Assignment Part 1: Conducting Incident Investigation-Due, Sunday, week 11
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Instructions
In this Assignment, you will practice:
Conducting incident investigation
Finding the causes of the incident
Providing corrective actions
Evaluate your understanding of the incidnet investigation process
How are you going to do it:
Assignment Instruction
Complete the assignment to earn 20% of their final mark.
The assignment consists of 2 Parts:
Part 1: Complete and submit Employer Incident Investigation Report.
As a Leader you are responsible for investigating certain incidents or near misses in the workplace to determine why an incident happened and what can be done to prevent similar incident in the future.
Part 2 to review key concepts and evaluate your understanding of the Part 1.
Part 2 will be available, once Part 1 is submitted.
Assignment Part 2 consists of 15 questions—mostly multiple choice.
You have 2 days to complete Part 2.
You have ONE attempt to complete Part 2.
Once you open Part 2, you will have 120 minutes to complete it.
Have your completed Assignment Part 1 open; it will help you to answer the questions and guide you through
Tools to help you complete the Part 1 successfully
Read the workplace incident scenario below.
Download Employer Incident Investigation Report (EIIR Form 52E40) (use DOC version for convenience) to conduct an investigation and record the findings.
You are required to complete sections 1 to 19 of this form.
Review Assignment _Video Instruction that I have recorded to guide you on completing this activity (Video instructions are attached in the assignment folder).
Review Incident Investigation Reporting (video by WorkSafeBC) to understand the general concept of workplace incident investigation.
Refer to the Guide to Completing an Employer Incident Investigation Report (EIIR) to go through the process of completing an EIIR.
Refer to the Sample of the completed Incident Investigation to report (EIIR) to get an idea of the completed EIIR report.
Completed investigation report, submit to this folder
Note: If the scenario does not provide some facts, you must make reasonable assumptions.
Workplace Incident Scenario
The employer, Pacific Coast Warehousing, is a storage facility operation that uses pallet jacks and forklifts to move product. Pacific Coast Warehousing is registered with WorkSafeBC (account #312435). Operating location number is not applicable.
On March 14th, of the current year, while in the shipping area, an experienced forklift operator, Pat Carter, was unloading materials and merchandise from incoming vehicles and stacking them to assigned places. At around 12:00, Pat stopped work for his lunch break. Pat steps off the forklift. A co-worker, Jordan Lee (Warehouse Associate), observes Pat’s fall and notices that the worker appears to be in some pain. Jordan rushes over to help, inquiring as to Pat’s well-being. Pat can’t bear any weight on the left ankle. Jordan notices that there is a ledge of about ½ to ¾ of an inch between two concrete slabs. Jordan helps Pat to the first aid room and is treated by the first aid attendant, Taylor Kim.
Supplementary Information
The first aid attendant, Taylor Kim observes swelling and bruising in the area of the left ankle and advises to see the doctor.
Taylor notifies Health and Safety committee co-chairs about the incident, as per the company injury reporting policy.
Pat reports to his Supervisor, David Brown, as per the company injury reporting policy and then leaves work to see his doctor.
Pat sees his doctor later the same day and is diagnosed with a left ankle sprain. The doctor estimates it will take 2-3 weeks for Pat to fully recover and in the meantime, he is restricted from standing or weight bearing on his left ankle. The doctor says Pat is totally disabled from working and sends in a Form 8 to WorkSafeBC.
Pat files a Teleclaim for compensation the next day. In his application he reports he sprained his left ankle at work. He also states he has never injured his left ankle before.
A week after the incident you discovered that Pat did not update his certification to operate forklifts. You’ve also been informed that the warehouse inspection was not completed in the past two months. According to the office workers, the warehouse staff were busy with the inventory and high demand for a new product that the company recently purchased.
The employer’s representative will need to conduct the investigation.
Committee co-chairs and the employer’s representative will need to recommend the controls.
For the date of the prelim incident investigation, use March 15th’s date.
Due on Jun 16, 2025 11:59 PM
Attachments
Assignment _ Video Instruction.mp4 (314.48 MB)
Assignment – Conducting Incident Investigation.pdf (476.24 KB)
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Rubric Name: Incident Investigation-scoring rubric
Criteria
Exceeds the Standards (Your report was VERY clear)
4 points
Meets the Standard (Your report was MOSTLY clear)
3 points
Approaching the Standard (Your report WASN’T VERY CLEAR)
2 points
Below Standard (Your report NEEDS MORE WORK)
1 point
Criterion Score
Content and Details
You have completed all sections of the report.
