This Document Contains Chapters 11 to 12 CHAPTER 11 Emergency Planning Essential Outcome After completing the lesson on this chapter, if nothing else, students should appreciate the importance of emergency preparedness and be able to identify and describe the essential elements of emergency and evacuation plans. Learning Outcomes After completing this chapter, students should be able to: define an emergency list the key elements in emergency preparedness describe the concept of an emergency plan explain the necessity of having emergency and evacuation plans describe the principles of fire prevention and suppression Key Concepts An emergency is any sudden set of circumstances demanding immediate action, but for the purpose of this chapter the focus is on emergencies that cause, or threaten to cause, damage or loss of property or life. Emergencies can be human caused or naturally occurring. Emergency planning involves anticipating and planning for emergencies as well as putting those plans into action as needed. Emergency planning also involves plans for getting things back to normal after the emergency, as well as the continuous refinement of plans based on experience and learning. Emergency preparedness is a crisis management process that involves five steps: signal detention (recognition that an emergency is possible or imminent); preparation; damage containment (the largest area of focus of most plans); recovery; and learning. Emergency plans need to consider issues that may occur at the precontact, contact, and post contact stages of an emergency. At the precontact stage, hazards are evaluated and an emergency response plan is developed; this may also include an evacuation plan. The plan will include a process for notifying the appropriate authorities, ensure that the proper emergency supplies and equipment are available and easily accessible (e.g., fire extinguishers), and include drills and rehearsals. An emergency manager must be identified as part of the plan. At the contact stage, fire plans and fire suppression strategies will be brought into play, along with first aid and medical attention as required by the situation. At the post contact stage, critical incident stress debriefings may be provided to help those who experienced trauma as a result of the emergency, and the effort will shift towards efforts to get things back to the way they were prior to the emergency. Student Motivation Unfortunately, emergencies and disasters appear to be taking place with regularity, so most students will have some familiarity with some recent examples covered prominently in the news media, such as the train derailment in Lac Magantic, Quebec, the record flooding in Calgary and High River, Alberta, and the mall roof collapse in Elliot Lake, Ontario. These high-profile events may cause students to be motivated to learn about how organizations plan for such contingencies and what constitutes a proper emergency plan. Barriers to Learning The content of this chapter is relatively straightforward, and the terminology used and the concepts described should pose little problem for most students. Engagement Strategies and Lesson Plan 1. Engaging Students at the Outset Learning objective: At the completion of this activity, students will be able to relate the importance of emergency planning to real-life examples, and explain emergency examples within the framework of precontact, contact, and postcontact activities. Show the class one or several short video clips of recent (preferably Canadian) disasters. Examples you could use include (but are by no means not limited to) the 2013 Alberta floods in High River and Calgary; the 2013 Lac Megantic train disaster in Quebec; the 2013 record rain event and subsequent flooding in Toronto; the 2012 shopping centre roof collapse in Elliot Lake, Ontario; and the 2012 explosion and fire in the lumber mill in Prince George, BC. Ask students to think about all the things that happen during a disaster of the magnitude shown in the clip(s), and to think about things could be done in anticipation of a possible disaster, the actions required during the event, and the work that needs to follow such an event. Use these examples and the subsequent discussion as a way to introduce the topic and the framework of precontact, contact, and post contact stages. 2. Lesson Engagement Strategies a. Learning objective: At the completion of this activity, students will be able to identify the range of human responses to catastrophic events (such as a natural disaster), and discuss the possible benefits and limitations of critical incident stress debriefing (CISD). Using a flip chart or chalk/white board, have your students brainstorm a list the possible responses to acute or catastrophic stressors (refer back to Chapter 7) caused by a disaster or an emergency. The list could include both psychological and physiological responses (e.g., anxiety, anger, guilt, shock). Discuss the function of critical incident stress debriefing (CISD) as described in the text. Discuss and solicit student opinions regarding the studies reporting on the efficacy of CISD and the controversy over the use of such programs. b. Learning objective: At the completion of this activity, students will be able to identify and list the key elements involved in pandemic planning. Assign Using the Internet Question 2 (below) as a small group in-class exercise. Organize the groups so that each has access to a tablet or laptop for researching the topic. As an alternative to online research, distribute the Ontario Ministry of Health plan for a flu pandemic, found at www.health.gov.on.ca/en/pro/programs/emb/pan_flu/pan_flu_plan.aspx, to half the groups, and the Canadian Centre for Occupational Health and Safety (CCOHS) Business Continuity Plan—Infectious Diseases document, found at www.ccohs.ca/pandemic/pdf/Business_continuity.pdf, to the other half. Have each group present a brief report on its findings: c. Learning Objective: At the completion of this activity, students will be able to apply the elements of emergency preparedness to a simple case involving the threat of biological terrorism. As an application exercise, assign students the case “Biological Terrorism.” Working in an even number of small teams, have them develop a list of considerations and plan elements as directed. Instead of having each team report to the entire class, have the teams pair up and share their lists with each other. 