OCCUPATIONAL HEALTH AND

SAFETY
INCIDENT INVESTIGATION
Advanced Diploma in Operations Management (NQF 7)
05 OCTOBER 2024
 Programme
• Introductions
• Orientation Week One

• ELO 3 Legislation
• ELO 1 Contributing factors Week Two
• ELO 2 Organisational Aspects
• ELO 4 Incident Investigation Week Three
• ELO 5 Mechanisms
• ELO 6 Roles and responsibilities Week Four

• Revision/Clarifying Week Five

• Examination
ELO 4. Demonstrate understanding of the documentation and
records required for accident/ incident recording and investigation.

• 4.1 Explain what is meant by an Occupational Injury or Disease

• 4.2 Categorise and explain the records that are required in the case of the
occurrence of an Occupational Injury
• 4.3 Outline the procedures to be followed in investigating an Occupational
Injury
ELO 4. Demonstrate understanding of the documentation and
records required for accident/ incident recording and investigation.

• 4.4 Identify the statistics that have to be kept in respect of Occupational

Injuries
• 4.5 Conduct an investigation into an Occupational Injury and complete all
the relevant documentation
• 4.6 Understand the auditing procedures for Occupational Health and Safety
Legal & Specific Requirements

Section 14 (OHS Act)

Section 24 (OHS Act)

Section 25 (OHS Act)

Section 38 (COID Act)

Extracts from MHS Act

Ignorance is not an excuse
for non-compliance!
 Sec 14 General duties of employees at work
Every employee shall at work-

(a) take reasonable care for the health and safety of himself and of other persons who may be affected by his acts or omissions;

(b) as regards any duty or requirement imposed on his employer or any other person by this Act, co-operate with such employer or
person to enable that duty or requirement to be performed or complied with;

(c) carry out any lawful order given to him, and obey the health and safety rules and procedures laid down by his employer or by
anyone authorized thereto by his employer, in the interest of health or safety;

(d) if any situation which is unsafe or unhealthy comes to his attention, as soon as practicable report such situation to his
employer or to the health and safety representative for his workplace or section thereof, as the case may be, who shall report it
to the employer; and

(e) if he is involved in any incident which may affect his health or which has caused an injury to himself, report such incident to
his employer or to anyone authorized thereto by the employer, or to his health and safety representative, as soon as practicable
but not later than the end of the particular shift during which the incident occurred, unless the circumstances were such that the
reporting of the incident was not possible, in which case he shall report the incident as soon as practicable thereafter.

"incident" means an incident as contemplated in section 24 (1);

 Sec 24 - Report to inspector regarding certain incidents
(1) Each incident occurring at work or arising out of or in connection with the activities of persons at work, or in
connection with the use of plant or machinery, in which, or in consequence of which-

(a) any person dies, becomes unconscious, suffers the loss of a limb or part of a limb or is otherwise injured or
becomes ill to such a degree that he is likely either to die or to suffer a permanent physical defect or likely to be
unable for a period of at least 14 days either to work or to continue with the activity for which he was employed or
is usually employed;

(b) a major incident occurred; or

(c) the health or safety of any person was endangered and where-

(i) a dangerous substance was spilled;

(ii) the uncontrolled release of any substance under pressure took place;

(iii)machinery or any part thereof fractured or failed resulting in flying, falling or uncontrolled moving objects;
or

(iv) machinery ran out of control, shall, within the prescribed period and in the prescribed manner, be reported
to an inspector by the employer or the user of the plant or machinery concerned, as the case may be.
 Sec 24 - Report to inspector regarding certain incidents

(2) In the event of an incident in which a person died,

or was injured to such an extent that he is likely to die,

or suffered the loss of a limb or part of a limb,

no person shall without the consent of an inspector disturb the site at which the incident
occurred or remove any article or substance involved in the incident therefrom: Provided
that such action may be taken as is necessary to prevent a further incident, to remove the
injured or dead, or to rescue persons from danger.
• The provisions of subsections (1) and (2) shall not apply in respect of-

• a traffic accident on a public road;

• an incident occurring in a private household, provided the householder forthwith reports the incident
to the South African Police; or

• any accident which is to be investigated under section 12 of the Aviation Act, 1962 (Act No. 74 of
1962).

• A member of the South African Police to whom an incident was reported in terms of
subsection (3) (b), shall forthwith notify an inspector thereof.
 Sec 25 - Report to chief inspector regarding occupational diseases

Any medical practitioner who examines or treats a person for a disease described in the
Second Schedule to the Workmen's Compensation Act, 1941 (Act No. 30 of 1941), or any
other disease which he believes arose out of that person's employment, shall within the
prescribed period and in the prescribed manner report the case to the person's employer
and to the chief inspector, and inform that person accordingly. [S. 25 substituted by s. 7 of
Act No. 181 of 1993.]
 Sec 25 - Report to chief inspector regarding occupational diseases

