Near miss investigation report

Injury-Illness and, near, miss, report and, investigation

near miss investigation report

How to write a near miss incident report?

Shall be attached to the detailed investigation report. 4.8.2 Legal Assistance If incident reports are being compiled that may be required by authorities outside the company, it is strongly recommended that legal advice is sought in the preparation of the report. Legal advice should also be considered if third parties, including other authorities than those directly competent in respect of the incident, request to be provided with copies of the report. Each such request shall be considered on a case by case basis taking into consideration the potential risks and exposures for Company, its directors and employees for possible criminal or civil liability. Seeking legal advice shall be done with prior consultation of Companys counsel. 4.8.3 Management review and Endorsement If for the incident an investigation team has been formed its detailed investigation report shall be reviewed by: Project Construction Manager; Home Office manager of Safety; as a check on the completeness and quality of the investigation and to obtain.

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In most cases human errors can occur because of the dormant latent failures. The latter are system shortcomings of a structural nature. Identifying and correcting these latent failures rather than merely correcting the active failures induced by them (symptoms is more effective in meeting the ultimate objective of the investigation, namely to improve the overall shwe performance. 4.7 Identification of Recommendations The investigation about process should identify actions to prevent recurrence. This can best be granny achieved by addressing the unsafe acts and unsafe conditions, and by identifying and correcting the latent failures. Not all causes can be completely eliminated, and some may be eliminated only at prohibitive cost. Some recommendations will therefore be aimed at reducing the risk to a tolerable level, while others will be aimed at improving protective systems (the defences) to limit the consequences. All recommendations shall be in the form of measurable action items with clearly defined action parties and a time scale for implementation. 4.8 Investigation Report.8.1 Format The investigation report is a presentation of all findings, includes the recommendations by the investigator(s) and the necessary follow-up action(s). The report shall follow the standard table of contents as shown in a attachment. The Incident Investigation Matrix or tripod incident Analysis and any supporting evidence such as photographs, sketches, a completed form (ref.

Company has adopted the tripod matrix approach as the standard. Subject matrix should give the answers to the following question: What prior events or conditions were necessary for this incident to happen? The incident matrix consists of beauty the following columns: incident tree; defences; unsafe acts; pre-conditions; latent failures; fallible decisions; recommendations. For definitions refer to Attachment. 4.6 Analysis of Findings The purpose of analysis is to establish the critical events and the underlying causes of the incident such that corrective measures can be taken to prevent future incidents. This requires investigators to have a clear understanding of the cause and sequence of activities and why one event or situation progressed to the next. Incident causation studies clearly identify that an incident is caused by a chain of events. These can be identified at differing stages in the incident causation sequence. Restricting the investigation to the unsafe acts or active failures will automatically result in the conclusion that human errors caused the incident.

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This will allow for ease of assessment when analyzing essays the incident (tripod approach). 4.5 Sequence of events In the fact finding stage of an incident investigation, it is crucial to obtain all facts essential to the understanding of the incident. This implies back tracking from the initial facts found, to discover the reasons behind them. Without a structure for identifying and following leads, it is difficult to ensure that the full scope of the investigation has been covered. Gaps that are left in the event sequence should be reviewed to identify alternative scenarios to complete the sequence. In doing this it may be helpful to consider the human factors sequence. 4.5.1 General The approach of tabulating events and then ordering them by date, time and place is an essential stage in establishing the sequence of events. 4.5.2 Incident Investigation Matrix The construction of a diagram or matrix showing the connections between the various events and conditions leading up to the incident has proved to be a useful technique in the investigation process, especially for more complex incidents. The literature shows a variety of approaches in depicting incidents and their preceding conditions.

This should be rapidly identified and the specialists should be involved early in the site assessment. 4.4.9 Conflicting evidence It is not unusual for different witnesses to give different accounts of an incident. Human memory can be unreliable and, even if not motivated by self-protection or other subjective arguments, one persons recollection of an incident can differ from anothers in quite important details. Investigators should note any significant differences in accounts of an event. Faced with conflicting witnesses statements, investigators should look for the similarities between the statements and commonality with other evidence. The objective is to use the evidence to understand the incident and not to prove the accuracy of individual statements, nor to apportion blame. 4.4.10 Identifying Missing Information As the investigation progresses, the investigator(s) should begin to identify the sequence of events and concentrate efforts on increasing their knowledge of areas of uncertainty. 4.4.11 Underlying causes and Human Factors As the extent of physical factors involved in an incident becomes clear, the investigator(s) should shift the emphasis of their investigation and questioning to the underlying causes and to the reasons for peoples actions.

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near miss investigation report

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If the investigation is a team effort, great care should be taken not to make a witness feel intimidated by too many interviewers. Experience has shown that interviews can be effectively conducted by a pair of interviewers and if appropriate, the witness could be accompanied by an independent friend. It should be remembered that an investigation team is often seen in a prosecuting role, book and there may be a reluctance to talk freely if people think they may incriminate themselves or their colleagues. An investigator is not in a position to give immunity in return for evidence, but must try to convince interviewees of the purpose of the investigation and the need for frankness. At the end of an interview the discussion should be summarized to make sure that no misunderstanding exist. A written record should be made of the interview and this should be discussed with the witness to clarify any anomalies. Any anomalies in the statement or conflicts with other evidence should be clarified.

4.4.7 Records and Procedures Documentation such as as-built drawings, inspection records, instrument and tachograph records, printouts, log sheets/books, maintenance records, work permits and load/time sheets may provide information relevant to the investigation. Written instructions and procedures provide evidence of pre-planning and individual responsibilities. The investigation should try to establish the extent to which these procedures and instructions were understood and acted upon, as these can indicate the effectiveness of training and supervision. The relevance and extent of application of procedures should be assessed during the investigation. 4.4.8 Conducting Special Studies Incidents of an involved or complex nature often require the analysis of specialists to determine causes of failure. Aircraft crashes, crane failures and explosions are examples of incidents, requiring specialist advice.

