Hazardous Occurrence Investigation, Recording, and Reporting Guide

1. Purpose

Employment and Social Development Canada (ESDC) is responsible for ensuring that the health and safety at work of every person employed by the employer is protected.

For the purposes of this guide, the term hazardous occurrence will cover accidents, all types of injuries, occupational diseases, other hazardous occurrences, and near misses as defined in Annex A.

The Hazardous Occurrence Investigation, Recording and Reporting Guide is intended to help ESDC fulfil its duty as an employer related to investigating, recording and reporting all hazardous occurrences in accordance with the authorities and references below.

2. Scope

The Hazardous Occurrence Investigation, Recording and Reporting Guide applies to all work locations and all employees within the Department, including Service Canada, the Labour Program, and all other service offerings managed within ESDC, as well as every person granted access to the workplace.

3. Authorities And References

The Hazardous Occurrence Investigation, Recording and Reporting Guide facilitates compliance with:

1. Section 125.(1)(c) Canada Labour Code, Part II
2. Canada Occupational Health and Safety Regulations – Part XV
3. NJC Occupational Health and Safety Directive – Part XVII

Note: Procedures for preventing, resolving and investigating actual or potential incidents of workplace violence are outlined in the Departmental Occupational Health and Safety (OHS) Program Module IV: Workplace Violence Prevention Policy and fall outside the scope of this guide.

4. Roles And Responsibilities

• 4.1 Managers

  4.1 Managers

  1. Follow established protocols, including the protocol for medical emergencies and those regarding the care of injured employees (first aid, medical aid, contacting emergency services if required).
  2. Ensure immediate action is taken to secure the accident scene and that it is not disturbed before the investigative process begins, if applicable.
  3. Notify the Workplace Health and Safety Committee (WHSC) or Health and Safety Representative (HSR) as well as the Regional OHS Advisor of the hazardous occurrence.
  4. Investigate, or appoint a qualified person to carry out the investigation, with the participation of the WHSC or HSR. The qualified person must have knowledge of the work procedures and safety requirements where the hazardous occurrence took place.
  5. Complete an OHS Incident Report and send a copy to the WHSC or HSR, management/site lead, and the Regional OHS Advisor within the prescribed time frames.
  6. In the event an emergency procedure is initiated, liaise with the management/site lead and your Regional Security Office.
  7. Ensure that corrective/preventive measures are implemented (and recommendations by the WHSC/HSR are considered) to prevent similar hazardous occurrences in the future.
  8. Where a work-related hazardous occurrence results in medical treatment or absence from work beyond the day of the injury or illness, complete a provincial Workers' Compensation Board (WCB) employer's report form in a timely and accurate manner.
• 4.2 Employees

  4.2 Employees

  1. Seek first aid, if required.
  2. Immediately report to their manager, verbally or in writing, all hazardous occurrences arising in the course of, or in connection with, their work.
  3. Do not disturb the accident scene before the investigative process begins.
  4. Cooperate with any person carrying out a duty related to investigating a hazardous occurrence on behalf of the employer.
  5. Where a work-related hazardous occurrence results in medical treatment or absence from work beyond the day of the injury or illness, complete a Guide on Hazardous Occurrence Investigation, Recording, and Reporting 6 provincial Workers' Compensation Board (WCB) employee form in a timely and accurate manner.
• 4.3 Workplace Health and Safety Committees (WHSC) / Health and Safety Representatives (HSR)

  4.3 Workplace Health and Safety Committees (WHSC) / Health and Safety Representatives (HSR)

  1. Participate in all investigations relating to hazardous occurrences in the workplace.
  2. Make recommendations to managers, site lead, and/or management lead on corrective/preventive measures related to hazardous occurrences.
  3. Review every OHS Incident Report related to their workplace.
  4. Monitor data relating to hazardous occurrences for their respective workplace.
• 4.4 Regional Occupational Health and Safety Committees

  4.4 Regional Occupational Health and Safety Committees

  1. Participate to the extent that the Policy Health and Safety Committee considers necessary in investigations related to hazardous occurrences within their respective region.
  2. Monitor data relating to hazardous occurrences for their respective region in order to identify trends and establish priorities related to preventing hazardous occurrences.
• 4.5 Policy Health and Safety Committee (PHSC)

  4.5 Policy Health and Safety Committee (PHSC)

  1. In conjunction with the National OHS Office, monitor data relating to hazardous occurrences within the department in order to identify trends and establish priorities related to the prevention of hazardous occurrences.
  2. Participate to the extent that it considers necessary in investigations related to hazardous occurrences.
  3. Participate in the review and evaluation of the Guide on Hazardous Occurrence Investigation, Recording, and Reporting.
• 4.6 Regional OHS Advisors