Any medical practitioner who examines or treats a person for a disease described in the
Second Schedule to the Workmen's Compensation Act, 1941 (Act No. 30 of 1941), or any
other disease which he believes arose out of that person's employment, shall within the
prescribed period and in the prescribed manner report the case to the person's employer
and to the chief inspector, and inform that person accordingly. [S. 25 substituted by s. 7 of
Act No. 181 of 1993.]
COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT,
(ACT 130 OF 1993)
Section 38: Notice of accident by employee to employer
(1) Written or verbal notice of an accident shall, as soon as possible after such accident happened,
be given by or on behalf of the employee concerned to the employer, and notice of the accident
may also be given as soon as possible to the commissioner in the prescribed manner.
(2) Failure to give notice to an employer as required in subsection (1) shall not bar a right to
compensation if it is proved that the employer had knowledge of the accident from any other
source at or about the time of the accident.
(1) Subject to section 43, failure to give notice to an employer as required in subsection (1), or any
error or inaccuracy in such notice, shall not bar a right to compensation if in the opinion of the
Director-General-
(a) the compensation fund or the employer or mutual association concerned, as the case may be,
is not or would not be seriously prejudiced by such failure, error or inaccuracy if notice is then
given or the error or inaccuracy is corrected;
(b) such failure, error or inaccuracy was caused by an oversight, absence from the Republic or
other reasonable cause.
GENERAL ADMINISTRATIVE REGULATION
8. Reporting of incidents and occupational diseases

1) An employer or user, as the case may be, shall-

(a) within seven days of any incident referred to in section 24(1) of the Act, give notice
thereof to the provincial director in the form of WCL1 or WCL2; and

(b) where a person, in consequence of such an incident, dies, becomes unconscious, suffers
the loss of a limb or part of a limb, or is otherwise injured or becomes ill to such a degree
that he or she is likely either to die or to suffer a permanent physical defect, such incident,
including any other incident contemplated in section 24(1)(6)
and (c )of the Act, shall forthwith also be reported to the provincial director by telephone,
facsimile or similar means of communication.
If an injured person dies after notice of the incident in which he or she was injured was given in terms of
subregulation (1), the employer or user, as the case may be, shall forthwith notify the provincial director of his
or her death

(3) Whenever an incident arising out of or in connection with the activities of persons at work occur to persons
other than employees, the user, employer or selfemployed person, as the case may be, shall forthwith notify the
provincial director by facsimile or similar means of communication as to the-
a) name of the injured person;
b) address of the injured person;
c) name of the user, employer or self-employed person;
d) address of the user, employer or self-employed person;
e) telephone number of the user, employer or self-employed person;
f) name of contact person;
g) details of incident: i) What happened; ii) where it happened (place); iii) when it happened (date and
time); iv) how it happened; v) why it happened; and h) names of witnesses.
 (4) Any registered medical practitioner shall, within 14 days of the examination or treatment of a person for a disease contemplated in
section 25 of the Act, give notice thereof to the chief inspector and the employer in the form of WCL22.

(5) Any other person not contemplated in this regulation may in writing give notice of any disease contemplated in section 25 of the
Act, to the employer and chief inspector.
GENERAL ADMINISTRATIVE REGULATION
9. Recording and investigation of incidents

(1) An employer or user shall keep at a workplace or section of a workplace, as the case
may be, a record in the form of Annexure 1 for a period of at least three years, which
record shall be open for inspection by an inspector, of all incidents which he or she is
required to report in terms of section 24 of the Act and also of any other incident which
resulted in the person concerned having had to receive medical treatment other than first
aid.
(2) An employer or user shall cause every incident, which must be recorded in terms of
subregulation (1), to be investigated by the employer, a person appointed by him or her, by
a health and safety representative or a member of a health and safety committee within 7
days from the date of the incident and finalised as soon as is reasonably practicable, or
within the contracted period in the case of contracted workers.
GENERAL ADMINISTRATIVE REGULATION
9. Recording and investigation of incidents

(3) The employer or user shall cause the findings of the investigation contemplated in
subregulation (2) to be entered in Annexure 1 immediately after completion of such
investigation.

(4) An employer shall cause every record contemplated in subregulation (1) to be

examined by the health and safety committee for that workplace or section of the
workplace at its next meeting and shall ensure that necessary actions, as may be
reasonable practicable, are implemented and followed up to prevent the recurrence of
such incident.
 RECORDING AN INVESTIGATION OF INCIDENTS
ANNEXURE 1
A. Recording of Incident
Name of Employer…………………………………………Completed By: ……………………………………………………………………………

Name of affected person…………………………………………………………………………………………………………………………………..

Date of incident…………………………………………………………………Time of incident……………………………………………………….

Part of body affected
Head or Neck Eye Trunk Finger Hand
Effect on Person
Arm Foot Leg Internal Multiple

Sprain/Strain Contusion Fractures Burns Amputation

Expected period of disablement
Electric shock Asphyxiation Unconsciousness Poisoning Occ. Disease

0 – 13 2–4 >4 – 16 >16 – 52 >52 weeks

days weeks weeks weeks Killed

Description of occupational disease or exposed to……………..……………………………………………………………………………………..

Machine/process involved/type of work performed/exposure…………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………..
Was incident reported to the Compensation Commissioner? YES NO
Was incident reported to Provincial Director? YES NO
Was incident reported to the Police? YES NO
SAPS Office and Reference: ...........................................................................................................................................................................
 B. Investigation of the above incident by a person designated thereto
Name of investigator……………………………………………………………Date of investigation………………………………………………….

Designation of investigator………………………………………………………………………………………………………………………………..

Short Description of incident………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………..

Suspected cause of incident………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………...

Recommended steps to prevent recurrence……………………………………………………………………………………………………………..

………………………………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………………………………...

Signature of Investigator……………………………………………………………………….Date…………………………………………………..
 C. Action taken by employer to prevent the recurrence of a similar incident
…………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………

Signature of Employer:…………………………………………………….Date:………………………………………………………………………

D. Remarks by Health & Safety Committee

Remarks………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………………

Signature of chairman of Health & Safety Committee:…………………………………………………………………………………………….