4.4.4 Background Information Appropriate background information should be obtained before visiting the incident location. Such information could include: procedures for the type of operation involved; records of instructions/briefings given on the particular job being investigated; location plans; command structure and persons involved; messages, directions etc., given from base/head office concerning the work. 4.4.5 Investigation Method The method of conducting an investigation consists of the following activities: fact finding; inspecting the location; gathering or recording physical evidence; interviewing witnesses; reviewing documents, procedures and records; conducting specialist studies (as required resolving conflicts in evidence; identifying missing information; recording additional. During the initial stages of every investigation, investigator(s) shall gather and record all the facts that may be of interest in determining causes. Investigator(s) shall be aware of the danger of reaching conclusions too early, thereby failing to keep an open mind and considering the full range of possibilities.

Checklists are very useful in the early stages to keep the full range of enquiry in mind, but they cannot cover all possible aspects of an investigation, neither can they follow all individual leads back to basic causal factors. Their limitations should be clearly understood. For a checklist see attachment. 4.4.6 Interviews people should be interviewed singly and be asked to go step-by-step through the events surrounding the incident, describing both their own actions and the actions of others. The value of a witnesss statement can be greatly influenced by the style of the interviewer, whose main task is to listen to the witnesss story and not to influence him/her by making comments or asking leading questions. This requires patience and understanding.

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The actual size and composition of an investigation team will depend on the writing circumstances. 4.4 Investigation Process.4.1 level of Investigation The level of investigation is set by the Project Construction Manager or by third party requirements. The basic point of reference is the actual and/or potential severity of the event. 4.4.2 Scope The scope of the investigation should be such as to achieve the following primary aims: to identify the root causes of the incident such that actions can be taken to prevent recurrence; to review the application of management practices and their impact. This may necessitate review of aspects remote from the location and time of the incident. 4.4.3 Timing An investigation should be carried out as soon as possible after an incident. The quality of evidence can deteriorate rapidly with time, and delayed investigations are usually not as conclusive as those performed promptly. A prompt investigation is also a good demonstration of management commitment.

near miss investigation report

The second action is to preserve the evidence at the location of the incident. The location should be left unchanged, to the extent possible, until the investigation team has inspected. If this is not possible, photographs, video pictures or even sketches ventures should be made of the scene. Access to the scene may be limited or fully restricted and adherence to authority requirements shall be observed at all times. A preliminary assessment of the incident should be made to identify the extend of injury or damage, and any potential for escalation. Damaged components or equipment should be lodged in a secure place pending more detailed analysis. In case the Project Construction Manager has decided to form an investigation team, typically such team would be composed from the following personnel: Project Construction Manager or his delegate; Company site safety Engineer, construction Superintendent and/or the relevant Construct Discipline Specialist; Subcontractor Safety representative(s Client.

Procedure.1 levels of Reporting.1.1, standard Reporting, all incidents shall be reported following the instructions in reference.1. For applicable forms to be used, see reference.2 and.3. 4.1.2, detailed Reporting, it is at the discretion of the Project Construction Manager to initiate a detailed investigation including reporting in case of: a serious and/or complex incident; any incident with a potential for serious impact on personnel, assets or environment. Subject initiative will be based on subjective personal reasons or as the result of an instruction from the home office or a third party. 4.2, preservation of evidence, the first action to be taken, after an incident has occurred, is to prevent further injury and arrange for any necessary medical treatment. Furthermore measures shall be taken to prevent the situation from escalating and causing further damage. Details can be found in reference.1.

He may delegate this responsibility to the company site safety Engineer or to another key member of his organization if he deems this best for the quality of the investigation. At the discretion of the Project Construction Manager, a detailed investigation resume as per this guide may be held and an investigation team may be formed if the complexity or other characteristics of the incident warrant. Alternatively the Project Construction Manager may be instructed by the home office or by a third party,. The client or local authorities to have a detailed investigation conducted. 3.2 Investigation, it is the responsibility of the investigator/the investigation team to conduct the investigation following the procedure as described in this guide through and including the distribution of the investigation report. 3.3 Site safety Engineer. It is the responsibility of the site safety Engineer to follow-up on the implementation of recommendations related to site assigned actions and to report the status to the home office manager of Safety.

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Bn-g-uc006 - guidelines for the Investigation of Incidents, (Near miss) Accidents. Purpose, general, responsibility, procedure, references, attachments. Purpose, the purpose of this guide is to define a consistent approach to the detailed investigation of accidents, incidents and near miss incidents (accidents) with the aim umum of achieving a high quality of analysis and reporting. For the purpose of this procedure accidents, incidents and near miss accidents will be referred to as incident(s) unless otherwise stated. The proper investigation of incidents and the subsequent reporting of findings and recommendations is an essential part of Safety, health, welfare and Environmental management on Company construction sites. Investigation findings may contribute to companys effort to try to prevent similar occurrences from happening in the near future. They will furthermore enhance companys continuous efforts of the preservation of human life, material assets and the environment and it will improve companys safety performance in construction execution. Responsibility.1 Project Construction Manager, the prime responsibility for incident investigation rests with the company Project Construction Manager.

Near miss investigation report
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Jan Eloff, madeleine bihina bella, "Software failure. Investigation : a, near, miss, analysis Approach". The student had been told that he was only to test the project with the assistance of a graduate.

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