CSA Z1005:21

National Standard of Canada

Workplace incident investigation

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  CSA Z1005:21

  August 2021

  
  

  Title: Workplace incident investigation

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National Standard of Canada

CSA Z1005:21

Workplace incident investigation

®A trademark of the Canadian Standards Association, operating as “CSA Group”

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ICS 13.200

ISBN 978-1-4883-3798-7

© 2021 Canadian Standards Association

All rights reserved. No part of this publication may be reproduced in any form whatsoever without the prior permission of the publisher.

Contents

Technical Committee on Incident Investigation and Prevention 3

Preface 6

0 Introduction 8

1. General 8

2. Guiding principles of successful incident investigation and prevention 8

3. Organization of this Standard 8

1. Scope 10

   1. Inclusions 10

   2. Exemptions 10

   3. Terminology 10

      
      

2. Reference publications 10

   
   

3. Definitions and abbreviations 11

   1. Definitions 11

   2. Abbreviations 13

      
      

4. Incident investigation and prevention program (IIPP) 14

   1. General 14

   2. Management commitment and leadership 14

      1. Responsibility, authority, and accountability 14

      2. Management representatives 15

      3. Worker participation 15

   3. Incident investigation and prevention policy 15

   4. Requirements 16

      1. Incident investigation planning 16

      2. Business continuity 17

      3. Documentation and record management 17

         
         

5. Incident response 18

   
   

6. Conducting investigations 18

   1. General 18

   2. Investigation initiation 18

      1. Pre-investigation 18

      2. Investigation initiation 19

      3. Investigation plan 19

   3. Investigations 20

      1. Scene management 20

      2. Other considerations 21

      3. Final hazards assessment and scene release 22

      4. Investigation team communication, coordination, and debriefing 22

      5. Data collection 22

      6. Documentation and record management 22

      7. Analysis 23

      8. Risk assessment 23

      9. Hazards related to deficiencies 23

      10. Findings 23

   4. Post-investigation 24

      1. Investigation team recommendations 24

      2. Incident investigation report 24

         
         

7. Action plan and validation 24

   
   

8. Verification and validation 25

   
   

9. Continual improvement 25

Technical Committee on Incident Investigation and Prevention

P. Sturm Sturm Consulting Inc., Coldwater, Ontario, Canada Category: Business Interest

Chair

P. Carolan Nunavut Employees Union (NEU), Iqaluit, Nunavut, Canada Category: User Labour

Vice-Chair

T. Winters Canadian Union of Public Employees, Ottawa, Ontario, Canada

Category: User Labour

Vice-Chair

K. Bennett WorkSafeNB/Travail sécuritaire NB, Saint John, New Brunswick, Canada Category: Regulatory Authority

A. Bieberstein Technical Safety BC,

Vancouver, British Columbia, Canada

Non-voting

K. Bondy Unifor,

Toronto, Ontario, Canada

Category: User Labour

D. J. Brown Workplace Safety North, Thunder Bay, Ontario, Canada Category: General Interest

C. Budzich Proactive Consulting Services Limited, Regina, Saskatchewan, Canada Category: Business Interest

J. Chappel Canadian Centre for Occupational Health and Safety (CCOHS),

Hamilton, Ontario, Canada

Category: General Interest

J. Colman WorkSafeBC,

Richmond, British Columbia, Canada

Category: Regulatory Authority

J. Downey Hatch Ltd.,

Mississauga, Ontario, Canada

Non-voting

1. Harkness Workplace Safety and Prevention Services (WSPS), Mississauga, Ontario, Canada

   Category: General Interest

   
   

2. A. Henry Fanshawe College of Applied Arts and Technology, London, Ontario, Canada

Category: General Interest

M. W. Hill Maury Hill and Associates, Inc., Carp, Ontario, Canada Category: General Interest

R. Jarvis Ford Motor Company of Canada, Limited, Oakville, Ontario, Canada

Category: User Management

H. K. Kahle WorkSafeBC,

Richmond, British Columbia, Canada

Non-voting

N. McCormick Corporate Health Works Inc., Winnipeg, Manitoba, Canada

Non-voting

R. Mitchell Electrical Safety Authority, Mississauga, Ontario, Canada Category: Regulatory Authority

A. Peart Public Service Alliance of Canada (PSAC), Ottawa, Ontario, Canada

Category: User Labour

R. J. Petersen Griffith Foods Limited, Toronto, Ontario, Canada Category: User Management

L. Polley C & R Engineered Solutions Inc., Fort Erie, Ontario, Canada Category: Business Interest

D. Reid City of Toronto,

Toronto, Ontario, Canada

Category: Regulatory Authority

D. T. Roberts Electrical Safety Solutions Inc., Mississauga, Ontario, Canada Category: Business Interest

D. Robertson Dilys Robertson & Associates, Cobourg, Ontario, Canada Category: Business Interest

R. Roy Stantec Consulting Ltd.,

Saint John, New Brunswick, Canada

Category: General Interest

D. Short The Redlands Group Inc., Oakville, Ontario, Canada Category: Business Interest

1. Somers Syncrude Canada,

   Fort McMurray, Alberta, Canada

   Category: User Management

   
   

2. Stoffman CLC and LDS Limited,

Vancouver, British Columbia, Canada

Category: User Labour

E. Triggs Alberta Health Services, Calgary, Alberta, Canada Category: User Management

C. Vannier Hydro-Québec,

Montréal, Québec, Canada

Category: User Management

L. Lopez CSA Group,

Toronto, Ontario, Canada

Project Manager

Preface

This is the second edition of CSA Z1005, Workplace incident investigation. It supersedes the previous edition, published in 2017 under the title Incident investigation.