❖ Injury is when a person has been harmed doing a task or job related task.
❖ Illnesses occur when a person is exposed to harmful agents that affect
their health.
❖ Diseases occur when an illness affects the person on a long-term basis.
❖ Damage is related to equipment or objects that have been altered or
affected in some manner.
❖ Interruptions to the business could be caused by altered or disrupted
process, staff, workforce, or energy sources.

It is important to report any of the above so that the business does not face any
legal battles and/or bad relations with government or regulatory organisations.
KEY INFORMATION

❖ An Occupational injury is any personal injury, disease or death resulting

from an occupational accident
❖ An Occupational injury is therefore distinct from an occupational disease,
which is a disease contracted as a result of an exposure over a period of
time to risk factors arising from work activity.
Back to Basics
Each time an incident occurs, an investigation takes place to find the
root cause. There are a number of factors to be considered : was it a
failure of :-
• Equipment
• Process
• People
• Environmental
• Etc ?
This is not a fault finding exercise and should not be treated as such.
Company Documents
These policies and procedures should include, but not be limited to :-
– Finance

– Human Resources

– Safety, Health & Environmental

– Quality

– Production / Manufacturing
SHEQ Structure / Framework
Policies and procedures

• Letters of appointment

• SHEQ Reps & SHEQ Committee members elected and

appointed

• SHEQ Committee meeting established periodically

Purpose of Investigation
Investigators find facts not faults.
Investigators must make sure that all parties are
confident that any information they provide will be well
received and serve to prevent a future recurrence – not
to meter out punishment.
Purpose of Investigation cont.
Investigations are often thought of as a totally reactive process.
Companies that regularly analyse and review investigation
reports and findings are able to proactively identify trends and
potential causes of future error.
General investigation analysis.
Steps taken to prevent
• Making engineering changes
• Including standards compliance
• Changing processes to reduce human errors
• Changing raw materials to reduce toxicity / TLV levels
• Redesigning work stations, improving work flows
• Carrying out job analyses and setting or revising standards
• Developing and implementing safe operating procedures
• Monitoring compliance and effectively
• Providing training and on-the-job coaching; and
• Including SHEQ compliance in performance management. past.
Types of Investigation methods
1. Failure Mode and Effects Analysis(FMEA)
Looks at equipment and singular component and accumulative
failures.
2. Fault Tree Analysis (FTA)
A quantitative and diagrammatic method of analysis which focuses on
the relationships and sequences of events leading up to the incident.
3. Manageme1nt Oversight and Risk Tree Analysis (MORT)
A more lengthy analysis system which is compatible with complex goal-
orientated management systems.
Types of Investigation methods
4. Cause-Effect Sequence Analysis
A simple, sequential and diagrammatic record of identified investigation facts.
5. Hazardous Operability Studies (HAZOPS)
Used most often in the chemical industry, high risk operations, or when planning a new plant
and/or processes.
6. “What if”
A simple and very useful technique used to assist in the evaluation phase of the investigation.
7. “Why”
Systematic probing which identifies why the condition existed, or why a certain standard, act or
omission set off a chain of uncontrolled events
No Harm
There are a number of acronyms to assist staff with ensuring no harm is
inflicted on a person or equipment.
One of these is :-
I dentification of deviations
S etting standards of conformance
S etting standards of accountability
M easuring against set standards
E valuating process
C orrecting and controlling deviations
 Cause & Effect of Incidents
Management

Symptom(s)
Origin(s)

Contact

Costs
Immediate

Damage /
Cause(s)

Incident
Cause(s)
Control

Harm /
Lack of

Root

Loss
Incidents are caused by sub-standard performance in The effects of incidents shown by the
one of the first 3 dominoes last domino
 Domino Effect
The candidates are well prepared successfully referenced Heinrich and/or Bird and Loftus with each
element clearly illustrated.
Ancestry and Social Environment - This first domino in the sequence deals with worker personality.
Heinrich believed that undesirable personality traits, such as stubbornness, greed, and recklessness could
be passed along through both ‘nature’ (genetics) and ‘nurture’ (social environment).
Fault of Person - Heinrich believed that a person’s genetic and social background could result in character
flaws such as bad temper, inconsiderateness, ignorance, and recklessness, and that these secondary
personal defects, contributed to unsafe acts, and/or the existence of unsafe conditions.
Domino Effect
Unsafe Act and/or Unsafe Condition - Unsafe acts and/or unsafe conditions are the direct causes of incidents.
Heinrich defined four reasons why people commit unsafe acts as: improper attitude, lack of knowledge or skill,
physical unsuitability, [and] improper mechanical or physical environment. Heinrich also identified the category of
‘underlying’ causes. For example: where a worker commits an unsafe act because of inadequate supervision, this
would be an underlying cause.
Heinrich felt that unsafe acts and unsafe conditions were the key factor in preventing incidents, and the easiest
causation factor to remedy – a process which he likened to lifting one of the dominoes out of the line.
Accident - An accident is any unplanned, uncontrolled event that could result in personal injury or property
damage, for example: if a person slips and falls, an injury may or may not result, but an accident will have
occurred.
Heinrich emphasized that the accident event and not the outcome (injury or property damage) should be the point
of attack.
Injury - Injury results from accidents. Cuts and broken bones are some types of injuries specified by Heinrich in his
‘Explanation of Factors’.
Management Responsibilities
Managers have a responsibility to manage performance and production to achieve
business objectives and targets and at the same time ensure compliance to SHEQ
standards.
Incidents are usually the result of unsafe workplace conditions, unsafe acts, inadequate
standards, or poor decision making by someone in the chain of events. Analysis shows
that about 20% of incidents are caused by poor workplace conditions. The other 80% are
caused by some form of human error or bad practice.
Management systems need to be set up and monitored so that both employers and
employees can take steps to control the causes of incidents.
Unsafe Conditions
1. Inadequate guards or protection
2. Defective tools, equipment, substances
3. Congestion/obstructed pathways
4. Inadequate signs / warning systems
5. Fire and explosion hazards
6. Substandard housekeeping /waste control
7. Hazardous atmospheric conditions : gases, dusts, mists, fumes, vapours
8. Excessive noise / heat / cold
9. Radiation exposure
10. Inadequate illumination or ventilation.
Unsafe Acts
1. Operating without authority
2. Failure to warn or secure
3. Operating at improper speed
4. Making safety devices inoperable
5. Using defective equipment
6. Failure to use personal protective equipment
7. Improper loading or placement
8. Improper lifting
9. Taking improper position
10. Servicing equipment in motion
11. Horseplay
12. Alcohol, drugs or other substance abuse.
Key Stages in health and Safety Incident Investigations