  4.6 Regional OHS Advisors

  1. Provide advice and guidance on procedures for investigating, recording, and reporting hazardous occurrences.
  2. Notify the National OHS Office of hazardous occurrences that need to be reported to the Labour Program within 24 hours.
  3. Review OHS Incident Reports and provide advice and guidance to managers on the adequacy of their content, and make additional recommendations.
  4. Forward completed OHS Incident Reports to Labour Program, as required, within specified time frames.
• 4.7 National OHS Office

  4.7 National OHS Office

  1. Lead the development of procedures, tools and training materials related to hazardous occurrence investigation, recording, and reporting.
  2. Monitor data relating to hazardous occurrences within the department in order to identify trends and establish priorities related to the prevention of hazardous occurrences.
  3. Enable the review and update of the Guide on Hazardous Occurrence Investigation, Recording, and Reporting, with the participation of the PHSC.
  4. Provide advice and guidance on complex hazardous occurrence investigations, as required, to the Regional OHS Advisors.

5. Hazardous Occurrence Investigation

• 5.1 Why Investigate?

  5.1 Why Investigate?

  The purpose of an investigation is to determine the factors that contributed to the hazardous occurrence. The investigation is not meant to find fault or lay blame, but rather focus on fact-finding to determine the direct and indirect causes of the hazardous occurrence and implement corrective/preventive measures to ensure that similar hazardous occurrences do not occur in the future.

• 5.2 Who Should Investigate?

  5.2 Who Should Investigate?

  All hazardous occurrences should be investigated, without delay, by a qualified person from within the department, with the participation of at least one member of the local workplace health and safety committee. The manager, supervisor, or team leader must notify the WHSC or the HSR of the hazardous occurrence as soon as possible. The committee co-chairs will designate one or more committee member to participate in the investigation. If only one committee member is designated it must be an employee member. Please refer to Annex E and Annex F for flowcharts describing WHSC/HSR responsibilities in the investigation process.

  The qualified person could be the manager, supervisor, or team leader of the employee involved in the hazardous occurrence, as they are likely to be familiar with the both the work and the person involved, and can usually take immediate corrective action, if required. The qualified person may also be someone external to the department, if it is warranted, given the situation. Since hazardous occurrences can vary in complexity this Guide on Hazardous Occurrence Investigation, Recording, and Reporting 8 may be a technical specialist depending on the circumstances of the hazardous occurrence.

  Your Regional OHS Advisor is available to provide you with advice and guidance throughout the investigation.

• 5.3 What to Investigate

  5.3 What to Investigate

  Incidents and accidents causing physical harm, or having the potential to cause physical harm are easily identified. Incidents and accidents causing psychological harm or having the potential to cause psychological harm are less identifiable and are often overlooked.

  Employees and managers must investigate all hazardous occurrences, including near misses, causing physical and/or psychological harm, or having the potential for such harm, as described in Annex A.

• 5.4 How to Investigate

  5.4 How to Investigate

  Through the investigation process, the manager or supervisor, in conjunction with the WHSC or HSR, should follow these series of steps to produce recommendations aimed at preventing a recurrence:

  Step 1

  Visit and control the scene. At this step, review the scene of the hazardous occurrence and cordon off the area to prevent the removal and/or disturbance of evidence, where required.

  Step 2

  Identify and interview any witnesses to the hazardous occurrence (see Annex B for information on Interviewing Dos and Don'ts)

  Step 3

  Consider the following throughout the investigation:

  • WHAT – What was the hazardous occurrence that happened?
  • WHO – Who was involved or injured?
  • WHERE – Where did the hazardous occurrence happen?
  • WHEN – When did the hazardous occurrence happen?
  • WHY – Why did the hazardous occurrence happen? (lack of training, supervision, rule enforcement, maintenance)
  • WHY – If the hazardous occurrence included an injury, why did this injury occur?

  Note: Where the hazardous occurrence involved a motor vehicle a copy of the police report (if available) must be obtained to supplement the investigation.

  Step 4

  Once all the relevant information has been gathered, review and analyze the information to identify the direct and underlying causes of the hazardous occurrence.

