HRM843 chapter 12 investigation
The benefits of incident investigations
Determines direct causes, identifies contributing causes, prevents similar incidents, creates a permanent record, determines cost, promotes safety awareness among employees
cognitive failure
a mistake or failure in the performance of an action that an individual is normally capable of performing
Five Dominos
background, personal defects, unsafe acts and conditions, incident, injury
Incident analysis
domino theory, swiss cheese model, bow tie analysis, normal incidents
the Investigation should concentrate on three factors
human, situational, and environmental
INcident/accident reports
identifies the agency of an incident, includes personal factors. the reports are submitted to OHS agencies and WCBS
BOw-tie Analysis
it combines a fault tree with an event tree. the left side shows the potential hazards and measures to control them and the right side shows the measures taken to mitigate the consequences of an event and resulting consequences
Environmental factors
light and noise
Investigative methods
observations or walkthroughts, interviews,re enactments
Four levels of defense for swiss cheese model
organizational influences, local working conditions, unsafe acts, defenses barriers and guards
high-reliability organizations
organizations in hazardous industries that maintain a high safety record over time
Investigative tools
photos, drawings, computer incident database, record checks
WHo should conduct the investigation?
the area supervisor assisted by the HR or safety specialist
The Swiss Cheese Model
the domino model but there are holes in the dominos where an incident results when the holes line up. unsafe acts are the product of the organizational culture, the level of supervision and other contextual factors
WHO investigates?
the supervisor, technical advisers and specialists, safety and health officer, safety and health committee representative, a safety team
Domino theory
the theory that every incident results from a series of events
Normal incidents
the theory that incidents are expected outcomes of interactive complexities
INcident investigations are strongly influenced by
timing, severity, and legal requirements
situational factors
was the machine operating in a satisfactory maner, were the safety measures functioning, what was the site of the incident, what equipment tools or objects were involved, were guards in place, what time of day,
Human factors
what was the worker doing? were they performing a regular task? was it being done according to procedure, did an unsafe act contribute