• The first stage would involve gathering all relevant information to establish exactly what had
happened including the location and time of the incident and the persons who might have been
affected. This would involve a visual inspection of the location, interviewing witnesses and
reviewing relevant documentation.

• Once all the information had been gathered, it would be necessary to analyse it, perhaps making
use of 5 Why Analysis or a similar tool, to establish the immediate and underlying causes of the
incident. This would then enable the investigators to identify the appropriate risk control
measures to prevent a recurrence of a similar incident.

• The final stage would be to produce an action plan, setting out objectives to be achieved, clearly
identifying responsibilities for their completion and maintaining a record of the progress being
made.
Key Stages in Health and Safety Incident Investigations

• The first stage would involve gathering all relevant information to establish exactly what had
happened including the location and time of the incident and the persons who might have been
affected. This would involve a visual inspection of the location, interviewing witnesses and
reviewing relevant documentation.

• Once all the information had been gathered, it would be necessary to analyse it, perhaps making
use of 5 Why Analysis or a similar tool, to establish the immediate and underlying causes of the
incident. This would then enable the investigators to identify the appropriate risk control
measures to prevent a recurrence of a similar incident.

• The final stage would be to produce an action plan, setting out objectives to be achieved, clearly
identifying responsibilities for their completion and maintaining a record of the progress being
made.
Effects Physical harm
(Injury, illness, disease)
Property damage*
(Plant, equipment, tools, materials, product)
minor serious Minor
reportable Serious
compensation Major
lost time Catastrophic
disabling *each company will determine their own classification according
fatality to the nature and size of the business, the industry category, and
catastrophic (multiple parties) the associated risks.)

Impacts on individuals, families and Financial impacts (economic effects)

communities (social effects) Insured costs
Disruption of family life Medical
Loss of normal functions Compensation
Unable to execute routine Building, plant, equipment,
responsibilities Some consequential losses
Discomfort, pain, suffering, hardship, Uninsured costs
and dependence on others Materials, tools, product damage / loss of sales
Stress and psychological problems Downtime and production output loss
Run-on effects of disability and/or Payment of benefits while under medical care
death of family member Supervisor/investigator time
Admin / meeting time
Retraining / supervision
Litigation
Planning
• Setting Ground Rules
• Policy & Procedures
• Pre-event assessment
• Additional Planning
• Selecting & Training Investigation Team Members
• Simulation as a Training Method
Planning
Possible investigation Team Structure
Minor
Major
Generic classification
Preparation
Death • Injury
STOP – STOP
BARRICADE – BARRICADE / SECURE
CALL POLICE – FIRST AID, where necessary
WITNESSES – WITNESSES

• Damage
– STOP
– BARRICADE / SECURE
– WITNESSES
Identification, Collection & Evaluation

Reconstruct event
Record scene
Interview victims & witnesses
Interviewing tips
Process & standard practice
Documentation
Finding the Root Cause(s)
STEP ONE
CONSOLIDATE ALL THE INFORMATION
1. List the key issues that have been identified.
2. Note your initial impressions gathered up to this point.
3. Review the witnesses’ statements.
4. Compare the key information provided by witnesses – commonalities and
contradictions or discrepancies.
5. Sort the events into the correct sequence.
6. Review the sketch of the scene.
7. Consult with subject experts.
8. Collect all the relevant documents.
9. Arrange for sample testing.
STEP TWO
IDENTIFY AND ANALYSE THE DIRECT AND ROOT CAUSES
OF THE INCIDENT

Simulation of pre-incident events

STEP THREE
EVALUATE YOUR FINDINGS
1. Consolidate information supplied by witnesses.
2. Compile a list of quantifiable deviations, deficiencies and non-conformance issues.
3. Differentiate between isolated issues and inter-related risks.
4. Record those issues.
5. Consolidate your findings in a logical sequence.
6. Call in team members and / or subject experts to assist with or confirm your overall
conclusions.
7. Inform all affected parties of your conclusion and your proposed recommendations.
STEP FOUR
FORMULATE AND DOCUMENT YOUR RECOMMENDATIONS
Recommendations should be well motivated – final authorisation for any expenditure may
depend on it!
Action plans should always address what is “reasonably practicable” for the present
circumstances.
Consolidate your recommendations and also provide a brief executive summary.
Have documents available for further discussion and verification.
List the root causes and direct causes.
Identify the control factors that were absent, inadequate, or not implemented at the time of
the incident.
Provide recommendations as to how these deficiencies can be rectified.
STEP FOUR
FORMULATE AND DOCUMENT YOUR RECOMMENDATIONS
Continues ....
Where possible, indicate which department or person is responsible for implementing the
actions.
Indicate a time deadline for implementation to be completed.
Indicate which items are “must have”, and which are “nice to have.”

