From Incident to Insight: Mastering Investigation for a Safer Canadian Workplace

Mallory Hendry  00:00:00 

Hello everyone, and thanks for joining us today. I'm Mallory Hendry, Content Specialist Manager with Canadian Occupational Safety, and I'm pleased to introduce today's webinar from incident to insight, mastering investigate, investigation for a safer Canadian workplace, sponsored by Avetta. We have with us today. Industry expert Peter Sturm, Chair of the CSA Incident Investigation Standard, CSA z1005 and he's going to guide you through the intricacies of this leading edge standard, including how it was developed its core principles and practical steps to implement it within your own organization. At the end of the presentation, Peter will participate in a question and answer period. So please be sure to type any questions you may have into the Q and A box within the webinar software. I'll turn things over to Peter now to get started, take it away, Peter.  

Peter Sturm  00:00:50 

Great. Thank you, Mallory, and welcome everybody. And I do want to thank CL's magazine and Avetta for this opportunity. And as I said, you know, as the introduction goes is that, you know, we're going to talk about instant investigations. I do want to challenge a bit our thinking on instant investigations and as to how it's evolving. And just to kind of give you a bit of, you know, the context of what is really happening out in the real world with respect to investigations. And I'm going to talk about some of the numbers that are out there. And there is an evolution going on, the traditional stuff that used to be the technical, write down the facts and move forward, and, you know, find out what the cause is, and then put in the recommendations. We're going to talk a bit about, maybe taking even a different perspective. You know, why we don't do investigations successfully? And you know, when I look at the numbers, and I'll show you some of them, we're going to see that if we were doing really good investigations, our numbers should be going down. We're not seeing that. I like to tell you also about a story of an individual that really has impacted me. Been around safety for many years. And so the case of Louis Whelan, because it really highlights some of the things that have happened with respect to investigations. And so how can we be effective, and how can we prevent future events? And being part of the CSA standard, in which we had 40 individuals sitting around the table for almost four years, and we didn't take any of the traditional ones that are out there. There's all kinds of third party things. We actually said we want to build it from square one, and the focus at the end has always been prevention. And I also want to talk to you, because I know most of you are in doing investigations in your workplace. And so you know, how do we become competent in what we do, and by competencies and looking at that, and actually in the standard we looked at that, we spent a significant amount of time as to, what are those skills, those experience that you have to have the attributes to be an effective investigator. So just before we start, so I know who's in the audience, I'm telling you, the numbers are absolutely phenomenal for the session, and it does really speak to the point about incident investigations out there. So tell me, how many investigations have you done and doing none is, you know, have never having to do one. This is a great session for you, but, you know, I just want to see, you know, have you had 10 to 25 have you done 25 just to give you a perspective as to who's out in the audience, and I can then formalize it. So go ahead, fill in those numbers that are there and so. And again, I also teach the investigations out of the University of Fredericton. And I, you know, I've done hundreds of students there, a lot of times they say to me, Well, I've never done one. And I said, that's great, because you're not coming now in with any perceptions or any things that others have told just how to do it. But one of the things with this session looking at instant investigations are basically we had a, you know, we have an issue, and what's the solution, and how do we get there? And going even one more step before that is, are the solutions to the point of getting there? So looking at the results that we have really interesting numbers here. I mean, a lot of you have done more than 25 investigations, so I'm hoping that during the Q and A you'll have a chance. But we've got a lot that have done none, about 15% out here in the group, we've got about another 15% that have done one to five investigations, which is great, and a lot of times in workplaces, they're not having those events that need an investigation, which so what are you doing that people aren't getting hurt, or you're not having the losses, or sometimes what happens is people aren't reporting them. So great to see about almost 44% of you in this group of almost 50% have had more than 25 investigations. So great. Let's kind of go from there. So let's just have some fun as we go through. So, you know, I look at instant investigations, and when I talk to colleagues about it, I say, you know, what are some of the things? And a lot of times they struggle with them. But you know what? You know I looked at, you know, what a movie title shattered truths, the accident files. Or when you look at, you know, grave inquiries, the fatal files. And. And this one I hear a lot, and sometimes it can be a comedy, is oops investigations, the company mayhem, the Chronicles, where it goes into that all of a sudden everything changes in the workplace, or love is on the line, accidental chemistry. So just a lot, little bit of fun with respect to that. So in today's session, going to talk about the incident investigation standard, as was Mallory mentioned the CSA 1005 and how to integrate that into your program. The secret here is, is that we are the only jurisdiction in the world, because I've looked at it that actually has a formal standard that was developed, for instance, investigations. I know other jurisdictions are looking at it. So when I ask that, when I'm working with my clients and saying, So, what standard are you following? And a lot of times they're following a program that somebody has thought what an instant investigation program should look like. And I'm going to show you, you know, the formatting that we went through in developing the standard, and you know the how to how to build a successful instant investigation program, and some of the insight that you can get the standard for free if you're here in Canada, and so you can build it yourself. A lot of times, people say, we don't have the time, money and resources to do it. You don't. You don't need those things to have there, because the standard is there, and it will walk you through those elements. And as I said at the opening, is the investigator competencies, and I'm going to show you some tools that are out there, that are available to you, and I look at my competencies on an ongoing basis, because what you need to do is you need to stay current. Your business is changing, that are expanding. We got new product lines, new services coming in. Is your investigation program changing? Or is it the same thing you were using 15 years ago. We need to stay current with that, because if we don't, then when you look at your management teams, if and if it doesn't, you know it hasn't changed with the way the business has changed, you're irrelevant. Your investigation is irrelevant, and many times your whole health and safety program is irrelevant. So I have a short video here, and I said, this is about you, and this is a scenario of, look at yourself as being this young person. And when you look at incident investigations, and we're going to kind of go chronologically through this, it's only two minutes long. But what I really like about it, and this is the feeling that I have had when I've gone out to do incident investigations, is I got this massive thing that I've got to move. You know, we've got a problem in the workplace, and how do I do it? And this video talks about change and how to change, and how to take your investigations. And you don't have to be amazing to do that. We are all amazing from the standpoint that if we have the tools to do it, we can move mountains. And in this case, how does this young man move a log out of there? So just watch this video very quickly.  