Provided all the details correctly (name, addresses, job titles, dates, time, places).
Determined what happened, why the incident occurred,
and how to prevent similar incidents from occurring in future.
You have completed most (>80%) of the sections but missed one or two.
Provided most of the details correctly, except one or two items (for example, indicated the wrong report date).
Determined what happened, why the incident occurred BUT haven’t provided corrective actions correctly.
You have completed some (60-80%) of the sections but missed two or three.
Provided some of the details correctly, except 3 or 4 items (for example, indicated the wrong report date, report type and type of occurrence).
Determined what happened BUT haven’t identified why the incident occurred and haven’t provided corrective actions correctly.
You have completed fewer than 60% of the sections.
Provided half of the details correctly.
Could not determine properly what happened, haven’t identified why the incident occurred and haven’t provided corrective actions correctly.
Score of Content and Details,/ 4
Sequence of events that preceded the incident
You have clearly identified significant events that led up to the incident.
Included dates and times.
Arranged all the events in
chronological order, from first to last.
You have identified significant events that led up to the incident.
Only dates and times are missing.
Arranged most of the events in chronological order, from first to last.
You have poorly identified significant events that led up to the incident.
Missed the dates and times.
Your chronological order of the events is hard to follow.
You have not identify significant events that led up to the incident
You have not organized the activities and events chronologically.
Score of Sequence of events that preceded the incident,/ 4
Determination of unsafe conditions or acts that contributed to the incident
You have identified at least 4 unsafe conditions,
acts, or procedures (for example, poor housekeeping or failure to follow safety
procedures), using “why” repeatedly
Avoided personal factors,
such as “worker was careless.”
You have identified 2 or 3 unsafe conditions,
acts, or procedures (for example, poor
housekeeping or failure to follow safety
procedures),using “why” repeatedly
Avoided personal factors,
such as “worker was careless.”
You have identified one unsafe condition,
act, or procedure (for example, poor
housekeeping or failure to follow safety
procedures).
Used personal factors,
such as “worker was careless.”
You have not identified unsafe conditions,
acts, or procedures.
Used personal factors,
such as “worker was careless.”
Score of Determination of unsafe conditions or acts that contributed to the incident,/ 4
Determination of underlying causes (reasons) of unsafe conditions or acts that led to the incident.
You have provided at least 4 underlying causes of unsafe conditions or acts that led to the incident, using “why” repeatedly
Example of underlying factors could include: lack of management commitment or resources for safety; poor worksite design, lack of inspection or monitoring for OHS issues, gaps in supervision)
You have provided 2 or 3 underlying causes of unsafe conditions or acts that led to the incident, using “why” repeatedly.
You have not used inadequate statements, like things that should have happened but did not (ex. “worker did not use PPE”).
You have provided one underlying cause of unsafe conditions or acts that led to the incident.
You have used inadequate statements, like things that should have happened but did not (ex. “worker did not use PPE”).
Underlying causes are not clear.
OR
You have not provided underlying factors of unsafe conditions or acts that led to the incident.
Score of Determination of underlying causes (reasons) of unsafe conditions or acts that led to the incident.,/ 4
Recommendation of corrective actions to prevent similar incidents
You have recommended at least 4 appropriate corrective actions to address the underlying cause and prevent similar incidents.
Corrective actions are consistent with the applicable regulatory requirements.
Included the names and job titles of the person responsible for it, and the completion date or anticipated completion date.
You have recommended 2 or 3 appropriate corrective actions to address the underlying cause and prevent similar incidents.
Corrective actions are mostly consistent with the applicable regulatory requirements.
Included the names and job titles of the person responsible for it, BUT missed the completion date or anticipated completion date.
You have recommended only one appropriate corrective action to address the underlying cause and prevent similar incidents.
Corrective actions are not consistent with the applicable regulatory requirements.
Included the names, BUT missed the job title of the person responsible for it, the completion date or anticipated completion date.
Overall, the corrective actions you have recommended are either not provided or are inadequate to address the underlying cause and prevent similar incidents effectively.
Corrective actions are not meeting the applicable regulatory requirements.
Have not included the names and job titles of the person responsible for it and the completion date or anticipated completion date.