  The direct cause is generally the first answer to the question "Why did the hazardous occurrence happen?" The underlying causes (sometimes referred to as root causes) usually involve a number of factors that contribute to the hazardous occurrence. Investigators should consider organizational factors such as the absence of a hazard assessment, procedures or policies, and a lack of supervision; training gaps such as a lack of information, training and instruction; unsafe acts; unsafe conditions or equipment; or personal factors, including lack of job knowledge and/or skill, failure to follow instructions, physical limitations, or misunderstood instructions.

  (For additional information on accident causation, refer to Annex C & Annex D.)

  Step 5

  Finally, based on the analysis and identification of direct and underlying causes of the hazardous occurrence make recommendations on corrective/preventive measures.

• 5.5 Recording the Results of the Investigation – Completing an OHS Incident Report

  5.5 Recording the Results of the Investigation – Completing an OHS Incident Report

  Once the investigation process has been completed, the results must be documented by the investigator in full using an OHS Incident Report, including detailing corrective measures and recommendations to prevent the incident from re-occurring.

  A completed copy of the report must be shared with the member(s) of the WHSC or HSR who participated in the investigation for their review and attestation.

  Completed copies of OHS Incident Reports must be retained by the employer for a period of 10 years.

6. Reporting Hazardous Occurrences

Recording and reporting hazardous occurrences enables thorough trend analysis and provides data that can be used in setting priorities for the departmental health and safety program, and planning the allocation of health and safety resources to prevent Guide on Hazardous Occurrence Investigation, Recording, and Reporting 10 such incidents from reoccurring. In addition, there are specific OHS Reporting Requirements that must be followed.

It should be noted that a hazardous occurrence, in some cases, may also constitute a security incident as per ESDC's guidelines on Reporting Security Incidents. As such, these incidents must be reported as a hazardous occurrence and as security incident.

7. Corrective/Preventive Measures

Corrective/preventive measures are essential in order to ensure that identified hazards have been adequately addressed to prevent similar hazardous occurrences from occurring in the future.

The WHSC or HSR should monitor the effectiveness of the corrective/preventive measures implemented through the investigation process, and may make further recommendations to support the prevention of future related incidents.

Follow-up actions should be taken to ensure that the corrective/preventive measures have been effectively implemented and may include: respond to the report by indicating what actions can be taken or not taken (and why or why not); develop a timetable for corrective actions; monitor whether the scheduled actions have been completed; check the condition of injured workers; inform and train other workers at risk; re-orient workers upon their return to work.

8. Additional Information And References

• National OHS intranet site – Employment and Social Development Canada:
  • National OHS Intranet
  • If a Work-related Accident Occurs Procedure
  • Module IV: OHS Reporting Process
• Labour Program – Employment and Social Development Canada:
  • A Guide to the Investigation and Reporting of Hazardous Occurrences
• Canadian Centre for Occupational Health and Safety (CCOHS):
  • Accident Investigation

9. Enquiries

Questions regarding the Hazardous Occurrence Investigation, Recording and Reporting Guide or its interpretation must be directed to the Regional OHS Advisor through the Human Resources Service Centre.

10. Monitoring and Evaluation

The Hazardous Occurrence Investigation, Recording and Reporting Guide will be monitored and evaluated in accordance with Module VI: Reporting, Monitoring, and Evaluation of the Departmental Occupational Health and Safety Program including regular reporting and data collection methods and with the participation of the PHSC, Regional Occupational Health and Safety Committees, WHSCs and HSRs, management, employees and OHS advisors.

11. Effective and Review Date

Version 2.0 of the Hazardous Occurrence Investigation, Recording and Reporting Guide takes effect on September 17, 2019 and replaces all previous versions. It will be reviewed every three (3) years, or as required, to ensure consistency with changes to OHS-related legislation, regulations and directives. The next scheduled review will be in 2022.

Annex A: What Is A Hazardous Occurrence?

A Hazardous occurrence is an undesirable event which results in (or has the potential to result in) harm, injury or illness (physical or psychological) to employees, material loss and/or property damage and for the purposes of this guide includes the following:

accident

an undesirable or unfortunate incident that occurs unintentionally and usually results in harm, injury, damage, or loss

disabling injury

an employment injury (physical or psychological) or an occupational disease that prevents an employee from reporting for work or from effectively performing all the duties connected with the employee's regular work on any day subsequent to the day on which the injury or disease occurred (time lost).

minor injury

an employment injury (physical or psychological) or an occupational disease for which medical treatment is provided and excludes a disabling injury (no time lost).

near-miss

an incident or event that did not result in injury, but by its occurrence could indicate a hazard or condition to warrant investigation.