Peter Sturm  00:10:15 

So in this video, it really talks about, you know, this, this barrier that you have, this big tree that's there, and you see people standing around and looking at you, but they're looking at you as to what to do. And ends investigations is very similar to that, because in the traditional world, you have something happening event, and you start to look at the you know, we got to do an investigation. But when you saw in this video, is one small individual starts to move it, and what happens is, when people see that you're trying to move that tree or that mountain that's in front of you, they come to help you. And that's how investigators need to take those it's not just about filling the form and moving from there. It's about taking that issue and that problem and getting it moved as it and as you could see, I was I watched the police officers that are in there like I look at that as the regulator, the kind of sitting around. They're waiting other people just complaining about what the situation is. But what happens is one person goes, you the investigator, and starts to push that tree and moving it. That's what investigations are about, and we need to change that. It's not about regulations and compliance. It's about making change in your workplace as you move forward. So starting today, we're going to talk about the incident in the investigation. But how do we get to innovation? How do we start to get that change? I will tell you, traditionally, in talking to a lot of senior business leaders, when you come to them with an investigation report, a lot of times they're shaking their head like you're bringing me another problem that I need to deal with. We need to start to shift our paradigm. We need to come in with the change and change that what is happening in the workplace. And so taking a couple of the analogies out there that if you fail to plan, you plan to fail. And I know a lot of workplaces that I'm going to show you, the pre investigation element of that we brought into the standard that I never knew before in all the courses that I've gone, is, do I plan for my next investigation? And how do I get there? Because if you fail to plan, you're going to fail anyways. And looking at that, so can we plan for investigation so we don't need to investigate those events, if our events are not coming, going down, if we're not, if we're having, you know, the similar ones are starting to go away, then we will start to get into change. And how do we start to do that? One of the questions I put out there is, a lot of people, how many of you using the third, third party investigation programs? One of the things is, we're just down in Denver at the ASSP conference, and I went to all the providers of the investigation programs, and I said to them, what standard are you basing it on? When they say, Well, no, we're looking at risk and we're looking at getting to to, you know, gathering the causes and finding out what happened. I said, Okay, that's great, but what is the standard that you look using? Okay? Because for me, it has to be aligned with the standard to do that, and I want to give that to you today. And how many of you have company specific programs? And I say, Well, who developed it? Well, I copied it off the internet. Or, you know what, Billy Bob was the safety coordinator before, and he or she developed it. You know, how many companies have specific acts investigation programs where they find fault to the worker? You know, when you know, some people talk about behavior based safety and human factors and all that, but we need to shift our thinking. When an event happens, there was a failure in the system. There was the system was not able to protect that worker to have an event from happening. And I always put the challenge out to to individuals in my courses, saying, you know, is there a situation that you have that couldn't be prevented? And everybody comes up with one. I say, You know what? Yeah, that's the trip and fall could have been prevented. That workplace violence situation could have been prevented. And how do we start to move that from there? But just a couple questions to start it. So what are the stats tell us. So I always put this out there and looking at it, you know, and sort of kind of going through it. So what are these stats? And these numbers tell us? Well, they're telling us 6000 people every day around the world are dying at workplace events. Okay, in the US, that number is about 15. And the shocker for me is that today, three people in Canada aren't going to be going home. And when I look at that number, and I say, wow, you know, so those that's what the stats are telling us. And I look at times, a lot of times you look at like this event here, and you look at all these people that are at this event. This is a safety event that was happening down in Denver, and I had a picture of it, but what I look at is, is that after today, this is what we have. We're losing people in our workplaces, and the seats are empty, and it's not changing. The numbers are actually been plateaued or getting worse. So why is that happening? Well, we have, you know, more. Industrialized, we've got more safety features, and what are those factors that happen? So I went to look at a couple of things. Institute for Work and health, out of Toronto, has some really good stats. They looked at 22,004 to 27 and they started to look at emergency department visits. So they're seeing a decline in the rate of injuries and severity. But what's happening is, is that you know such high severity injuries remain steady, and rates among women have increased. So is that telling us that more people are getting hurt and what's happening in those situations? And they were looking at workplaces to go from there. And so when you look at that, this is just the numbers here. 993 people in 2002 died in Canada going to work. And trying to put that into a bit of a perspective, is that's about if every plane that's out there, there's about 200 people in a plane. If we had five aircraft 