Remember that incidents are caused by management systems failure. The methods
below will help to guide you and identify possible options available.
Risk Control Methods
There are two methods of risk control –
Engineering control:
Assess the conditions and existing or other possible controls
The environment (structures and installations, plant, equipment, tools).
The conditions (light, air, humidity, noise)
The design of work stations.
The process.
Preventive maintenance.
 Risk Control Methods
Administrative control:
Carry out environmental surveys, evaluate the results, and document plans to remedy
deviations from standards.
Evaluate inspection reports, SHE committee minutes, incident investigation reports,
and survey results.
Implement employee selection and pre-placement standards and procedures.
Provide risk focused training and test for competence at all levels.
Ensure compliance methods and levels – standards, controls and implementation.
Verify biological monitoring and medical surveillance programme requirements, reports
and recommendations.
Risk Control Methods
Administrative control Continues ....
Reduce exposure times wherever possible.
Issue ‘fit for purpose’ PPE and monitor the use, care, storage,
maintenance and replacement.
Follow up and action any deviations reported at monthly SHE
Committee meetings.
Determine whether reported incidents are due to unsafe acts, unsafe
conditions, and / or corporate culture and personal value and belief
systems.
 Risk Control Methods
Control measures should also ensure that you have established procedures
at different levels in the workplace – for example
Employees who are at the “point of risk”
SHEQ representatives
Supervisors / foremen
Line managers
Department, division and senior managers
SHEQ Committees
Contractors, vendors and visitors
 Financial Considerations
Risk financing can either be self funded or covered by insurance
companies or in-house insurance systems, or a combination.
Costs can be divided into the direct and indirect costs of preventing or
reducing the frequency and severity of incidents. Examples:
Insurance premiums
Administrative costs of risk management
Uninsured losses
Cost of measures to prevent incidents (training, engineering
modifications, human resources, )
Conclusions
1. Tolerate – the risk is known, it has been quantified and evaluated, and under the
anticipated circumstances exposure should not result in serious harm or loss - “live
with it”;
2. Treat – take action that will prevent or minimise the chance of exposure and keep it
within acceptable limits - “make changes to bring the risk factors within acceptable
limits”;
3. Transfer – place the risk elsewhere, where facilities and conditions are available to
handle the hazard without an exposure risk, or where it is handled by experts under
well controlled conditions – “find a specialist”,
4. Terminate – the process or activity as no “reasonable” controls are available -”
discontinue the activity or process that poses the risk.”
 Restoration of Normal Operations

When you are satisfied that you have all the necessary evidence, the site should be
restored so that normal operations can carry on.
1. Store any necessary evidence in a secure place.
2. Identify damaged equipment and materials and arrange for its repair or disposal.
3. Inform people involved of what is happening and when they can expect feedback.
4. Arrange for an inspection of the workplace to make sure that there are no new or
additional risks as a result of the incident.
5. Arrange for inspections and equipment checks if necessary.
 Post Investigative Functions
Records & Storage of Documentation
A quality investigation record file contains the following:
Documents, sketches, photographs of the scene.
Witness statements, recordings, and investigator notes.
Standards or operating procedures used for benchmarking.
MSDS information.
Relevant documentation – e.g. documented checks, inspections, works orders, repairs
and/or planned maintenance information, etc.
Information on who was notified and when.
Copies of Dept. of Labour reports.
Copies of CC reports.
 Post Investigative Functions
Copies of minutes of meetings held.
Checklists that indicate that all reasonably practicable steps were taken to identify direct
and root causes. You can cross-reference other documentation and don’t have to
include it all in this file.
Copies of final report to management.
Comment and feedback following SHEQ Committee meeting, together with their
comments and recommendations.
Documented action plan to remedy deficiencies, indicating responsible persons and
completion dates. Indicate if this is an interim or total preventive measure.
Reporting
Additional Acts
• Occupational Health & Safety Act
• Mines Health & Safety Act
• COID Act
• Environmental Conservation Act
• National Environmental Management Act
• Hazardous Substance Act
• National Water Act
Additional Acts
• Basic Conditions of Employment Act
• Employment Equity Act
• Labour Relations Act
• Nuclear Energy
• Skills Development
NOTE: Employers are expected to identify and source all
• Standards Act legislation that applies to their risks and operations.
• Transportation Act
• SABS codes of practices
QUESTIONS?
A PRACTICAL GUIDE
TO THE RISK
ASSESSMENT
PROCESS
 ILO PROPOSED
RECOMMENDATION
CONCERNING HEALTH AND
SAFETY
“Employers should undertake hazard
assessment and risk analysts and then
develop and implement where appropriate
systems to manage the risk”
ILO PROPOSED CONVENTION
CONCERNING HEALTH AND
SAFETY

“the employer shall assess the risk”

THE OCCUPATIONAL HEALTH
AND SAFETY ACT 85 OF
1993
‘REASONABLY PRACTICABLE’
Means practicable having regard to:

- the severity and scope of the hazard and risk

- the state of knowledge reasonable available
concerning the hazard and risk and of any
means of removing or mitigating that hazard
or risk
- the cost of removing or mitigating that
hazard or risk in relation to the benefits
deriving therefrom
THREE STEPS TO RISK MANAGEMENT

