance’s, accidents and incidents should be classified, and analysed on a regular basis. Accident frequency and severity ratings should be calculated in accordance with accepted industrial practice for comparison purposes.

Classification and analysis should be carried out of:

Reportable or lost-time injury/illness frequency or severity rates

Location, injury type, body part, activity involved, agency involved, day, time of day (whichever is appropriate)

Type and amount of property damage

Direct, and root causes.

Due attention should be given to accidents involving property damage. Records relating to repair of property could be an indicator of damage caused by an unreported accident/incident.

Accident and illness data/information is vital, as it can be a direct indicator of OH&S performance.

However, caution in their use should be exercised, for example:

Most organizations have too few injury accidents or cases of work related illness to distinguish real trends from random effects

If more work is done by the same number of people in the same time, increased workload alone may account for an increase in accident rates

The length of absence from work attributed through injury or work-related illness may be influenced by factors other than the severity of injury or occupational illness, such as poor morale, monotonous work and poor management/employee relations

Accidents are often under-reported (and occasionally over- reported). Levels of reporting can change. They can improve as a result of increased workforce awareness and better reporting and recording systems

A time delay will occur between OH&S Management System failures and harmful effects. Moreover, many occupational diseases have long latent periods. It is not desirable to wait for harm to occur before judging whether OH&S management systems are working.

Valid conclusions should be drawn and corrective action taken.

At least annually, this analysis should be circulated to top management and included in the management review.

Incident investigation, nonconformity, corrective action and preventive action continued

3) Monitoring and communicating results

The effectiveness of OH&S investigations and reporting should be assessed. The assessment should be objective, and should yield a quantitative result if possible.

The organization, having learnt from the investigation, should:

Identify the root causes of deficiencies in the OH&S Management System and general management of the organization, where applicable

Communicate findings and recommendations to management and relevant interested parties

Include relevant findings and recommendations from investigations in the continuing OH&S review process

Monitor the timely implementation of remedial controls, and their subsequent effectiveness over time

Apply the lessons learnt from the investigation of non-conformance’s across its whole organization, focussing on the broad principles involved, rather than being restricted to specific action designed to avoid repetition of a precisely similar event in the same area of the organization.

4) Record keeping

This can be accomplished rapidly and with a minimum of formal planning or it can be a more complex and long-term activity. The associated documentation should be appropriate to the level of corrective action.

Reports and suggestions should be sent to the management appointee, and, where appropriate, the employee OH&S representative, for analysis and filing.

The organization should maintain a register of all accidents.

Incidents that had the potential for significant OH&S consequences, should also be included. Such a register is often required by legislation.

Typical output:

Accident and non-conformance procedure
Non-conformance reports
Non-conformance register
Investigation reports
Updated hazard identification, risk assessment and risk control reports
Management review input
Evidence of evaluations of the effectiveness of corrective and preventive actions taken.

Hints for Implementation
Again this is one section of ISO 45001 , which has clear links to ISO 9001 and ISO 14001. If you have a quality and/or environmental management system you should already have a corrective/preventive action process. You could use this as a framework for health and safety non-conformances, or if possible
totally integrate the systems.

At first, your OH&S audit team will raise most of the non- conformances. However, in the long run, it is worthwhile encouraging all staff to play an active role in reporting non- conformance or observations. This is particular important for near miss incidents which often go unreported.

Understanding such events will allow you to put in place controls measure so that the problem is avoided. Remember prevention is always better than a cure.

Common non-conformances

Common non-conformances brought up in the pre-certification and certification audits include:

Procedures and responsibilities inadequately defined to ensure that non-conformities, corrective and preventative actions are taken

No record of investigation of the cause of the non-conformance only of the action taken

Failure to take appropriate corrective action

Preventative action not demonstrated to ensure that the same problem does not arise again.

Self assessment questions:

Have you developed procedures for investigating, correcting, and preventing system deficiencies?

Have responsibilities been assigned for taking and tracking the completion of corrective actions?

Have you established a process to revise procedures or other OH&S documents based on corrective/preventive actions?

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