Peter Sturm  00:15:54 

crash in Canada, or half fatalities with it, there would be an outcry, but we don't. So you look at that number of five, like a 200 people in every single one of them, that's a lot of people, and that doesn't include the lost time injuries. So when I look at things like incident investigations, I really see the opportunity, because we have to change something to get that we don't have 1000 people every day, every year, dying in Canada. And for me, the sad part is that at the end of the day today, three people you know will not be going home, three families are going to be impacted, three workplaces are going to be severely impacted by this and starting to look at those things. So just to give you a bit of context, as Mallory said the beginning, we have the CSA said, 1005 I'm going to show you a way as to getting a copy. You can get read access only to all of the CSA standards. It's a hidden secret. My suggestion is, go read it. Take a look at it. Take from what you can and if you want, you can also purchase it so it is available there. If you have any American colleagues, I know, I have friends in the US, you can get a copy of the standard through ANSI and the ASSP site. So it's available there. We also did a book that was written back couple years ago, and it has the CSA standard integrated into it, so you've got a couple tools to be able to take your incident investigation programs to that next level and from there. So what are the excuses for not doing an investigation? And when I'm in a session, you know, doing on this topic is I always get all the excuses and things that we get. So we're going to take a poll, and as they post the poll. So what are the excuses that you've heard for not doing an instant investigation. You know, we don't have the time to investigate. Or it was just Jamie or Mary or or Narinder as usual. They're at fault, right? They're accident prone. Or the other one is, we'll do it tomorrow. However, it never happens. Okay? I've been a lot of places. We've gone in and had shown them a list of their claims. They say to them, can I see, you know, the instant investigation for Mary that happened last September? Oh, we never got to it. Oh, no, you know, give it some time. It'll go away. Okay, there are some people in leadership roles, so that's what they think. You know what? If I deal with it today, now, I gotta do the investigation, or I don't have time for this, the safety stuff. And I hear that all the time, and, you know, and people know what I do, you know, you get that, that the rolling of the eyes up heaters here again, like, you know, it just takes away time from the job we want to get done. So as the stats are coming through, we'll take a look at and see what you guys are saying, yeah. So we're seeing right there that, you know, 39 40% are saying we don't have the time to do it, right? 22% are saying, you know, we'll do it tomorrow. Never happens. And it's interesting. Here is, you know, 22% are saying, I, you know, I don't have time for the safety stuff. Really interesting, because for me, when an event happens, if you don't do anything about it, it's gonna happen again, right? That definition of a sand insanity, doing the same thing over and over again and thinking you're gonna get a different result, you're not, I guarantee you, and I'll bet money on it, you're gonna get the same one. So just some interesting perspectives on it that are there so, you know, and again, just giving you the same list, I like this one here at the end, you know, identifying failures and breakthrough breakdowns at their site, it's going to make them look bad. Going to get on the radar with head office or whatever. You know, don't have the money and the time. I am amazed how many organizations don't have the money and the time to put in the changes that they need. But for some reason, when it happens the second time and now this time, the impact is even greater. They find a time interesting. And another one that really bothers me is is that we don't have time to make the changes in the workplace, but we do have time to pay for lawyers at $500 an hour to keep us out of getting into trouble. Could have taken a couple $1,000 and solved the problem. So that's what we need to do with our in. Investigations and change that paradigm. Want to show you this video. This is an actual video that was done in in Durham. For me, it's really interesting, because a lot of times people say, Well, I don't know anything about construction. I don't know anything about manufacturing. You don't Okay, you can look and start to deduct. What happened here? This is a very tragic event. I'm going to play the video. I'm going to talk as we're going through it is that this was done by someone in a drone in the area. And when this was playing out, the news media was all over it. If you look at the news media outlets on it, it happened back in 22 you can see, this is in Durham. They had to wait that day for the fire department from Toronto to come in to do the rescue. This is the rescue for individuals down in a hole. I'm going to show you what the hole looked like. This is the extrication of getting those individuals out of that hole. If you look way to the left, there's a trench box there. So when you look at a scenario like this, I'm looking at they're just at the end of the job, trying to get it done. They're just going to do a last connect. And you can see people that are there. They didn't pull the trench box because it's sitting there right at the side. So when you start to look at these scenarios, there could have been four fatalities, and you're looking to the side as to what happened here. For me, this is how you start to learn. You don't have to be an expert in the area, but you start to ask the questions, why is a trench box at the side? You can see that they've almost finished this. The excavation has been done. They were looking at this last connection, trying to get it done. I don't have any inside information on this, but when you start to look at that, this is just amazing. And a lot of workplaces have this type of event to happen, this type of data that's there. And you can see, this is a construction job that went all the way down the road. They're just wrapping up, okay? The the pipeline, the the whatever, the storm sewer, whatever is being in you can see also the water there. Okay, did it have an impact on weakening the the ground around it? And it'd be interesting. And again, I'm not trying to find fault. I'm trying to learn from this scenario, because from these situations, and for me, the big piece was that they didn't have in place the response to be able to deal with it. So just again, an interesting scenario. And so we can learn from those type of events. These are photos that were taken later. This is what the site looked at at that time, with the bodies in there. And you know, with all due respect to the individuals, we need to learn as to what's going on in that scenario. And so you know, from that, that part of it, and that's where our incident investigations help us. Here's the trench box. Probably it was too small. May not have been used at the time, or it could have been, hey, we need to get this done. It's one connection. We're going to do it. You can see that they're just putting in a couple last pieces of pipe in that scenario. And so for me it is, this is what incident investigations. We need to learn about it every day. We hear about trench collapses. Okay, it happens in construction all the time. And I start to question, why is it? And sometimes it's time constraints, sometimes it's getting it done, sometimes it's the understanding of it. But how do we use our investigations to get to those results. Another really good example, if you want one, is the Lac Megantic one. This was done by Don Ross, who did this one. What I like about this one? He did look at the failures of the company, but he actually looked at Transport Canada, who he was working for, and looking at what they had done that hadn't covered it off. And we talks about the train derailment. So if you really want a good example of an incident investigation, it was done by trained professionals. But he also talks about things that had happened. So he talks about the failure of the company, he talks about the failure of the equipment. He talks about the failure of the infrastructure to, you know, to be able to do it, and the policies and procedures, and he brought this down. So he did a phenomenal job in looking at that. So what warrants, you know, a simple reporting of an event, or do we need a full investigation? We're going to talk about that, and what is the criteria and the analysis, and when can we get into a full investigation? So the CSA standard is part of the suite. All of these standards are available and read only, access for free for anyone. And z1 1000 now is 45,001 so when you look at these standards, it is important that they're available there for you to help you, and they have to be integrated. Because when you look at things like 1002 1003 the psychological health and safety, the training standard, the risk assessments, they should be all part of your health and safety management system. And incident investigations is tied to that. So how do we get to that point of going from there and here's, here's the breakdown of what they are. There is going to be a link in the in the Q and A the chat that you'll be able to go and access these for free. We're going to give you the links here. There will also be an email going out later, within a day or so after, with copies of the slides and all that kind of stuff. And please, if you have questions as we go along, and I'm not addressing them for you, put them into the Q A, and what will