• Identify the hazards

• Assess the risks

• Develop the systems

BACKGROUND

- Many people already carry out risk assessments

on aday to day basis

- They note changes and unsate working conditions

and take the necessary corrective actions

- This has to become more systematic under the

OHS Act 1996

- Risk Assessment is a continuous process, not a one

off exercise

- The law will not be satisfied by a single risk assessment

report for all time
 THREE FORMS OF
OF RISK ASSESSMENT

• Baseline Risk Assessments

• Issue Based Risk Assessments
• Continuous Risk Assessment
 BASELINE RISK ASSESSMENT
Companies need to establish the overall Safety, Health
and Environmental Safety Risk conditions in the
Baseline Risk Assessments

A Baseline Risk Assessment is an initial

Safety Risk Assessment that focuses on abroad overview
in order to determine the Safety Risk profile
ISSUE BASED RISK ASSESSMENT

• Normally associated with management of change

• e.g.:
• new machine
• new procedure or system of work
• new substances
• after an accident or a near miss
• as new knowledge comes to light about hazards
CONTINOUS RISK ASSESSMENT
- The most powerful and important form
- Should take place continually as an integral part
of day to day management but may not be
sophisticated
- Mainly conducted by first time supervisors
- Formal training is essential
- e.g.. Pre-work checklist. Critical task analysts planned
task observation.
- Emphasis is on hazard awareness though hazard
identification
 Definitions
•Safe
means free from any hazard
•Hazard
means a source of or exposure to danger.

•Danger
means anything which may cause injury or damage to persons or property
•Risk
means the probability that injury or damage will occur
 WHAT IS A SUITABLE AND
SUFFICIENT RISK ASSESSMENT?

- This means considering all the risks which arise

because of work and work activities

- It should enable the Manager to develop and

implement systems to manage the risk

- It should be appropriate to the nature of the work

- It should remain valid for a reasonable period of

time
 GENERAL PRINCIPLES
1. All relevant risks are systematically addressed
- identify major don’t concentrate on minor
- consider those aspects of work which are hazards
- take into account and critically assess safety controls and
measures
- be systematic
- look at all aspects of the work activity
2. Address what actually happens
- actual practice, not instructions
- consider non-routine operations
- pay attention to changes/interruptions
HAZARD IDENTIFICATION

I can see
a hazard!!
 PRACTICAL HAZARD
IDENTIFICATION

- The adoption or a systematic way of seeing

hazards
- Needs to be carried out carefully otherwise all
that follows is pointless
- Essential part of the risk management process
- Acts to change the way that people think, creates
hazard awareness
 THE ROLE OF THE
SAFETY PROFESSIONAL
- To facilitate the risk assessment process
- To ‘steer’ not ‘lead’
- advise on the gathering of data
- team selection and training advice
- development of the process
- selection of tools
- conditioning of team
- May assist in the development of Codes of
Practice
‘SLICING THE CAKE’
 WHY A SYSTEMATIC APPROACH
TO HAZARD IDNETIFICATION?

- While visiting workplace and seeing things more

clearly are important
- Need a comprehensive and complete approach
- Variety of tools available
- Team needs to agree toll, with advice from safety
practitioner
- Team may need to receive formal training
 RISK MEASUREMENT
- Once hazards have been identified, they have to
be prioritised
- Need to demonstrate responsible approach to risk
management
- Purpose of Risk Assessment
to help management make better decisions
- Helps change worker understanding and sets a
direction for management
 BASICS

Risk = Consequence x Frequency

Frequency= Exposure x Probability

 CONSEQUENCE

“the degree of harm”

The potential severity of the injuries or ill health

and or
the number of people affected
 EXPOSURE

How often and for how long

the workers are exposed to the hazard
 PROBABILITY

The chance that a person, or persons,

will be harmed during the exposure period
RISK MANAGEMENT
Section 8(2)(d) of OHS Act 1996

Hazard Assessments

Risk Assessments

Control Measures
Eliminate/Control at Source/Minimise
In so far as the risk remains, provide PPE
and institute a programme to monitor the risks.
 REPORTING AND RECORDING

- Vitally important to record a risk assessment so

that there is evidence that it has taken place and to
show that management is taking appropriate
action
- The record must be easily accessible to
employees, their representative and to inspectors
- While the recording of the risk assessment is
important, the creation of a paper system is not
THE REPORT SHOULD INCLUDE:

- the major hazards identified in the assessment:

those hazards which pose serious risk to
employees, or other who may affected, if they are
not properly controlled
- a review of the effectiveness of existing safety
measures and controls
- those who may be affected by the major hazards
or significant risks, especially those who are
particularly vulnerable
 REVIEW AND REVISION
- Need to regularly review the risk assessment
- A continuous process, not a one-off exercise
- If changes occur, the risk may change
- Need to use risk assessment, to manage change
- Part of good management/business practice
- If knowledge changes, the risks may change
- Particularly after an accident, ill health incident or
near-miss need to re-visit risk assessment
 RISK CONTROL PRINCIPLES (1)
- It is always better, if possible, to avoid a risk
altogether
- Risk should be combated at source rather than
adopting secondary measures
- Whenever possible, work should be adapted to the
individual rather than the individual adapting to
the work
- Advantage should be taken of technological
progress when treating risks
 And finally

10 Steps to

Effective

Risk Assessment
 STEP 1
Make sure the
risk assessment
process is
practical and
realistic
 STEP 2

Involve as many people as possible in the process

especially those at risk and their representatives
 STEP 3
Use a systematic
approach to ensure
that all hazards and
risks are
adequately
addressed
 STEP 4