The major changes to this edition include the following:

1. definitions have been updated to align with the terminology found in CSA Z45001;

2. the requirements of an incident investigation planning program (Clause 4.4.1) have been updated;

3. the previous Clause 5 has been removed and the content revised and added to Clause 4.4.1 and Clause 6; and

4. the informative Annex material has been revised and moved to CSA Z1005.1.

   CSA Z1005 adheres to management system principles, such as those set out in CSA Z1000, Occupational health and safety management. Use of Z1005 is not contingent on an organization having an occupational health and safety management system (OHSMS); however, it does specify a Plan-Do- Check-Act cycle to ensure that management system deficiencies are identified and addressed.

   
   

   CSA Z1005 also complements CSA Z1002, Occupational health and safety — Hazard identification and elimination and risk assessment and control. When hazards are identified and eliminated, and when risk is assessed and controlled in accordance with the principles in CSA Z1002, then the number of work- related incidents can be reduced or prevented. CSA Z1005 encourages the use of these investigative principles as a prevention tool. Principles in this standard are designed to be used before, during, or after an event to effectively respond to, or ideally, proactively eliminate, that event, similar events, or other safety deficiencies identified during the investigation, taking investigative principles beyond the traditional approach. The principles of this Standard are intended to be scalable.

   CSA Z1005.1, Implementation Guideline for CSA Z1005, Workplace incident investigation, was developed as a companion document that provides advice on how to best apply this Standard.

   
   

   CSA Group acknowledges that the development of this Standard was made possible, in part, by the financial support of the Canadian Association of Administrators of Labour Law — Occupational Safety and Health (CAALL-OSH), including Provincial and Territorial Governments, as well as the Government of Canada. CSA Group is solely responsible for the content of this Standard, and CSA Group and the

   funding bodies disclaim any liability in connection with the use of the information contained herein.

   This Standard was prepared by the Technical Committee on Incident Investigation and Prevention under the jurisdiction of the Strategic Steering Committee on Occupational Health and Safety, and has been formally approved by the Technical Committee.

   This Standard has been developed in compliance with Standards Council of Canada requirements for National Standards of Canada. It has been published as a National Standard of Canada by CSA Group. Notes:

   1. Use of the singular does not exclude the plural (and vice versa) when the sense allows.

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   5. This Standard is subject to review within five years from the date of publication. Suggestions for its improvement will be referred to the appropriate committee. To submit a proposal for change, please send the following information to inquiries@csagroup.org and include “Proposal for change” in the subject line:

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CSA Z1005:21

Workplace incident investigation

0 Introduction

1. General

   This Standard is designed to be used with related occupational or technical standards. It is intended to be referenced by other Standards as the primary set of requirements for the management of occupational health and safety incident investigation and prevention.

   
   

   This Standard can be incorporated into an existing occupational health and safety management system (OHSMS) or used independently by an organization to plan proactively and systematically. Where systems are already in place, it is important that an incident investigation and prevention program (IIPP) integrate and align to the goals of the overall system.

   
   

   While not specifically addressed in this Standard, some incidents might require a regulatory or criminal investigation by the authority having jurisdiction. In these instances, the organization needs to be aware that all data captured through the course of the investigation could be considered evidence in a regulatory enforcement or criminal proceeding. Organizations need to be aware of any legislation that could apply, or local authorities that need to be notified.

   Workplace incident investigation legislation differs from jurisdiction to jurisdiction in Canada. It is the user’s responsibility to determine how applicable legislative requirements relate to this Standard.

   
   

2. Guiding principles of successful incident investigation and prevention

   This Standard is based on the following guiding principles:

   1. legislated incident investigation requirements are a minimum standard of practice;

   2. incident investigation provides the greatest opportunity for improvement when it is used as a tool for prevention and learning;

   3. it is preferable to use hazard identification, risk assessment, and control principles proactively or early in the design of a work system, rather than use incident investigation to solve issues afterwards;

   4. a systems approach identifies and determines the influence of the workplace system on the occurrence of the incident (see CSA Z1005.1, Annex F);

   5. worker participation is essential to the success of incident investigation and prevention;

   6. effective investigations analyze all possible potential contributing workplace factors, and analyze how those factors influenced the outcome and present findings and recommendations as an opportunity to learn and prevent further occurrences or to improve the practices and processes within the organization; and

   7. the effectiveness of an IIPP is maximized when it is integrated into the organization’s OHSMS, where one exists.

   
   

3. Organization of this Standard

This Standard specifies requirements for and provides guidance on the activities required to manage all aspects of incident investigation in accordance with the Plan-Do-Check-Act cycle and management system principles, such as those set out in CSA Z45001.