happen is we'll we'll get answers for you, because Mallory. They're taking it all down, getting it ready for us, so you start to look at those standards that are there. So for me, the thing is, is that you've got references, like documentation, but you also have the free access to the CSA standard to be able to access that information and build your program, build your investigation program to get you the results. Because what it does is that it goes through the process of working from there, just very, very quickly. Traditionally, happens today, we have something happen. You know, people go to the scene the emergency, and what do they do? They clean it up right away, and they go back to normal. Lot of times, don't even investigate it. You'll get, sometimes you'll get, they'll, they'll do it. They'll, they'll have an event happen. They'll respond right away. The health and safety coordinators or the supervisor will get there, they'll kind of put something together, but nothing really changes. And so when you look at that, or you can move from ProAct, you know, to proactive, and being part of it, rather than being reactive. And that proactive response needs you. We don't have emergency plans where we try to figure out what to do at the time of the emergency. The same thing, for instance, investigations, you don't try to do that at the time you have an event, because your response is going to be limited as to what you can do, and it has to go back to your safety management system, where was the failure in the system to protect the worker. I will tell you about 99% of the time they're going to say, we need to train the worker in, you know, give them training so to prevent the event, maybe the training is wrong. You ever look at that and saying, You know what? Yeah, we sent them and what, had them watch a video that wasn't related to what they wanted, or we didn't give them the policy or procedure, or we get the traditional thing in the orientation they everybody just checks off the box. So how do we look at that? How do we look at our system in preventing those events? How do we get building a culture? I will tell you, and I tell this with the classes that I teach, is that people in the workplace are watching how you're doing the investigation, because they want to know that if this happens to them, how are how are they going to be held, held in this are they going to be engaged and come up with solutions and help through the process, or is it going to be the blaming and shaming, which happens in many workplaces? It's just easy to say, you know Billy Bob, you know next time, be more careful. What you really said to them is, it's your fault, and that's not what its investigations are about. And when you look at it, has to be sustainable. It has to be over a period of time to get there. So what we did with the investigation standard, sorry, this screen's a bit small if you, especially if you're coming through on your phone, but the center part, everybody does that. You go to the scene, you get the witness statements, you control the scene. You know. Do you have it in control? You know, is it, you know, are the police doing an investigation, or is the Ministry of Labor doing an investigation? Is your legal counsel said to do an investigation, or is the media there looking at it, or maybe even the Union? But what I'm talking about is, this is your investigation. And so what we said to them is they can do theirs. We can do ours because ours is about preventing the police are looking to lay charges under the Criminal Code. The Ministry of Labor is looking to lay charges with the under the Occupational Health and Safety Act. The legal team is going to be looking at protecting the organization, which is fine, but what we're looking at is we're looking at, how do we prevent it from happening? And media is going to be looking for that story, or someone will be there or from that so to the left of it is the pre investigation part. It's actually more work than what you do in the middle, because if what it does is it gets you ready for the investigation part, the back end of it is the analysis of binding and a lot of places, I'm amazed that even with my students as we talk, how many investigation programs don't even ask for a recommendation, they document it happened at what time who was involved? Peter was lifting a 53 pound box. What do you you know next time? Be more careful. Told Peter that we're going to send them for more training, and that's it. So what this did was it started to build a system. And so what you look at is, you got to deter what your response going to be? Is it going to be just first aid? Is it going to be near miss? What are we going to do? Excuse me, what resources do I need? Do I need to have people helping me? Do I need a vehicle to get there? When you talk to Don Ross about going to black Megantic, he says he was working in Ottawa at the time black galantic was in Quebec. He lived in Nova Scotia. So he gets the call, Hey, we got a train derailment. We want you to go up. So what does he do? He takes his, you know, little thing. He had this little investigation bag. He goes down, he shows up, and he goes, Oh, my God, what the heck happened? And he talks about that when you've had, you know, chances. Don has passed away, but we had chances to talk to him about it. And so you determine what the resources are, and if you don't have the right resources, you gotta go back. Do you protect yourself as an investigator? Do you so looking at that, look at your communication procedures. Who's going to Who are you going to talk to? What are you going to do? Do you secure the scene? Are you going to wait for the you know, the police? To do their investigation, the Ministry of Labor do their investigation, the environmental team to be there if you had a spill or release. The legal team. You know by the time you get there, there's going to be nothing left. You can still do your investigation. You don't need to wait for them. How do you get the data? So we started to talk about evidence versus data. This is about data. Well, who's going to be on your team to do it. What's going to you're going to have an initial investigation send in a report so that senior leadership knows what goes on. What's your plan? Okay, what about your your team, investigation pieces, and you're seeing control. And we also had in there is the psychosocial part of for the investigator, an investigator is a human being. And many times you're going to be going in and you're going to know the people involved, or you're going to know the families involved. What about your psychosocial health? And so that should be part of it. Also. It's right in the standard the D section, the analysis findings gets really into it, and the post investigation gets into what is your mitigation strategy, and then you write your report. So that's kind of the systematic approach that's in there. This is kind of the same thing that I've kind of put into one slide, but again, looking at witness management, the psychological injury prevention. How do you do that, getting you to see an investigation? You need to have your communication elements there. How do you document it and put it together and then do the analysis, and going from there. And so we broke it down into the five areas, and I've gone over them for you here. And so when you start to look at that, that starts to move it. It goes back to plan. Do Check Act. It's part of the fundamental approach for health and safety. And I've just given you here the four the clauses that are aligned to it. So all you have to do is you have a link to the standard. Just go in and take a look at the clause four, and it gets you, how do I plan for investigations? How do I get senior management, commitment and responsibility? What is a policy going to be? How am I going to engage the stakeholders, and is there a planning and preparation process? It gets then into the response. We have an emergency response, which deals with the situation at the time, but we also need to have our investigation response and then conducting the investigation down at the bottom, you can see what's your action plan going to be, in validation and the verification that what you did was with the right stuff. But I love class nine. How do we know our investigation program is the best that it can be. So when you start to look at that, and you can even break down the process, the whole investigation process, what's your planning who's going to be assigned it? Who's going to control the scene? I know in many workplaces, and I don't, I believe it's just a natural response is people will start to clean up the scene, right? There'll be people if you know to get it. But what's your hazard assessment? Also, I'm going into place where there was now a chemical release. Do I have the PPE I need? Do I have the right people that understand the process? Who do I need to call in? What about your data collection? How am I going to collect that data? And I'm not looking at it, you know, from the standpoint of data, and there's a list in the standard as to what data is. It could be a record. It could be it could be a piece of equipment. It could be the witness statements. It could be photos of the area. There's just so much. And how do you bring it together? So when you look at that, when you look at that tree in the middle that we saw in the first scenario, that's what that is. You've got that in the middle of the table. And how do you start to move that forward? One of the things that didn't get into the standard last time, but was multiple causation, and so I'm sharing this with you is, is that you have the incident, you're going to have primary, secondary and additional causes, and you need to start to