3. Lesson Plan Notes and Lecture Outline * You can access various video clips on local and national emergencies at www.youtube.com, such as the Kelowna Fire Storm 2003, www.youtube.com/watch?v=MVp80WCU-mYUse. These pictures set the tone for student awareness and discussion around the importance of emergency preparedness and the challenges of responding to emergencies. * A guest speaker from the Red Cross, fire department, or other emergency planning organization can be asked to describe emergency planning and business continuity planning. * Short videos/DVDs such as the Workers’ Compensation Board of BC’s “Expect the Unexpected” are available through government departments in different jurisdictions. Visit www.worksafebc.com/publications. A list of DVD titles on Workers’ Compensation can be accessed at WorkSafeBC Library Services, www.worksafebc.com/about_us/library_services/assets/pdf/videos_titles.pdf. A. Introduction: Emergency Preparedness Ask students to read and discuss the opening vignette, “Deepwater Horizon.” Use PowerPoint slides to describe (define terms) and give examples of recent organization emergencies and their emergency planning (emergency preparedness and response to emergency). Give an overview of the emergency organizations in your region. Refer students to OH&S Notebook 11.1, “Emergency Measures Organization.” Access the website of your local EMO site to show students debriefing reports on past emergency responses and other information on emergency-related topics in your region. Ask students to form small groups to discuss and answer Using the Internet Question 1 (What emergencies have occurred in your local area in the past five years? How effective was the emergency response?), as well as Discussion Question 2 (What type of emergencies should organizations in your area be prepared for?). Have the student groups share some recent examples of emergencies (and potential emergencies) and the level of preparedness and response to the emergency. Emphasize the importance of mitigating disasters through effective emergency planning. Refer to examples and video clips to describe the importance of using the five-stage crisis management strategy: signal detection, preparation, damage containment, recovery, and learning. B. Precontact: Assessing Hazards and Planning Potential Responses Ask students to read and discuss OH&S Today 11.1, “Norwalk Outbreak at Mount Allison.” Use PowerPoint slides to describe and give examples of the elements necessary in the management of emergencies: an emergency plan, an emergency manager, a fire plan, an evacuation plan, and a medical attention plan. Also, the basics of an emergency plan: hazard evaluation, emergency response plan, training, an evacuation plan, notification of authorities, supplies, and drills. Ask students to form small groups to discuss and answer Exercise Question 1. (Determine whether your workplace or school has an emergency response plan. Compare this plan with the one outlined in this chapter.) Have the student groups share examples of the emergency plans they discussed. You may want to have a guest speaker talk about a recent emergency, emergency preparedness, and the integration and responsibilities of HRM (or refer to a recent emergency). The Summer 2004 issue of the BC Human Resource Management Association’s People Talk magazine on emergency preparedness has several articles on the emergency planning for the devastating Kelowna and Kamloops fires and the integrated strategic HRM approach that was implemented. Visit www.bchrma.org/resources/people_talk_magazine/view_back_issues.htm. C. Hazard Evaluation: Future Proofing The risk of natural disasters varies from region to region in Canada. Ask students to read OH&S Notebook 11.2, “Future Proofing and Access the Natural Hazards Map of Canada,” www.publicsafety.gc.ca/res/em/nh/index-eng.aspx, to determine the risk of various disasters in their region based on historical precedent. D. Contact: Fire Plan Use PowerPoint slides to describe (using Figure 11.1, “Fire Triangle,” and Figure 11.2, “Fire Tetrahedron”) the fire process and requirements for extinguishment. Engage students in a discussion about what should be considered when developing a fire prevention program. The elements include the following: (1) structural design (building codes), (2) barriers, (3) detection and suppression (smoke alarm, fire extinguisher), and (4) storage (combustibles stored in isolated area). Ask students to form small groups to discuss and answer Exercise Question 2 (Prepare a fire prevention and suppression plan for your own home or apartment.) Have the student groups share examples of the fire prevention and suppression plans they discussed. E. Postcontact: Critical Incident Stress (Refer to Lesson Engagement strategy a, above) F: Preparation and Response to a Potential Influenza Pandemic (Refer to Lesson Engagement strategy b, above) You can summarize this chapter by challenging students to expand and improve on the quality of their thinking, learning, and problem solving about emergency preparedness and response by discussing the preparation and response to a potential influenza pandemic. An alternative activity would to have students describe how you would prepare an emergency response plan for a small business. Pick a particular industry. Refer to the WorkSafeBC publication “How to Prepare an Emergency Response Plan for Small Business” at www.worksafebc.com/publications/health_and_safety/by_topic/assets/pdf/emergency_response_guide.pdf. Assessment Tools To quickly assess student learning against the chapter learning outcomes, at the end of the class: Observe and note the presentations delivered as part of the Lesson Engagement exercises, above. Draw the fire tetrahedron shapes on the board and ask students to as well. Instruct the students to properly label the four triangles without referring to their text or notes. Reflections on Teaching Good teaching requires ongoing self-assessment and reflection. At the completion of this lesson, you may find it helpful to reflect on the following, and consider whether you want or need to make any adjustments for subsequent lessons. What worked in this lesson? What didn’t? Were students engaged? Were they focused or did they go off on tangents? Did I take steps to adequately assess student learning? Did my assessments suggest that they understood the key concepts? What (if anything) should I do differently next time? How can I gather student feedback? How can I use this feedback for continuous improvement of my teaching? Additional Resources Weblinks Ontario Ministry of Community Safety and Correctional Services Emergency Management website: www.emergencymanagementontario.ca/english/home.html. Students may be interested in downloading and printing this Emergency Preparedness Pocket Guide, also available on the Ontario EMO website: www.emergencymanagementontario.ca/stellent/groups/public/@mcscs/@www/@emo/documents/educationalmaterial/ec157521.pdf. Manitoba Emergency Measures Organization website: “Interim After Action Report on the 2011 Flood”: www.gov.mb.ca/emo/general/2011floodaar.pdf. Videos This video on emergency preparedness is directed at families/individuals; however, it describes the essential aspects of planning that are transferable to a workplace situation: www.emergencymanagementontario.ca/english/multimedia/videogallery/videogallery.html. There are additional