Reporting > Investigation

Power Tech Industries will investigate all near misses, unsafe conditions, unsafe work practices, illness, accidents, property damage, time loss incidents, first aid incidents, medical aid incidents, and work refusals. The potential for subsequent loss will determine the time and effort spent on the investigation. If an investigation is required, it will be conducted immediately after an incident report has been filed.

The intent of all investigations is to identifying the causes of a loss and controlling or eliminating hazards to prevent a recurrence of the loss without fault finding; to utilize this system as a learning experience and to ultimately create a safe and healthy working environment for all its employees and contractors. To ensure investigations are conducted in a thorough manner, an employee competent in the work being performed when the incident occurred will assist in the investigation. Power Tech Industries is committed to these procedures.

After most incidents have occurred, the direct and underlying causes and the preventative actions must be determined.

•Incidents and other problems are seldom, if ever, the result of a single cause. This must be remembered throughout the investigation as several causes should and will be identified

•Failure to limit the damage caused in an incident is due to substandard practices or conditions existing. These are the immediate or direct causes of the incident.

DIRECT/IMMEDIATE CAUSES are the symptoms of the real problem or cause. They can be identified easily because they can be seen, felt or experienced. Some typical examples of immediate causes include:

•SUBSTANDARD PRACTICES:

▪operating equipment without authority

▪failure to warn

▪failure to secure

▪operating at improper speed

▪making safeguards inoperable

▪using defective equipment

▪failing to use personal protective equipment

▪improper loading

▪improper lifting

▪improper position for task

▪servicing equipment in operation

▪horseplay

▪under influence of drugs

•SUBSTANDARD CONDITIONS:

▪Inadequate guards or barricades

▪Inadequate or improper protective equipment

▪Defective tools, equipment, materials

▪Congested or restricted action

▪Inadequate warning system

▪Fire and/or explosion hazards

▪Poor housekeeping

▪Hazardous environment

▪Noise exposure

▪Extreme temperature

▪Inadequate or excessive illumination

▪Inadequate ventilation

•INDIRECT/BASIC CAUSES - Identify why an immediate cause exists by determining the personal and job factors that may have contributed to the loss. Some common basic causes include:

•PERSONAL FACTORS:

▪Inadequate physical capability

▪Lack of knowledge

▪Lack of skill

▪Stress

▪Improper motivation

•JOB FACTORS:

▪Inadequate leadership or supervision

▪Inadequate engineering/purchasing standards

▪Inadequate tools and equipment

▪Inadequate maintenance

▪Inadequate work standards/procedures

▪Wear and tear

▪Abuse or measure

Even after the basic causes have been identified, we need to ask why do these situations exist and what can be done to eliminate or control them in a practical manner?

LESSONS LEARNED/PREVENTATIVE ACTION - Identify practical solutions that will control or eliminate the critical immediate and basic causes.

MANAGEMENT CONTROL - Senior Management will review all reports to ensure the report is complete, that all details are clear, all questions are answered, and that all causes and preventative action has been identified. He must then determine what practical action can be taken to prevent or control the consequences of a similar incident (it is rarely determined that no action is required). Senior Management will sign off on the investigation and all related work orders once it has been determined all recommendations and controls have been implemented and proven effective.

Supervisors will assist in implementation of all accident/incident investigation recommendations and monitor them for effectiveness.

The Safety Advisor will initiate and co-ordinate all incident investigations, and follow up on the investigation through completion. Investigation findings will be discussed with all employees at safety meetings. This person is also responsible for coordinating all health and safety activities, such as safety meetings, field inspections, accident/incident investigations, hazard reports, new employee orientations.