identify them. You can take this chart, take the factors out, and start to identify I just wanted to show you a simple way to do it for a very, very complex factor. It could be the culture in the workplace that police production is more important. It could be the standards and procedures. Was a copy that we got off the internet. It could be the equipment didn't have preventive maintenance, or, you know, it wasn't maintained, or wasn't the right piece of equipment, or, as in the case that I saw in the video at the beginning, they didn't use the trench box, and two people died. There should have been four fatalities that day. So when you start to look at that, so looking at the prevention approach is really critical. And so again, looking at the system failure when we looked at those styles and management in the prevention system, and how to go from there. And so, you know, again, does your investigation program to your man link to your management system? Is it integral, or is it just a bolt on? Does does it look at preventing future events? And if it doesn't, then why are you doing it? If it's to fill out a form, do you have the competencies, and I'm going to talk about them and give you, showing you a list. Are the same things happening over and over again, or possibly they are happening over and over again and they're not being reported. And the big one that I go with, and what's keeping you up at night, when I go into workplaces and I start to look at that and I go, Oh, this is just a disaster waiting to happen, now is the time to use the investigation tools, not when the event happens. So kind of moving from there. So. Competencies in the investigator. So we got one more pool to go through. Let's go through it right now. We'll get the team to post it. So how confident or comfortable do you personally feel about investigations? Okay, and let me know. And so when you start to look at that, and I will tell you that I go through an ongoing review every so often, because things change. My clients change the type of work that you do. I'm doing some work for a municipality today. I'm doing some work for utility tomorrow, and I'm working with a chemical either the day after. So what are the skills that I need and starting to take what they use? So the chemical companies I work with, I work with the chemical companies across the country is they're into process safety, really big. It's on the process and all that. But how do they integrate the individual in there? And that's what we have conversations about. So looking at those things that come in. So the poll results are going to be coming in soon. So 75% of you, sorry, 47% of you feel that 75% of the time you're good at it. Okay, good. You know that's that's being good. 50 35% of you say 50% of the time. Some of you, 8% are at 100% love to have a conversation with you. What are you doing that's Well, anytime, and about 10% aren't feeling comfortable. And it's okay to not feel comfortable. It's okay to feel it being 50% or 75% because this is an ongoing process, I will tell you that it will make you a better safety professional using those tools that we have in investigations. It does because it's intuitive, because you're identifying problems sooner, you're getting to them, and you're coming up with solutions. I tell people that, if you're into investigation program, isn't as important as your strategy and your company, your goals, your objectives, and it's not mentioned in there, it's not in your sustainability report, then we need to get to there. It's not the company's fault. It's about us getting it into our workplace. And so those are ways that you can kind of go from there. So competence is Shab you have to understand risk. I will tell you, financial people and senior leaders in business know about risk. We need to talk to them about risk and health and safety, and it's the risk of their people, and how do we control that? And we need to have that conversation and be very comfortable with it. If you're going to talk about TR I, Rs, and you know, incident rates and all that, they don't care. Okay, it doesn't go it goes in one year and out the next. But if you start to talk about risk, which instant investigations will help you to get there now, you're starting to talk their language, and you're talking about productivity. If you bring in a change with your instant investigation program, should productivity not go up? I think it would. Should production not go up. You should be doing the activities safer, right, and without having factors coming into play. So we need to do that. And that's where senior leaders and boards of directors really, really are interested in health and safety. When you make it part of what's important to them, which is risk. How do you interact with parties? You know, are you going to wait for the Ministry of Labor to do your investigation for you? Don't. You can do it. Their focus is on compliance. Yours is on prevention. They're going to tell you, it's about prevention. It's not if it isn't in the green book or whatever legislation you have in your jurisdiction over there, it's about leadership. Okay, how are you demonstrating leadership with your incident investigations, people are watching you. They're watching you to see what you're doing and how you're doing health and safety that's impacting them in the workplace. Provide direction, okay? And you don't have to know all of it. You can actually even ask for help to do that. Communication skills, written and oral are good, but the oral one is better. Are you listening to people, and that's part of the process and your witness statements. Are you listening to what's happening in the workplace and going from there, what having knowledge or regulations and industry practices, I would even take it to the point of best practices and public resolution and mediation, people are going to want to find fault, and what you have to do is take them out of that and say, You know what? Let's leave that for later. Let's get to how do we prevent that situation from happening again? And so here's a couple of things that came out, and this is stuff that's in the CSA standard. It's in the guidebook that's associated with it, but it'll help you. So team interaction, you can't do it yourself. That young boy pushing that tree, and starts to push it, and then gets 30 people around them to move it right, and they have fun doing it, going from there, the interviews, the legislation, what are those best practices dealing with difficult people you're going to get people they're going to be mad at you, you know, and not because you're there, a bit, because you're doing the investigation. Or how do you get them to shift their way of thinking. So again, couple free tools are available, CSA, CSA, there is a link there. There are modules. There are 13 different modules in there, free to use. You can if you're looking for 13 brand new things for your health and safety committee or your leadership team to do it's in there. There are two. Tools in there that we developed that you could take I'm going to show you one of the tools. How do you prepare for an investigation? What's the impact of bias? Okay, your supervisors believe that production overrides health and safety. How do you get them to change? And the way you get them to do that is it could be engagement of the leadership team, but also it could be, what's the value add for them? How do you do that, making recommendations. What are the gaps? What are the competencies? So those tools are available for you. They're for free. Please use them. There's 13 of them in there. So with the investigation competencies, I'm going to do this one very quickly. We looked at, you know, the newbie level, a, okay, new to safety. Just there today, your health and safety coordinator. And way to the level a level D, where we talked about, you know, the people that have been in there for a long time, and you've got in the in the middle of there. So when you start to look at that, you can take these, these competency tools, and there's tools in there that'll help you to move forward, to be to get in it. And there's questions in there. So just self assessment tools that are in there. There's a matrix, and with that matrix, then comes the solutions that are there. And so what happens is, what we did it for each of the areas, then we gave you suggested training plan to go with it. You know, you don't know anything about it. Purchase a standard. See what's in there. Take a look at it. Look at take a course on on it there those type of things. Review, investigations. Are you doing good investigations versus if you're at 76 and you're good at it, well, maybe you start to look at some different things, like the Chemical Safety Board and Transportation Safety Board. I look at their investigations. What did they do? Well, what didn't they do? Well, what can I take away from it? Because they do investigation. That's their role in what they do. And so the evolution of investigations, just to kind of wrap it up, is doing some research now to move forward. The big piece that's coming in is that when you look at this here, this bullseye, a lot of times we're standing around that circle and we're looking in, what did they do? How did they do it? I'm asking you to change your perspective on this is put yourself at the middle, so you're in the middle and there. So what's your purpose, or your cause, or your belief, the reason why you're doing that investigation? And start to look out totally different perspective. And this is some work that's kind of going on right now, and I'm going to integrate it into to the next versions of the book, because what's happening to me is, is that I think us looking in at the problem is a problem. 