emergency preparedness videos available on this site. Suggested answers to exercises and cases Discussion Questions 1. Who should be involved in developing emergency response plans? Answer: Emergency response is largely up to individuals. As events overwhelm an individual’s capacity to respond, governments respond in a progressive manner beginning with local emergency organizations (e.g., municipal emergency services, emergency measures organization) and then provincial and federal emergency measures organizations. Visit the following: BC Provincial Emergency Program (PEP), www.pep.bc.ca Federal Public Safety and Emergency, www.publicsafety.gc.ca/index-eng.aspx Other organizations involved in emergency measures: health and safety committees municipal and regional governments fire departments utility corporations regional districts the RCMP 2. What type of emergencies should organizations in your area be prepared for? Answer: Naturally occurring emergencies include the following: floods (lakes and mountain streams), earthquakes, SARs, and wind bursts and heavy rains. Emergencies caused by humans include computer crashes or viruses, chemical spills, plane crashes, forest fires, explosions, and violence. 3. Decide what type of fire extinguisher would be most effective in the following fire situations: a hair dryer engulfed in smoke grease burning in a frying pan rags smoking in the garage a log that has rolled from the fireplace onto the living room floor a coffee machine whose wires are shooting flames Answer: CO2, halon CO2, dry chemical CO2, dry chemical water CO2, halon 4. Although this chapter has focused on health and safety implications, there are also public relations issues in an emergency. What principles would be appropriate for an organization to adopt in dealing with the media/public during an emergency? Answer: Effective management of information, ranging from designating responsibility and setting clear policies and procedures to communicating with the public, is extremely important. The development and use of technology to communicate quickly to the media and other external sources could be an important consideration. Using the Internet 1. What emergencies have occurred in your local area in the past five years? How effective was the emergency response? (Hint: Local EMO sites often have debriefing reports on past emergency responses.) Answer: Kelowna—Okanagan Mountain Provincial Park Fire The Summer 2004 issue of the BC Human Resource Management Association’s People Talk magazine on emergency preparedness has several articles on the emergency planning for the devastating Kelowna and Kamloops fires and the value of having human resources as a strategic component. Visit www.bchrma.org/resources/people_talk_magazine/view_back_issues.htm. 2011 Manitoba Flood The Manitoba EMO also has an Interim After-Action Report on the 2011 flood available on its website: www.gov.mb.ca/emo/general/2011floodaar.pdf. BC Health Care Workers—Sudden Acute Respiratory Syndrome (SARS) The WCB’s Prevention magazine (www.WorkSafebc.com) published an article, “SARS in the Workplace—Meeting the Challenge” (February 2004), describing the challenges of protecting BC health care workers from the emerging respiratory infection called SARS (severe acute respiratory syndrome). The challenge was to manage information quickly, effectively, and efficiently, whether it involved keeping people current on the constantly changing science, updating protocols, facilitating centralized and rapid decision making, or communicating information and addressing concerns and fears with everyone involved. Workplace Shooting in Kamloops The coroner’s inquest made several recommendations highlighting the need for businesses and governments to plan for potential workplace violence. Other emergencies include floods, plane crashes, winds and snowstorms, and earthquakes. What plans are being made for the predicted flu pandemic in your area? (Hint: What information is available from government agencies? And what firms are publishing pandemic plans?) Answer: As an example for students, the Ontario Ministry of Health has a recently updated plan for a flu pandemic: www.health.gov.on.ca/en/pro/programs/emb/pan_flu/pan_flu_plan.aspx. As well, the Canadian Centre for Occupational Health and Safety (CCOHS) has a “Business Continuity Plan—Infectious Diseases” document available for download from its website. Visit www.ccohs.ca/pandemic/pdf/Business_continuity.pdf. Plans for Predicted Flu Pandemic: 1. Government Agencies: • Public Health Agencies: Provide guidelines for pandemic preparedness, vaccination strategies, and public health measures. • Local Health Departments: Share specific plans and recommendations for managing outbreaks in the community. 2. Firms Publishing Pandemic Plans: • Large Corporations: Many publish detailed pandemic response plans covering employee health, remote work arrangements, and continuity strategies. • Healthcare Providers: Develop protocols for managing patient care and infection control during a pandemic. Information Sources: • Government Websites: Offer updates on health advisories and preparedness plans (e.g., CDC, WHO). • Company Websites: Include their specific pandemic response strategies and guidelines for employees. These plans typically focus on minimizing disruption, maintaining public health, and ensuring continuity of essential services. Exercises 1. Determine whether your workplace or school has an emergency response plan. Compare this plan with the one outlined in this chapter. Answer: The necessary elements in the management of emergencies include an emergency plan, an emergency manager, a fire plan, an evacuation plan, and a medical attention plan. The basics of an emergency plan are these: hazard evaluation emergency response plan training evacuation plan notification of authorities supplies drills 2. Prepare a fire prevention and suppression plan for your own home or apartment. Answer: When a fire prevention program is being developed, the following should be considered: structural design (building codes), barriers, detection and suppression (smoke alarm, fire extinguisher), and storage (combustibles stored in isolated area). Other areas to consider include these: hazard evaluation (possible home hazards: propane barbecue, cleaning solvents), emergency response plan (discuss and have emergency information and phone numbers posted), and evacuation plan. What does it cost to create and maintain a comprehensive emergency plan for a specific organization? Choose a specific organization and try to estimate these costs. Consider the costs (e.g., time) associated with developing a plan, training employees in the plan, drills or practice (e.g., evacuation drills), and maintaining the plan to ensure currency. Answer: Planning costs depend on the size of the committee/task team involved; training costs depend on the number of employees in the organization, the