Aim to identify major risks,

don’t waste time on the minor,
don’t obscure the process in too much detail
 STEP 5
Gather all the
information you can
and analyse
is at best as
possible before
start the
risk assessment
STEP 6

Start by
identifying
the hazards
 STEP 7
Assess the risks
arising from
those hazards
taking into
account the
effectiveness of
the existing
controls
 STEP 8

Look at what actually occurs and exists

in the workplace and, in particular
include non-routine operations
 STEP 9
Include all employees at risk
including visitors and contractors
 STEP 10

Always record the assessment in writing

including all assumptions you make,
and the reasons why
 Hazard Identification and Risk
Analysis is a process that will add
value to your organisation in terms of:

- improved employee knowledge

- improved employee skills
- empowered workforce
ANY QUESTIONS?
 CASE STUDY- PROCESS RISK ASSESSMENT
Case Study: Risk Assessment of Material Stacking Process
Conducted by: Fred Oosthuizen
Date: 19 August 2024
Company: Online Safety Services
Location: 2 Totius Road, Rynfield AH, Benoni, 1501

Table of Contents
Executive Summary
Introduction
Methodology
Process Description
Results and Recommendations
Discussion
Conclusion
References
 CASE STUDY- PROCESS RISK ASSESSMENT
Executive Summary
This report presents a risk assessment of the material stacking process at Online Safety
Services. The assessment identifies potential hazards, including the risk of falling materials,
worker injury, and equipment damage. The methodology used involves hazard identification,
risk rating, and the evaluation of existing controls. Recommendations include improved
training, enhanced safety protocols, and regular equipment inspections. The assessment
concludes that while the current controls are generally effective, additional measures can
further reduce residual risks.
 CASE STUDY- PROCESS RISK ASSESSMENT
Introduction
The following risk assessment has been conducted on behalf of Online Safety Services,
focusing on the material stacking process in the warehouse. This assessment aims to identify
and evaluate potential health and safety hazards, assess the effectiveness of current controls,
and provide recommendations for risk mitigation. The assessment is part of an ongoing
Occupational Health and Safety (OHS) program, emphasizing the importance of proactive risk
management to ensure a safe working environment.
 CASE STUDY- PROCESS RISK ASSESSMENT
Methodology
The risk assessment methodology utilized in this report follows a systematic approach
involving:
Hazard Identification: Identifying potential hazards associated with the material stacking
process.
Risk Rating: Evaluating the severity and likelihood of each hazard using a risk matrix. The risk
is rated based on the potential consequences (severity) and the probability of occurrence.
Risk Tolerance: Determining acceptable risk levels based on company policy, with any risks
above this threshold requiring immediate attention and control measures.
Residual Risk Calculation: Assessing the risk remaining after existing controls are applied.
Recommendations: Providing control measures to mitigate identified risks, focusing on the
hierarchy of controls—elimination, substitution, engineering controls, administrative controls,
and personal protective equipment (PPE).
.
 CASE STUDY- PROCESS RISK ASSESSMENT
Introduction
The following risk assessment has been conducted on behalf of Online Safety Services,
focusing on the material stacking process in the warehouse. This assessment aims to identify
and evaluate potential health and safety hazards, assess the effectiveness of current controls,
and provide recommendations for risk mitigation. The assessment is part of an ongoing
Occupational Health and Safety (OHS) program, emphasizing the importance of proactive risk
management to ensure a safe working environment.
 Risk Matrix
Risk Rating
1- 2- 3– 4- 5-
Basic Risk Matrix
Low Minor Medium High Extreme High

Almost Certain 5
Likelihood or probability

Likely 4

Possible 3

Unlikely 2

Rare 1

Extreme Risk
Eliminate, avoid, implement specific action plans / procedures to manage & monitor
Moderate Risk
Proactively or actively manage
Monitor & manage as appropriate Tolerable Risk
Risk Matrix
 Risk Matrix
PROBABILITY
RISK Practically
impossible
Conceivable but
unlikely to occur
Is known to occur “it
has happened”
Quite possible-
happens regularly
Might well be
expected-Happens

MATRIX 1 2 3 4
often
5
No injury / illnesses / Virtually no damage /
damage disruption to 1 1 2 3 4 5
SEVERITY \ EXPOSURE

operation
Minor damage / brief
Minor injury – first aid case disruption to operation 2 2 4 6 8 10
More severe injury –
require medical assistance
Partial shutdown / med
damage
3 3 6 9 12 15
Serious damage /
Serious injuries – lost
workday
disruption of operation 4 4 8 12 16 20
Substantial damage /
Loss of life / multiple
serious injury
total loss 5 5 10 15 20 25
of operation
Risk Result
01-06 = Possible Risk – Attention needed. Risk perhaps tolerable
07-14 = Medium Risk – Immediate correction required
15-25 = High Risk – Management intervention required

ADDITIONAL REQUIREMENTS /
PERSONNEL INVOLVED DOCUMENTATION REQUIRED TRAINING REQUIRED EQUIPMENT/PPE INVOLVED
REMARKS
 RISK CLASSIFICATION RISK RE-CLASSIFICATION
ACTIVITY HAZARD RISK REMEDIAL ACTIONS TO BE TAKEN

Type RANK RANK

S/E P S/E P
S/H/E (SxP) (SxP)

S 4 3 12 • Ensure that the electrical supply is fully isolated. 4 2 8

• Inspect all electrical connections & plugs on a monthly basis.
• Risk assessment briefing for all operators

• Possible fatality due to

Using Hydro Boiler • Electricity electric shock
• Possible burns

S 3 3 9 • Ensure that all joints are checked for leaks before use. 3 2 6
• Risk assessment briefing for all operators

• Possible severe bodily

injury due to burns to skin
Using Hydro Boiler • Hot surfaces
or scalding from contacting
hot surfaces and water.