Peter Sturm  00:42:28 

How do we change that? And a lot of times that's where you look at compliance. You know, what is the organization? Is it meeting compliance? And we get that asked by questions by our senior leadership. But again, what differentiates us from other organizations and make us a high performer. And I believe that if we can stand in the middle and we're doing this process, and look out at the various elements, it's going to take us to this next level. And so it's called this diffusion of innovation, and you're going to get here in the 34% you're going to get people that are going to be early into the process and looking at it so things to come from there. See something, say something, we see it all the time. I'm now going into is I'm trying to change my paradigm. Is that when I see something, I try to say something, but when I say something, I'm going to do something. But when I'm with my investigations, now I'm going to change something. So I'm becoming the change that we want to see, not trying to change the whole organization, but changing the way I as an investigator moving forward. And I put that challenge out to you. And so when you start to look at that, it starts to change our paradigm from it. There are some courses out there I just want to show very quickly. So what we've done is we've done some courses, we do some work courses through ASSP, and we're starting to integrate, if you can look at just this day one, you know what's an accident. We start to look at those different elements. But then we start to look at the standard, right? Because the standard now is showing us about the scope of the investigation. And then what we do is it goes into our pre investigation or investigation preparation, so it becomes a process. So you develop this for you, for your organization to be as effective as possible. And so when you start to look at that, it just kind of, then these are the steps that we go through to get there. And it takes each of the clauses that are in the investigation standard. And if you want to build your own investigation program, you can take this and go from there. And so it really starts to take you to the 14 or 15 different ways to make your instant investigation program the best that it can be. So we do have some time. Try to leave at least 10 to 15 minutes. I know there were some questions, and I think it's really important you do have you can have my question, my access to contact me, gladly, be able to talk to any of you from that perspective, and we'll go from there. So go back to Mallory, please. Thank you. 

Mallory Hendry  00:44:52 

All right, yeah, we've had a few questions come in here. One of them is, how are an organization's insurance rates affected based on the results of these investigations?  

Peter Sturm  00:45:03 

That's a really good point. So my History Originally, I started with State Farm, going back and I did investigation, motor vehicle investigations. That's what it was. I was an adjuster and doing that. And so I'll tell you a secret that we had was and we got all the ones where, usually, you know, our clients were at fault. They ran a stop sign, they ran a light. And so what we did is, is that, and so what would happen is, is that we would have to then engage Council, and we would do our investigations very, very, very detailed. We were at the scene. Just to give you a bit of a perspective, is that if at eight o'clock there was a motor vehicle accident, what happened was the agent. So the person would call their agent, we would get the information, usually around by 850 and 830 in some cases, not all the time. We would get information that, hey, at, you know, young and steals, there was a major event, we'd go right away. We'd get out to the scene, get those type of things. So when you look at it from an insurance company perspective, is you need to give them the information to be able to with your investigation, to get to the results. So in our case, if it's a workplace situation, it could be the property damage goes to a private carrier, but you got your workers comp where the worker's been injured. Now, if there are questions with it and you do a detailed investigation, I would share it with with the company. So I just did some work for a client, and what the situation was, the worker was experiencing some and this was a traumatic event, but worker thought it was traumatic. He was having problems with the equipment, saying it was malfunctioning. He didn't feel safe, and the inference was that it was going to turn into a lost time claim. So what I said to the, to the to the client, I said, you need to do an investigation. You need to gather the information. So he actually did a video of what that worker experienced that day, within a day or two after that. So that became part of the data that he had, he got statements from the workers to so what happened? So he understood, and it wasn't to find fault. There may have been something involved with it. So what happened in this case was the claim was denied, because there wasn't, because when you look at it, did the the event or the injury, you know, did it arise out of the employment? And was he in the course of employment, we couldn't find that relationship between the two. So from a saving of money, your incident investigations should save you money. From the standpoint is others that are going to be involved with it will not put the effort into it. And now, do you want to be in control of the situation, or do you want the situation to control you? So to answer the question very quickly, it should reduce either your costs with the property damage. I've seen that happen many times, and it should look at your workers comp. It could be a mitigating factor in the case, and what you would do at that time is offer the person modified work. So now what happens is, is that I know, from a WSIB perspective, or workers comp, is you as the employer, are in control of the situation, rather than relying on other sources that will possibly negatively affect you on your premiums or your costs, the workers entitled to it. Great if they're not, then you need to do your investigation. Next question, Mallory, 

Mallory Hendry  00:48:16 

That's great. Great advice. Does the standard recommend any specific causation model, or models for the investigation analysis. 