number of sites they maintain, and so on. The same holds true for practice and drills; the costs to maintain the plan depend partly on the organization’s policy on how often the plan is updated. Case Case 1: Biological Terrorism The necessary elements in the management of emergencies include an emergency plan, an emergency manager, a fire plan, an evacuation plan, and a medical attention plan. The basics of an emergency plan are these: hazard evaluation, emergency response plan, training, an evacuation plan, notification of authorities, supplies, and drills. The Summer 2004 issue of the BC Human Resource Management Association’s People Talk magazine on emergency preparedness has several articles on the emergency preparedness. Visit www.bchrma.org/resources/people_talk_magazine/view_back_issues.htm. CHAPTER 12 Incident Investigation Essential Outcome After completing the lesson on this chapter, if nothing else, students should be able to ascertain the steps involved in investigating workplace incidents and the tools and techniques involved. Learning Outcomes After completing this chapter, students should be able to: describe the intent and steps of an incident investigation gather information to analyze the human, situational, and environmental factors contributing to incidents outline the legal requirements of incident investigation results explain the concept of a walkthrough survey list the steps to conducting interviews concerning an incident conduct a re-enactment complete the various types of incident and injury reports Key Concepts The investigation of incidents is an important component of hazard recognition, assessment, and control (RAC) programs. Incident investigations have these benefits: they determine the direct and contributing causes of the incident, they help prevent similar incidents, they create a permanent record of the incident and the associated costs, and they promote safety awareness among employees. The timing, severity, and legal requirements of each incident strongly influence the investigative process that will be followed. The information collected during an incident investigation will include details of the human factors (e.g., what workers were doing at the time of the incident); situational factors, such as the equipment or agents involved; and the environmental factors, such as light or noise. Incident investigations may be carried out by a variety of individuals, including supervisors, technical advisors and specialists, health and safety officers, representatives of health and safety committees, and/or a safety team. These investigators may use a variety of investigative methods, including observations or walkthroughs of the incident scene, interviews with witnesses, and re-enactments of the incident. Photographs, drawings, computers, and other tools are used to supplement the investigation. Incident/accident reports record crucial information such as the agency involved (i.e., factors that caused the accident); the incident type (e.g., a fall to a lower level); and the personal factors involved (e.g., fatigue). Following the collection of the data, the incident can be analyzed. Several theories or approaches can be taken, including the domino theory, the Swiss cheese model, bow-tie analysis, or the theory of normal incidents. Student Motivation Most people like a good mystery, so relating this chapter to the work of detectives or private investigators may be a good way to pique interest and motivation to study the topic. The investigative phase of an incident investigation can be explained as a methodical process, while the analysis phase can be explained as a critical thinking exercise. These two different but complementary approaches may appeal to a variety of student learning styles and preferences. Barriers to Learning The content of this chapter should pose few learning barriers for most students. The terminology used and models/theories described are relatively clear and straightforward. Engagement Strategies and Lesson Plan 1. Engaging Students at the Outset Learning objective: At the completion of this activity, students will be able to identify examples of data findings from incident/accident investigations. Show the class the computer animation video of the final moments of the Cougar Flight 491 disaster (www.tsb.gc.ca/eng/medias-media/videos/aviation/A09A0016/index.asp). Call attention to the counter at the top left of the screen, showing altitude loss as time elapses. Ask the class to try to imagine what it must have felt like to have been on that helicopter during those moments, and invite a few students to share their reactions. Discuss and use this activity as a powerful way to bridge to the first lesson plan activity (see Lesson Plan Notes and Lecture Outline, below). 2. Lesson Engagement Strategies a. Learning objective: At the completion of this activity, students will be able to identify, classify, and discuss the types of information collected during the incident investigation process (first part). Provide the class with an incident scenario, such as a worker falling and injuring herself after slipping on some spilled liquid on the shop floor. Divide the class into small groups, using the same scenario for each or a different one. Instruct the teams to work through the three factor categories (human, situational, environmental) and to develop a list of questions that might be asked during the investigation. Encourage students to build and expand on the examples provided in the text. b. Learning objective: At the completion of this activity, students will be able to identify, classify, and discuss the types of information collected during the incident investigation process (second part). Refer again to the Flight 491 incident previously discussed. Show or distribute the information contained in the Transportation Safety Board of Canada (TSB) website on the Q&A page concerning the incident: www.tsb.gc.ca/eng/medias-media/fiches-facts/A09A0016/A09A0016.asp (see Web link, below). Ask the teams to review the explanations of the 16 findings, and categorize them as human, situational, or environmental. Review and discuss. c. Learning Objective: At the completion of this activity, students will be able to conduct a re-enactment of a workplace incident. Set up a scenario of a workplace incident, such as the slip-and-fall example cited earlier (see Lesson Engagement Strategy a, above). Ask for student volunteers to help role play the incident, including the roles of the victim and witnesses, while other students role play investigators. Guide their actions, referring to the re-enactment guidelines described in the chapter. Debrief and clarify as necessary. 