CSA Launches New Standard for Incident Investigation

Photo by Greg Huszar

When you are building your safety program, it’s hard to know where to start. Provincial legislation and regulations define what is required as a bare minimum, but they don’t explain the how-to. In Saskatchewan, legislation prescribes which events require an investigation, but do not explain how to conduct one. Unfortunately, the time to learn is not after an incident has occurred.

The Canadian Standards Association (CSA) has launched the Z1000-05 Incident Investigation standard to assist employers to pre-plan for an incident, learn how to control a scene, gather evidence, and hopefully prevent incidents from occurring.

The new Incident Investigation standard (Z1000-05) is part of the CSA’s Z1000 suite of Occupational Health and Safety Standards to assist employers to develop or enhance their safety management systems. The full suite of standards includes hazard identification, inspections, psychological health and safety, managing work in confined spaces, hearing loss prevention, emergency preparedness, and the recently launched incident investigation.

Chris Budzich, President of Proactive Safety Consulting and a representative on the CSA committee that wrote the Z1005 standard, appreciates how easy the system is to use. He says, “Even if an employer starts out with no knowledge of safety, you can purchase from the suite and set up a robust safety management system. The Z1000 suite was designed for organizations of any size to implement a safety system, but the way that this been approached is that each one of the standards could be a standalone item if you wished. If you only wished to have information on incident investigation, then the Z1000-05 standard could operate on its own.”

Employers can choose from the standards to augment gaps in their own safety systems, or choose individual sections to work together. For example, the new Z1000-05 Incident Investigation standard and the Z1000-02 Hazard Identification standard are intended to function together.

Like all CSA standards, the thorough Incident Investigation standard was developed for use by employers of any size. Budzich says, “It will guide you through line by line through controlling the scene right off the bat to how to control these hazards.”

The Investigation standard was developed from the best investigative practices in use, rather than drawing from one particular model of investigation. “We tried to write it so that it’s very scalable,” says Troy Winters, Chair of the CSA Committee that developed the CSA Z1000-05 Investigation Standard and Safety Advisor for Canadian Union of Public Employees (CUPE), National Office. He explains the practices outlined in the standard can apply to events of any size: from near misses, to incidents that have caused or could cause an injury.

“Every incident needs to be investigated whether it’s a paper cut or a chemical explosion. All injuries must be reported, all injuries must be investigated.”

Photo by Greg Huszar

This includes investigating the circumstances around dangerous conditions.  He gives the example of a puddle on the floor. If you find a puddle on the floor, you ask: How did that come to be? Is a pipe leaking? Why is it corroding? How is that allowed to be? Is there a procedure in place to inspect it? “You wouldn’t leave a puddle laying in the middle of the floor at your house, why is it happening at work? If it isn’t fully investigated, the next time someone slips, they fall and break their neck. It isn’t just the dangerous conditions, it’s the near misses that cause an incident to take place.”

Phil Germain, Vice President of Prevention and Employer Services for the Saskatchewan Workers’ Compensation Board agrees, “You have to ask the ‘five whys’. Injuries and fatalities happen because multiple things break down at the same time. You have to ask those questions.”

In the example of the puddle on the floor, asking: why was it left there? How did it get there? Is a pipe leaking? Why is it leaking? The root cause analysis of a near miss or dangerous condition will prevent future incidents and injuries.

If an incident does happen, the Incident Investigation standard assists employers to be prepared ahead of time. Both Budzich and Winters emphasize the value of the pre-planning module of the standard (Section 5). “No one wants to make decisions while the fire is happening – a metaphorical fire or the actual fire – that’s not the time for decision-making,” says Winters. The standard guides employers through questions such as:

  • How will we communicate the incident? Who do we tell and when?
  • What are we going to do if it’s serious?
  • What do we do if we have a confined space incident?
  • Who will be on the investigation team?
    How will the incident impact the people around the scene?
    What psychological factors will we have to consider?
  • What supports will we access to protect the mental health of witnesses and the investigation team?

“If you don’t have all of the pre-loaded, pre-set up, pre-processes in place then that really hurts your investigation. It can be something as simple as: you don’t really know who’s going to be on the investigation team. It seems pretty simple, but it’s not something you’re going to be deciding 10 minutes after the incident takes place,” explains Winters.

The CSA standard is not specific to a jurisdiction, and goes beyond the occupational health and safety requirements in a jurisdiction. Budzich explains that if there is legislation, the legislation in a jurisdiction will always have authority over the CSA standard. However, OHS regulations are the minimum for what a company should do to preserve life and health. The legislation will say there has to be an investigation, but it doesn’t explain the mechanics of how to conduct the investigation. “This standard is designed to ensure that you have a thorough investigation process in place.”

The formal process will be crucial if, as an employer, you have a serious incident occur.  Some incidents require formal and legal investigations. This standard teaches how to gather evidence properly because any evidence an investigation team collects could be asked for by the formal investigation team looking at the incident in an OHS or criminal investigation.

The Investigation standard was developed by 30 people from across Canada – a combined 1,000 years of experience. The committee researched and wrote the standard from scratch to completion in less than two years: the fastest standard ever developed. Winters explains that all CSA committees follow a balanced matrix user group model. The model decrees that no group be larger than its two smallest user-groups combined. This provides a balance so that no user group is over-represented. This committee was comprised of members from the Regulatory group, User – Labour, User- Employers, User – Interest (trainings, consultants), User – General Interest, and five associate members with other knowledge and information to bring to the committee.

Above and beyond – The Annex

The committee also compiled 20 pages of additional information that isn’t required but is good to have. This is included in the Annex of the standard:

  • Investigation team competencies,
  • How to work with video and photos,
  • How to address investigative team bias,
  • How to conduct interviews
  • Data analysis
  • Testing your hypothesis
  • Scene control

Although an investigation occurs after an incident, Winters believes that by pre-planning, an employer can help ensure he or she doesn’t have to use the investigation process, “If they follow this, and implement the standard, I think it will prevent injuries and incidents from happening.”

To purchase the new investigation standard or any of the other resources from CSA, visit http://shop.csa.ca/