Peter Sturm  00:48:24 

Good question. Really good question. We didn't use any other causation models. We asked the investigator to review them. So in my teachings, what I usually look at is at the reason model. I just like because reason seems to be up there. But that was back in the 1990s 2000s and looking at others. So when you look at causation, is what we do, is we go back and look at so one of the causation, causational models that I really like is, do you go back to your risk assessment and your hazard assessment, and did you address that issue? Because a lot of times you didn't, but we didn't think it was going to be a situation that could happen here? Well, there's a problem there. There's a problem in your system. So what I suggest to people is, is that go and look at the standards that we have with respect to our I believe we do health and safety really, really well in Canada. And you know, for all the courses that we go into and you look at the legislation, is there anything in the legislation? Is there anything in the hazard and risk assessments. Do we look at, you know, the physical, chemical, biological agents that were involved? So we have the tools to be able to go back into our system and look at it. So we don't suggest any causational models. What we do suggest is to look at your system and for every company that's going to be different, right? 

Mallory Hendry  00:49:42 

Thank you again, and the next one here, can you elaborate on how you change your investigation technique from outside in to Inside Out? What exactly do you do differently? 

Peter Sturm  00:49:53 

So a lot of times. So one of the things is, and that's a really great question, is the perspective that I'm looking at it. A lot of times when I would go to a scene of an event, and I would sit there, and I would, I would start to look at it, and I started to look at, you know, what others were doing with respect to the event, to getting to it. What I do now is, is that I actually put myself in the middle of it, and what I start to look at is, is that I start to look at it from a different perspective of, you know, the default that I thought maybe had happened here, or the failure that had happened here. And what I start to look at is, okay, so how is an investigator? Do I take the steps that I have in the standard? And I start to look out of that situation, a really good analogy. And one of my colleagues that work with the Transportation Safety Board was when they do their investigation, a lot of times they will do train, drill mids and plane dramas, so the the debris field could be three kilometers away. So what they do is they start at the center point, and then they just start to do circles and look at the perspective, and they start to go out and out and out. And so what happens now is, is that you're not looking in at the the the zone where the event happened is you're standing in the middle of the zone, and now you start to walk around and you're going to change your perspective. Because what's going to happen is you're going to see things differently. Oh, the racking. There was a racking in the right position or in a healthcare situation. Hey, access into this area where we had the workplace violence situation. I could see how somebody could come in and not be able to see them, but if I look from the outside in, I wouldn't have seen that. So that that, for me, is kind of the analogy. But taking that into your investigation program, I was starting from inside with you, and then moving out, and what you're going to find is, do I have the skills, do I have the tools that I need to get this job done right? Rather than, Oh, you know, I'll look, I'll get that later. So it's, it's a I'm trying to articulate, but it's changes that looking from the inside out, and it starts to really change your perspective on incident investigations as you go through and it will identify the system failures that you will see as you go from there. Okay, but great question. I need to do some more work on it, but I think it's, it's, for me, it's changing the way I see the world of investigations.  

Mallory Hendry  00:52:14 

No, absolutely. Those were great examples. The next question here, is there a plan from the provincial or federal authorities to standardize incident investigations for workplaces? So, for example, create a toolkit that will help employers. 

Peter Sturm  00:52:28 

That's a really good question. When I'm teaching my classes, a lot of times people refer either to work, say, BC, they've done some good work. They refer to CCHS magazine. Sorry, CCHS out of Hamilton, and also, there's been some really good work going on in in Nova Scotia. The one thing I don't think you're going to start to see changes in directing on how to do that, the one thing that everybody should know is that a lot of the standards of safety standards are actually supported by a group called Kalash across Canada, where it's the ministries of labor and the workers comp kind of get together. So a lot of the funding that goes into building the standards, which we don't you know, that goes to CSA pays for them to be developed. So they know about them. I know that from scenarios they meet, usually on a quarterly or semi annual basis, so they know about them. I don't know, from a regulator perspective, they've usually kind of said that, you know, go back to the IRS, the internal responsibility system, you know, look to other standards, but they don't direct you to them. So indirectly, they've, I think they've acknowledged them by supporting it financially, because they do pay some money to CSA to do it. And then CSA makes money when they publish things as to what they sell, so they do know about it. So, and I know that the works APC has done some good work in there. I know CCO HS, if you read through their sections on instant investigations, and a couple of their team members are on the standard, it's very aligned to it. So it's there. So from a federal perspective, indirectly, it's there. But it's a good question. They know about it, and I think it's one of the best kept secrets out there. But I've also been pushing it to other jurisdictions, saying, Here's a standard plan. Do check. Act is global. You can take it. It doesn't, you know, doesn't say anything in there. That's Canadian, and I think we do health and safety well in Canada, so it's available to them. But good question, yeah, they know. 

Mallory Hendry  00:54:29 

And in your opinion, based on your experience, do you think having the injured worker in the investigation room provides better results than just speaking with the management alone, and they're asking from the angle of the regulators? 