3. Lesson Plan Notes and Lecture Outline * A guest speaker from the WCB can be asked to describe incident investigations. Short videos/DVDs, such as the BC Workers’ Compensation Board’s “Investigating an Accident” (which includes a trainer’s manual), are available through the government departments in the different jurisdictions. The one mentioned here is at www.worksafebc.com/publications. A. Rationale for Incident Investigation Engage students in a discussion about what they remember about the Cougar Flight 491 helicopter incident that resulted in the deaths of 17 people on March 12, 2009. Highlight that the resulting investigation took almost two years and resulted in numerous recommendations. Ask the class the following questions: What was the purpose of the investigation? How was the investigation conducted? What were the root causes of the incident? Why do an incident investigation? (What were its benefits?) Refer students to the opening vignette, “Flight 491,” for the answers to these questions. Highlight that it was determined that the physical cause was the failure of titanium studs in the gear box of the helicopter, which allowed oil to leak out of the gear box; however, there were other factors at play that contributed to the tragic outcome of the incident. Emphasize that an investigation explores the four or five root causes or factors that contribute to an incident or incident. Incorporate the students’ answers and use PowerPoint slides to define and describe the benefits of an incident investigation. A critical component of an organization’s RAC and OH&S programs is the analysis and account of an incident or incident based on information gathered by a thorough examination of all the factors involved. The aim of the investigation should be outlined clearly (i.e., the recommendations will prevent a recurrence of a similar incident). The benefits of incident investigation are these: it determines the root and contributing causes, prevents recurrence of similar incidents, improves safety procedures and practices, creates a permanent report, determines costs, and raises the level of safety awareness among employees. B. Critical Factors in the Investigation Process: Timing, Severity, and Legal Requirements Use PowerPoint slides to explain how timing, severity, and legal requirements strongly influence incident investigations. Timing delays may lead to memory loss and distortion of details, changes at the incident site, and the removal of important evidence. It is recommended that the following types of incidents, based on severity, be investigated: lost-time injuries, minor injuries that are treated by a doctor, close calls, and incidents with property damage. Accidents must be reported to the WCB, normally within three days. The BC Workers’ Compensation Act—Part 3, Division 10, and the BC Workers’ Compensation OH&S Regulation, Section 3.4, outline incident reporting and investigation. They call for immediate notice of certain incidents, list which incidents must be investigated, and outline the investigation and reporting process. Describe the legal requirements for conducting incident investigations. Refer to OH&S Today 12.1, “What to Investigate.” Refer also to Case 1, “Incident Investigation.” C. Legal Requirements for Investigations and Reports Provide students with an overview of the regulatory requirements for conducting incident investigations by accessing the OH&S legislation website in your jurisdiction. Refer to OH&S Notebook 12.1 and OH&S Today 12.1, “What to Investigate.” D. Types of Information Collected: Human, Situational, and Environmental Factors (and Who Investigates) Refer to Lesson Engagement Strategies a, and b, above. E. Investigative Methods, Tools, and Reports Ask the students to form small groups to discuss Case 1, “Accident Investigation,” and to present their conclusions to the class. Incorporate the students’ answers, using PowerPoint slides to describe the guidelines for conducting an observation/walkthrough, an interview, and a re-enactment. Use PowerPoint to describe and/or illustrate the variety of tools and reports used in conducting incident investigations. Assessment Tools To quickly assess student learning against the chapter learning outcomes, at the end of the class: Observe the discussions and reports from the Lesson Engagement activities (see above) to help assess students’ comprehension of incident factors. Use the case reports to help determine the groups’ grasp of incident investigation processes and steps. To assess individual comprehension of the key learning outcomes, have each student write and submit a brief summary of the case used in the exercise. Reflections on Teaching Good teaching requires ongoing self-assessment and reflection. At the completion of this lesson, you may find it helpful to reflect on the following, and consider whether you want or need to make any adjustments for subsequent lessons. What worked in this lesson? What didn’t? Were students engaged? Were they focused or did they go off on tangents? Did I take steps to adequately assess student learning? Did my assessments suggest that they understood the key concepts? What (if anything) should I do differently next time? How can I gather student feedback? How can I use this feedback for continuous improvement of my teaching? Additional Resources Weblinks Transportation Safety Board of Canada (TSB) website, Q&A page on the Cougar Flight 491 incident: www.tsb.gc.ca/eng/medias-media/fiches-facts/A09A0016/A09A0016.asp. Videos The Transportation Safety Board of Canada (TSB) website has a computer animation video re-creating the last moments of Cougar Flight 491: www.tsb.gc.ca/eng/medias-media/videos/aviation/A09A0016/index.asp. Suggested answers to exercises and cases Discussion Questions 1. What three factors should be considered as potential contributors to any incident? Answer: human, environmental, situational 2. Describe the methods that can be used in incident investigation. Answer: observation or walkthroughs, interviews, re-enactments 3. What tools can assist the incident investigator? Answer: Camera, with flash Water-resistant pens and pencils for drawings Computers Tape measures Straightedge ruler Flashlights Video Accident investigation forms Investigation checklist DO NOT ENTER tape Tape recorder 4. What steps should be taken to properly re-enact an incident? Answer: A re-enactment requires a qualified observer and the witnesses’ own words, and whatever will make it possible to act out the events. 5. Give an example of how human, environmental, and situational factors can combine to result in an incident. Answer: One example of a human factor was when a worker assumed that the tanker truck he was driving was carrying PH7 alum water treatment additive (it usually did). He went to clean the tank and cut with a torch the aerator pipe, which caused a deadly explosion. The tanker contained waste oil and gasoline that ignited and exploded. Poor communication was a contributing factor. Also, the employee made a poor decision. A situational factor was that there wasn’t any testing equipment available and that the tankers did not normally carry waste oil and gasoline. Another example: Read OH&S Notebook 12.3, “Analysis of an Incident.” An example of a human factor was that the work was not being performed according to procedures (the carpenter removed the legally required saw guard). An example of a situational factor was that the safety measures were not functioning satisfactorily—the correct equipment was not made available by management. (The supervisor had requested that the company purchase a new saw guard.) 