non-disabling injury

an injury (physical or psychological) that may or may not have required first aid, did not require medical treatment, and did not prevent the employee from reporting to work.

occupational diseases

An occupational disease is a health problem caused by exposure to a workplace health hazard.

other hazardous occurrence

is any hazardous occurrence which resulted in any of the following circumstances:

1. Electric shock, toxic atmosphere or oxygen deficient atmosphere that caused an employee to lose consciousness;
2. The implementation of rescue, revival or other similar emergency procedures such as a hazardous substance spill, bomb threat, lock down, shelter-in-place, or emergency evacuation;
3. A fire or explosion;
4. Any damage to an elevating device that renders it unserviceable or a free fall of an elevating device; or
5. Any damage to a boiler or pressure vessel that results in a fire or the rupture of the boiler or pressure vessel.

What is Psychological Harm?

Psychological harm can include:

1. an emotional reaction to one or more traumatic work related events that are sudden, unexpected, powerful, shocking and outside of the range of a person's ordinary experiences e.g. hostage-taking incident, physical violence, etc.);
2. an emotional reaction to a work related physical injury;
3. an emotional reaction to an accumulation over time of work related stressors that do not fit the definition of a traumatic incident and that are excessive or unusual when compared to normal pressures and tensions* experienced in the workplace.

* Normal pressures and tensions include, for example, interpersonal relations and conflicts, health and safety concerns, collective bargaining issues, grievances, and routine actions taken relating to the management of employees, including workload and deadlines, work evaluation, performance management, transfers, changes in job duties, reclassification of position, lay-offs, terminations, and reorganizations, to which all employees may be subject from time to time.

For a complete list of OHS definitions refer to the Glossary on iService

Annex B: Interviewing Dos And Don'ts

When conducting an interview, you want to obtain the witness' description of the event, in their own words. Consider the following interviewing Do's and Don'ts.

* These should not be questions that can be simply responded to with "yes" or "no" answers. The questions you ask the witness will vary with each accident, but some general questions that should be asked each time are:

• Where were you at the time of the accident?
• What were you doing at the time?
• What did you see, hear?
• What were the environmental conditions (weather, light, noise, etc.) at the time?
• What was (were) the injured worker(s) doing at the time?
• In your opinion, what caused the accident?
• How might similar accidents be prevented in the future?

Annex C: Accident Causation Model

This model provides a guide for uncovering any possible causes and reduces the likelihood of looking at facts in isolation. Remember that these are sample questions only, not a comprehensive checklist.

Task

Explore the actual work procedure being used at the time of the accident. Members of the accident investigation team should 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?

Material

Seek out possible causes resulting from the equipment and materials used. Members of the accident investigation team should look for answers to questions such as:

• Was there an equipment failure?
• What caused it to fail?
• Was the machinery poorly designed?
• Were hazardous substances involved?
• Were they clearly identified?
• Was a less hazardous alternative substance possible and available?
• Was the raw material substandard in some way?
• Was the use of personal protective equipment (PPE) required?
• Was it available?
• Was the PPE used?
• Were users of PPE properly trained?

Environment

The physical environment, including any changes to that environment, around the time of the accident are factors that need to be considered. Members of the accident investigation team should look for answers to questions such as:

• What were the weather conditions?
• Was poor housekeeping a problem?
• Was it too hot or too cold?
• Was noise a problem?
• Was there adequate light?
• Were toxic or hazardous gases, dusts, or fumes present?

Personnel

Factors specific to personnel may have contributed to the accident and should be considered. Members of the accident investigation team should look for answers to questions about the personnel directly involved such as:

• What experience did they have performing the task/work in question?
• Did they have any physical limitations that may have affected the task/work in question?
• Have they disclosed any health conditions that may have contributed to the accident?
• Were they tired?

Management

Failure of management systems may have contributed directly to the accident or been an underlying cause. Members of the accident investigation team should look for answers to questions such as:

• Were employees made aware of existing or potential hazards?
• Were written safe work procedures available?
• Were employees aware of and familiar with the safe work procedures?
• Were they being enforced?
• Was there adequate supervision?
• Had employees completed all required training and was it up to date?
• Had hazards been previously identified?
• Had procedures been developed to overcome them?
• Were unsafe conditions corrected?
• Was regular maintenance of equipment carried out?
• Were regular safety inspections carried out?