Peter Sturm  00:54:43 

So the regulators are going to talk to the worker, sometimes quite a ways after I mean, I kind of come from a quasi regulatory perspective. You know, the the real value that I would really see with the worker that was injured is to ask them. Uh, what can be done differently? And so which can inform your recommendations? Because that's data. That's an you know, and and too often, there's a lot of companies that we don't, you know, that don't say, So, what do you think we should have done differently? Well, you know, you should have given me, you know, $10 raise. Well, that's not I'm asking is, what could we have done differently? And sometimes what they'll say is, well, you know, I've been asking for the last three years to fix that piece of equipment because it wasn't working right. Okay? So that's our preventive maintenance program, or our senior leadership account, or our leadership accountability piece. What it really does is, and, you know, talk to workers, you know a lot of people well, you know, privacy and all that. I don't need to know names. I don't need to know. I need to know, what is it that I can do as an investigator to get the best outcomes so that it doesn't happen again? And I would ask coworkers, co workers are also very good. There are people that may have worked in the area. A lot of times, we kind of limited to, you know, the supervisor, and you know, we've got a statement from the supervisor. Supervisors, a lot of times, don't know the work. So ask the people that do I one of the people that I find that is really interesting in the workplace is maintenance. They're everywhere in the workplace, and going from there, one of the interesting things doing things like donut shops, where you get multiple locations. And I asked the question like, why does this site have a lot of events, and the other ones don't. And it usually comes down to leadership, but it comes down to some certain factors of say, well, you know, the neighborhood isn't good or whatever, but that isn't it. You know, they just, there's just a way of thinking behind it. So, yeah, I mean, from a an investigation perspective, is I would ask as many as people that you can that that will get you the best recommendations and next steps, outcomes that will prevent the event from happening, and that's where you build your skills as a an investigator. Because what happens is, is that when you do that, you will ask those questions that need to get answered, and you will get the answers, and if you're not getting the answers that you need, then we need to look at some other way to do it. So, yeah, I mean, I would ask workers, from a regulatory perspective, if they're trying to find fault that that's one of the things that I find. I mean, some, some ministry inspectors, are looking at the prevention part of it, but the, primary focus is the fault finding, and how are they not in compliance with the Occupational Health and Safety Act? Their big challenge, from a regulator perspective, is, if that issue isn't in the regulations, then how do they move forward? And many times, they don't do anything about it. But the problem is, is the problem will continue to happen, but because it's not in the regulations, they don't do anything about it, or it gets filed, you know? And so it's an interesting dilemma. I still believe it's on the on the investigator and building those right skills to get to being to getting to the right results. 

Mallory Hendry  00:57:58 

Great tips. Thank you again, Peter, we're at time. But Shall we do one more? Do you think?  

Peter Sturm  00:58:03 

Sure. 

Mallory Hendry  00:58:04 

And then I just want to let the audience know that Peter will see all of the questions that have come in, and he can get back to you just not live, but he will get to them. So this last one here, the organization I work for, has, until recently, insisted that the supervisor of the worker or workers who had an accident or incident should lead that investigation? I'm not a fan of this. What are your thoughts and who should lead accident investigations in any organization? 

Peter Sturm  00:58:33 

So that's a really good question, and you will get that the only problem times, sometimes is it's the pox in the handhelds. Okay? Analogy, where someone now, so if I'm a supervisor and I'm doing an investigation, and I didn't do something that I was supposed to, and if, if they can honestly do that, saying, Hey, I wasn't supervising, right? I didn't provide direction. But a lot of times, people aren't going to do that, they're going to defer. And so what they'll defer is usually to fault finding, or it's somebody else's problem, or it was purchasing didn't do the right thing and all that. What you really want to do is, and when the standard what we did is we looked at bias. If you have a supervisor that you know will not have bias, which is very hard not to have, then go ahead and do it, but invariably, there's going to be some bias in that. And so when you start to look at those scenarios, is that if the there's going to be bias, and that bias could also be the investigator, then they need to be removed from the process. You want to keep it clean, that the issue that you're going to find is that if a supervisor does the investigation and the the findings, sometimes they have the right findings. I mean, I would have them as part of it. You could, you could interview them, and all that is that, what is it going to do, the to the trust in the workplace? Are employees going to say that? Just sweeping it under the rug, or that, you know, yeah, they put the blame on Johnny and maintenance because, you know, they didn't want to take any fault for it. So you do really want to have that independence, and that's where I hope, within some investigations, that if you can demonstrate through your competency, the ability to be unbiased, to be open to different ideas, to be able to question and get to the right situation, then that's great. So, but there would be something you know, if in your workplace, they don't trust the supervisors you're you're not going to get the impact that you want, and people will clam up. They will not they everybody is afraid that they're going to get somebody in trouble, even if they don't like them, but it's just that thing that's instilled in us and in our culture, so you need to be able to make that decision. So what I would do is take the list of biases that are in the standard and sit down and say, Could that supervisor do that investigation without attributing it to any of the biases that are there, and go from there. What a lot of workplaces do is, is that they'll get a supervisor from another area to be part of the investigation team, so now there's no bias. They will ask the questions. They might not know the process, but they'll try to figure that out, and they may come up with some solutions, and then people will see that there is no interest in there of, you know, self serving interests that will come into play in the investigation. But really good question. So that's kind of a way I would kind of go with it. I would go with the biases, and then if you know there's clearly no bias, then you know, I'd go from there. But thanks for the question, Mallory, where we brought it. That's a really, really good point. 

Mallory Hendry  01:01:44 

Yeah, absolutely. Well, thank you so much, Peter for sharing your insight and expertise with us today. I know I enjoyed it. I final housekeeping item here is that everyone will receive an email with a link to the recording, as well as some additional resources, including a white paper on incident investigation by Peter and Scott DeBow, which is or who is Avetta's Health and Safety Director. So thank you again, Peter. Thanks everyone in the audience for joining us. Keep an eye out for other upcoming webinars and enjoy the rest of your day. Thank you. 

Peter Sturm  01:02:15 

Thank you very much, guys.