6. Given our focus on analyzing and understanding incident causation, it is worth noting that some safety professionals now refuse to use the term “incidents.” They contend that doing so implies that incidents are random and unforeseeable whereas we know that most incidents are foreseeable. What are the pros and cons of this position? Do “incidents happen” or are all incidents preventable? Answer: Divide the students into two groups to debate the merits (pros and cons) of the two positions: "incidents happen" or “all incidents are preventable.” Debaters will be assigned one of two positions: (1) Accidents happen, or (2) All incidents are preventable. Students should prepare to argue in favour of one position. The debate has two rounds. In the first round, each team learns the position of the other debating team. Each team has five minutes to explain their position as comprehensively as possible. At the completion of the first round, the debating teams are given five to ten minutes to prepare criticisms of the other team for the second round. In round two, each debating team has five to ten minutes to criticize the position of the other team. There is a team of student judges. The judges listen to the different sides presented; then, after the debate is over, they tell the debating teams what they believe is the stronger answer to the debate question. You will want to summarize the debate by emphasizing the three facts of incident causation: Incidents are caused. Incidents may be prevented if the causes are eliminated. Unless the causes are eliminated, the same incidents/incidents will happen again. You will then ask the students, “Can all the causes be eliminated?” Consider the human factor, the decision of the employees to follow certain behaviours. To have no incidents is a wonderful goal, but is it practicable? Is the goal achievable? There are so many factors that contribute to an incident, is it possible to consider every single thing? Every event, incident, or disaster is composed of a series of happenings that result in some negative condition. The debate can lead to a discussion on the Domino Theory, the Swiss Cheese Model, and Normal Incidents (i.e., the Domino Theory asserts that if any one of the domino categories does not happen, then the injury probably will not occur).You may want to use PowerPoint slides to illustrate and describe and these theories. 7. Some safety professionals now talk about “system risk.” In essence, they suggest that incidents do not result from single causes; rather, they are the result of multiple events working together. How might the factors identified in this chapter interact to result in an incident? Answer: Refer to the sections in the text on the Domino Theory, the Swiss Cheese Model, and Normal Accidents. System Risk and Incident Causes: 1. Multiple Contributing Factors: • Human Factors: Errors or lapses in judgment by employees. • Organizational Factors: Inadequate safety policies or training. • Technical Factors: Equipment failures or design flaws. • Environmental Factors: Unsafe working conditions or inadequate safety measures. 2. Interaction of Factors: • Example: An incident might occur when a lack of training (human factor) interacts with faulty machinery (technical factor) in an unsafe work environment (environmental factor), exacerbated by insufficient safety procedures (organizational factor). Conclusion: Incidents often result from the complex interplay of multiple factors rather than a single cause. Understanding and addressing these interactions is crucial for effective risk management and prevention. Using the Internet 1. Search news media and online reports to find accounts of workplace incidents. For at least one such report, try to identify the human, situational, and environmental factors contributing to the incident. Answer: Hazard Alerts publications.healthandsafetycentre.org/s/HazardAlerts.asp. Example of Workplace Incident: Incident Report: Warehouse Forklift Accident 1. Human Factors: • Operator Error: The forklift driver was not following established safety procedures. • Lack of Training: The driver had recently joined the company and had not received comprehensive training on forklift operation. 2. Situational Factors: • High Workload: The warehouse was experiencing high volumes of shipments, leading to a rushed and stressful environment. • Communication Issues: There were poor communication practices between forklift operators and warehouse staff, contributing to confusion about the movement of goods. 3. Environmental Factors: • Crowded Workspace: The warehouse layout was congested, limiting maneuverability for the forklift. • Inadequate Signage: There were insufficient warning signs and markings indicating safe zones and pedestrian areas. Conclusion: The accident resulted from the interaction of human errors (inadequate training and procedural lapses), situational pressures (high workload and poor communication), and environmental conditions (congested layout and lack of signage). Addressing these factors holistically can help prevent similar incidents in the future. 2. Take the incident investigation training for supervisors presented at employment.alberta.ca/whs/learning/Incident/Incident.htm. Exercises 1. Many incident investigations, such as traffic and airline investigations, conclude that “human error” is the principle cause. Yet we know that situational and environmental factors also play a role. Why do we emphasize the role of humans in incident causation? Does this result in an underemphasis of these other factors? Answer: Situational and environmental factors can be managed more easily than human factors. For example, mechanical failures can be linked to human error. There seem to be at least three forms of human cognitive failure; these relate to memory, focus, and physical skills. Emphasis on Human Error in Incident Causation: 1. Focus on Human Error: • Immediate Visibility: Human errors are often more visible and directly linked to the incident, making them easier to identify. • Responsibility: Emphasizing human error can simplify the attribution of fault, focusing on individual actions or decisions. 