• Injuries from slipping and S 3 3 9 • Risk assessment briefing for all operators 3 2 6
falling due to slippery • Competent & experienced operators
surfaces. • Wear the required PPE

• Spilled water
Pouring water from boiler

Approved by appropriate Manager: _________________________

Date: _________________________
 SAFE WORK PROCEDURE – HYDRO BOILER
INTRODUCTION

Before any work can start all workers must be informed and trained on the procedure and of all hazards identified.

AIM

The aim of this document is to provide the procedure to be followed when working at the Hydro Boiler

SCOPE

Firstly the responsibility of the supervisor will be discussed followed by the Safe Work procedure.

SUPERVISORY RESPONSIBILITY

A supervisor will always be available to supervise operations. Should any incident take place the supervisor will stop all activities and informed the foreman, safety officer and
manager of the incident.

RECORD OF TRAINING

Competent persons working with the Hydro Boiler

REQUIRED PPE

No personal protective items to be worn by those employees who uses the Hydro Boiler

PROCEDURE

The following procedure must be strictly adhered to:

• Only one person may operate this Hydro Boiler at any one time
• Staff making use of the Hydro Boiler to be aware that it consists of boiling water and the surface may be hot and pouring water from boiler could lead to burns on hands and skin

DOCUMENT ACCOUNTABILITY

Keep written records of checks and faults. This will indicate recurring problems and may be used in a court case that the Company was diligent in its safety.

DOCUMENT REVIEW

This safe work procedure must be reviewed annually.

 CASE STUDY- PROCESS RISK ASSESSMENT
Process Description
The material stacking process involves the following steps:
Input: Receiving materials such as pallets, boxes, and other equipment.
Process: Workers manually or with forklifts stack materials in designated storage areas.
Output: Stacked materials ready for retrieval and use.
Inputs:
Pallets
Boxes
Forklifts
Process Changes:
Automation of stacking via forklifts
Improved stacking protocols
Outputs:
Organized stacks of materials ready for use or shipment
Process Flow Diagram/Photograph:
(Include a simple flow diagram or photograph of the stacking area.)
 CASE STUDY- PROCESS RISK ASSESSMENT
Risk Assessment
List of Hazards Associated with the Process
Falling Materials: Risk of materials falling from stacks.
Worker Injury: Potential for musculoskeletal injuries during manual stacking.
Equipment Damage: Risk of forklifts or other equipment causing damage during stacking.
Adverse Health/Safety Effects per Hazard
Falling Materials: Can lead to serious injury or fatality.
Worker Injury: Can cause strain injuries, back pain, and other musculoskeletal issues.
Equipment Damage: Potential for minor to severe equipment damage.
Severity/Consequence
Falling Materials: High (serious injury or death)
Worker Injury: Medium (musculoskeletal injuries)
Equipment Damage: Medium (financial and operational impact)
 CASE STUDY- PROCESS RISK ASSESSMENT
Probability of Occurrence
Falling Materials: Medium
Worker Injury: Medium
Equipment Damage: Low
Inherent Risk Calculation
Falling Materials: High risk (due to severity)
Worker Injury: Medium risk
Equipment Damage: Low risk
Existing Controls
Falling Materials: Use of safety barriers and correct stacking techniques.
Worker Injury: Training on proper lifting techniques and use of lifting aids.
Equipment Damage: Regular equipment maintenance and operator training.
 CASE STUDY- PROCESS RISK ASSESSMENT
Residual Risk Calculation
Falling Materials: Medium (with controls)
Worker Injury: Low (with controls)
Equipment Damage: Low (with controls)

Recommendations
Falling Materials: Implement stricter stacking guidelines and increase the frequency of safety
inspections.
Worker Injury: Introduce ergonomics training and consider mechanical aids for manual
stacking.
Equipment Damage: Enhance operator training and conduct regular equipment checks.
 CASE STUDY- PROCESS RISK ASSESSMENT
Process Description
The material stacking process involves the following steps:
Input: Receiving materials such as pallets, boxes, and other equipment.
Process: Workers manually or with forklifts stack materials in designated storage areas.
Output: Stacked materials ready for retrieval and use.
Inputs:
Pallets
Boxes
Forklifts
Process Changes:
Automation of stacking via forklifts
Improved stacking protocols
Outputs:
Organized stacks of materials ready for use or shipment
Process Flow Diagram/Photograph:
(Include a simple flow diagram or photograph of the stacking area.)
 CASE STUDY- PROCESS RISK ASSESSMENT
Discussion
The risk assessment highlights key legal requirements, including compliance with the Occupational Health and
Safety Act (OHSA) and the need for regular risk assessments. Follow-up actions may include air quality
monitoring and noise assessments, depending on the identified hazards. The prioritization of actions is based on
risk ratings, with the most severe and probable risks addressed first.
Conclusion
The material stacking process presents several potential hazards, with falling materials posing the most
significant risk. While current controls are effective, the implementation of additional safety measures, such as
enhanced training and stricter stacking guidelines, is recommended. Overall, the process is considered low-risk
with the proposed improvements.
References
Occupational Health and Safety Act (OHSA)
Company Risk Assessment Guidelines
Relevant industry standards and best practices
THANK YOU

ANY QUESTIONS?