Annex D: Possible Causes of Hazardous Occurrences

Insufficient or Improper Training

• Lack of training
• Safe work procedures not established
• Safe work procedures not understood
• Lack of job knowledge
• Lack of job skill
• Instructions misunderstood

Carelessness, Recklessness, or Horseplay

• Running
• Jumping from elevations
• Throwing material instead of passing it
• Failure to follow instructions
• Failure to follow safe work procedures

Inadequate or Incorrect Equipment

• Lack of specifications for purchases
• Lack of necessary personal protective equipment
• Improper or inadequate clothing
• Unguarded or ungrounded equipment
• Inadequately guarded equipment
• Use of improper tools or equipment

Improper use of Equipment

• Operating a vehicle at an unsafe speed
• Riding in unsafe position
• Failure to use personal protective equipment provided
• Failure to lock out
• Failure to shut off equipment not in use

Equipment Failure

• Lack of maintenance
• Lack of maintenance staff
• Worn, cracked, broken, etc.

No Warning Signs or Markings

• Failure to place warning signs, tags, etc.
• Starting, stopping, moving without warning

Defective or Unsafe Floor, Wall

• Slippery surface
• Uneven walking surface

Illness or Health Condition

• Physical limitations
• Personal health condition or allergy
• Environmental sensitivities

Third Party, Co-worker, or Visitor Actions

• Hazards related to property or operations of another employer
• Threatening actions (verbal or physical)
• Bullying or harassment

Conditions Caused by Weather

• Natural hazards (flooding)
• Lack of visibility
• Slippery surfaces

Agents

• Chemical Agents
• Biological Agents
• Mould/Fungus
• Blood
• Scented products (perfumes; lotions)

Organizational Causes

• Inadequate safety inspection program
• Lack of follow-up for safety correction
• Safe work procedures not established
• Lack of appropriate supervision or monitoring

Dust

• Indoor
• Outdoor

Noise

• Indoor
• Outdoor

Annex E: Incident Investigation and Reporting Involving A Workplace Committee

Notes:

* Manager may appoint themselves as the qualified person.

** If only one committee member is designated, they must be an employee member.

• Long Description

  Incident Investigation and reporting involving a Workplace Health and Safety Committee

  Step 1

  Employee reports the incident to their manager

  Step 2

  Manager ensures appropriate First Aid is administered, secures the scene, and calls for assistance.

  Step 3

  Manager appoints a qualified person to lead the investigation and notifies the Workplace Health and Safety Committee.

  Step 4

  Investigator and the Workplace Health and Safety Committee co-chairs receive a notification.

  Co-chairs designate one or more members to participate in the investigation.

  The investigator begins the investigation and the Workplace Health and Safety Committee member participates in the investigation.

  Investigation

  • plan (establish priorities; prepare questions);
  • interview witnesses;
  • analyse information (facts and evidence);
  • determine causes; and
  • identify corrective and preventive measures.

  Step 5

  The investigator completes an OHS incident report.

  Step 6

  Workplace Health and Safety Committee member reviews, comments, and signs report. Manager implements corrective measures.

  Step 7

  Manager submits OHS incident report based on established reporting requirements.

  Designated Committee member shares report for discussion at next WHSC meeting.

  Regional Occupational Health and Safety Advisor reviews the OHS incident report, provides guidance and recommendations, and submits report to Labour Program, as necessary.

  Step 8

  Workplace Health and Safety Committee or the manager follow up with the other on the status of the corrective measures.

Annex F: Incident Investigation And Reporting Involving A Health And Safety Representative

Notes:

* Manager may appoint themselves as the qualified person.

• Long Description

  Incident investigation and reporting involving a Health and Safety Representative (HSR)

  Step 1

  Employee reports the incident to their manager

  Step 2

  Manager ensures appropriate First Aid is administered, secures the scene, and calls for assistance.

  Step 3

  Manager appoints a qualified person to lead the investigation and notifies the Health and Safety Representative.

  Step 4

  The Investigator and the Health and Safety Representative receive a notification.

  The investigator begins the investigation and the Health and Safety Representative participates in the investigation.

  Investigation

  • plan (establish priorities; prepare questions);
  • interview witnesses;
  • analyse information (facts and evidence);
  • determine causes; and
  • identify corrective and preventive measures.

  Step 5

  The investigator completes an OHS incident report.

  Step 6

  Health and Safety Representative reviews, comments and signs report.

  Manager implements corrective measures.

  Step 7

  Manager submits OHS incident report based on established reporting requirements.

  Regional Occupational Health and Safety Advisor reviews OHS incident report provides guidance, recommendations and submits report to Labour Program, as necessary.

  Step 8

  The Health and Safety representative or the Manager follow up with the other for the status of the corrective measures.