2. Impact on Other Factors: • Underemphasis of Situational Factors: By focusing primarily on human error, situational factors like workload, time pressure, or inadequate procedures may be overlooked. • Neglect of Environmental Factors: Environmental conditions, such as unsafe equipment or poor workplace design, might not be adequately addressed if the focus remains solely on individual mistakes. Conclusion: While human error is a significant factor, an exclusive focus on it can overshadow the critical role of situational and environmental factors. Effective incident investigations should adopt a systems approach, considering how multiple factors interact to contribute to incidents, rather than attributing causes solely to human error. Cases Case 1: Incident Investigation Answer: WorksafeBC’s “Investigation of Accidents and Diseases” (www.worksafebc.com/publications) is a reference guide and workbook that discusses concepts and methods that can help an employer implement and perform effective investigations in their workplace. It includes exercises and sample forms. Students can approach this case in two ways: They can review the case and answer the question at the end of the case: “Describe the investigative methods and tools you would use to investigate the incident.” You may want to expand the case analysis to include additional questions such as these: “Describe the critical factors you would consider and your strategy for approaching the investigation.” “What types of information need to be collected?” “Who will be involved?” “Describe the methods and tools you would use.” “What reports, records or forms would help you report, investigate, and analyze the workplace injury?” “How will you analyze the data collected?” OR They can approach the case from an inspection point of view and develop a list of critical questions (the 5 Ws and How) to determine what can be done to ensure that similar incidents do not occur again. Ask students to identify what questions will help recognize the root causes of the incident. Students can develop a root cause analysis checklist incorporating questions concerning the human, situational, and environmental factors that contributed to the incident. Root Cause Analysis—Contributing Factors: Human, Situational, Environmental—Questions to Ask There are three facts to incident causation: accidents/incidents are caused; accidents/incidents may be prevented if the causes are eliminated; and unless the causes are eliminated, the same accidents/incidents will happen again. Students need to look for the root cause of why the forgings fell on the worker and caused third degree burns over 20% of his body. To identify all the causes, you need to ask this question: “What can the owner/president, superintendent, employee do to prevent the incident from recurring?” The incident investigation must determine and report the following factual information (the 5 W’s and How): Who was involved or injured? Where did the incident happen? When did the incident occur? What were the immediate and basic causes? Why was the unsafe act or condition permitted? How can a similar incident be prevented? To determine what can be done to ensure that similar incidents will not occur in the future (the goal of incident investigations), an inspection needs to be carried out by knowledgeable people and a representative of the workers (e.g., supervisors, technical experts, HR and safety specialists, safety committee, president, day shift superintendents). An important question to ask is, “Why wasn’t there a joint OH&S committee to identify and resolve health and safety problems in the workplace” (which is legally required when 20 or more workers are regularly employed in a workplace)? Asking the question, “What can the owner, management supervisor, and employee do to prevent the incident from recurring?”, can identify the root cause of the incident. The safety inspection must identify as many root causes as possible by including human (e.g., unsafe acts), situational (e.g., unsafe conditions), and environmental factors (e.g., physical chemical biological and ergonomic factors). Inspections must be done on a regular basis. Important questions to ask in this case are, “Why hadn’t the plant been thoroughly analyzed for hazards? Why was production viewed as more important than safety?” The supervisors should do inspections continuously each time they pass through the production area. They are accountable for the safety of workers under their control, and they should have identified the risk factors involved in increasing production. They should have been constantly looking for and correcting any hazards that might arise, such as workers’ unsafe acts (e.g., Why did the forging fall? Why were employees operating poorly maintained equipment?), unsafe conditions (e.g., Why was the equipment faulty? Why wasn’t there a preventative maintenance program? Why were there delays in making plant and equipment improvements? Why was the equipment inadequately maintained?) and environmental factors (e.g., Were hazardous materials present? Were there physical impacts or sudden changes to conditions?). Did the supervisor ensure the employee was adequately trained and aware of all the health and safety hazards? The employee needs to understand his principal rights and responsibilities: to refuse dangerous work without penalty, to participate in identifying and correcting health and safety problems, and to know about hazards in his workplace. Was the employee aware of the risks and hazards involved in the work he did? Did the employee show a lack of precaution, poor judgment, or unsafe behaviour? Did the employee deviate from standard job procedures or practices, which would require disciplinary action from the supervisor? The employer is ultimately responsible for the overall safety of all employees; the supervisor is responsible for ensuring the OH&S of all workers under his/her supervision; the employee is responsible for following safe workplace procedures and reporting health and safety problems to the health and safety committee that is responsible for identifying and recommending solutions. A safe workplace is the shared responsibility of the employer, supervisor, worker, and safety committee. Employers are legally responsible for ensuring the health and safety of all their workers. They must establish a health and safety program that incorporates OH&S into the organization’s business planning, strategies, and systems, and they must establish plans, policies, and procedures to control hazards once they have been identified (Workers Compensation Act, Division 4, Sections 3.1 to 3.4; OH&S Regulation, Part 3, Section 3.3). An important question to ask in this case is, “Was the owner and management team showing due diligence and a commitment to employee safety?” Refer to the WCB booklet “Effective Health and Safety Programs—the Key to a Safe Workplace and Due Diligence” (www.worksafebc.com/publications) for a due diligence checklist and an OH&S program checklist. Another important question to ask in this case is, “Was there an OH&S program that included OH&S policies, procedures, inspections, health and safety committees, training, maintenance of records, and investigations (the core elements of an OH&S program)?” BC Workers’ Compensation Act, Part 3, Division 10 (BC—WCB OH&S Regulation Section 3.4)—Accident Reporting and Investigation Make sure the injured worker is cared for before beginning the investigation. The employer must immediately notify the WCB of an incident that has resulted in serious injury to an employee, involved a possible structural/equipment failure, and/or resulted in a possible situation of continuing danger to the workers. A WCB officer will conduct an inspection in order to ascertain the cause and particulars of a work-related incident (WCA, Part 3, Division 11—Inspections, Investigations, and Inquiries, Authority to Conduct Inspections). The employer and workers must not disturb the scene of the incident except to attend to the injured employee, secure the area to minimize the risk of further injury, and protect property from further deterioration. The employer must immediately investigate the cause of the incident. The investigation must be carried out by persons knowledgeable about the type of work involved and knowledgeable about how to conduct investigations. The president/owner and the day shift superintendent would be part of the investigation team, which would need to involve several other experts, ranging from technical advisors and specialists to safety and health officers/specialists. The organization does not have a safety and health committee that is trained in investigations. A joint OH&S committee is legally required when 20 or more workers are regularly employed in the workplace. A committee should meet regularly (and prepare reports) and should have a minimum of four members representing both the employer and the workers. Their duties and functions include identifying and evaluating unhealthy or unsafe situations, making recommendations for corrective action, consulting and advising on OH&S issues, and participating in inspections and incident investigations. They are required to be trained in these areas. (WCA, Division 4) The investigation must identify the causes (unsafe acts and situations) and make recommendations for corrective action of the incident. An accurate record of the incident scene requires immediate access to an investigative tool kit. This will have been prepared in advance and include the following items so that details, ranging from measurements and weights to positions, can all be recorded. Camera, with flash Water-resistant pens and pencils for drawings Computers Tape measures Straightedge Flashlights Video Accident investigation forms Investigation checklist DO NOT ENTER tape Tape recorder Lots of photos and drawings should be included to provide detailed evidence. The incident reports should be completed as thoroughly as possible. All witnesses need to be identified and interviewed individually as soon as possible. Investigative methods can include observation, walkthroughs, and interviews. Interviews should be conducted with anyone who has any relevant information, even if they were not present. Listen carefully and use open-ended questions. Incident investigations are important because they help employers determine why an incident happened, so that they can take steps to ensure it will not recur. Once an investigation is complete, the employer must ensure that an investigation report is prepared, including recommendations for corrective measures that will help prevent the incident from happening again. (WCA, OH&S Regulation, Section 3.4) An employer must ensure that an incident investigation report is prepared and provided to the OH&S committee/owner and the WCB. It must contain the information outlined in the sample incident/investigation short and long reports illustrated in your textbook. The report should provide some explanation of the causal factors of unsafe acts and/or conditions and reveal what conditions are need to prevent the incident from happening again. Other reports require completion (e.g., physician’s report, witness reports). The owner/president must immediately take corrective action (and report and post) to prevent the recurrence of similar incidents.
Training records and maintenance/production schedules can offer the investigator valuable insights. It is likely that the investigation of this serious incident will reveal earlier incidents of a similar nature. The plant was never thoroughly analyzed for hazards, and the owner was aware that it was not as safe as it should be. It is the employer’s legal responsibility to ensure that workplaces are regularly (weekly and monthly) inspected and that hazards and unsafe work practices are identified. The inspection includes checking how work is performed by workers so that unsafe work practices and conditions can be corrected (WCA, OH&S Regulation, Section 3.5 to 3.8). It would seem that in this case, the lack of inspections—including corrective action in such areas as unsafe defective equipment, improper working conditions, physical hazards, unsafe work practices, improper planning, and inadequate equipment maintenance—may have been a cause or factor contributing to the incident. Business owners are responsible for providing and maintaining the land and premises being used as a workplace in a manner that ensures the health and safety of anyone at or near the workplace. They must ensure that employers and prime contractors at the workplaces have all the information they need to identify workplace health and safety hazards. They must eliminate or control those hazards (WCA, Division 3, Section 119). Buildings, structures, excavations, machinery, tools, and workplaces must be maintained in such a condition that workers will not be endangered. Employers must ensure that each machine and piece of equipment in the workplace is capable of safely performing the functions for which it is used, that it is operated only by authorized workers, that manufacturers’ recommendations are followed, that equipment is inspected, tested, and maintained according to the requirements of the regulation, and that safeguards are provided for the protection of workers (WCA, OH&S Regulation, Section 4.1 to 4.12). Using checklists, being objective, and considering the chronological events and all contributing factors will help the investigation team evaluate the evidence. The recommendations should support the basic cases of the incident, not the symptoms. It is important that the injury data be analyzed to identify trends that may help reduce future lost-time injuries. A safety program audit can be conducted. On example is to use computer software to gather and analysis injury data. Case 2: Office Accident You can approach Case 2 and incident investigation by following the process described in the above Case 1. Solution Manual for Management of Occupational Health and Safety Kevin E. Kelloway, Lori Francis, Bernadette Gatien 9780176532161, 9780176657178
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