Chapter 9: Investigation and Reporting¶

9.0 Purpose and Scope¶

This chapter establishes requirements for reporting and investigating incidents, injuries, near misses, and hazardous conditions at 4Core. Investigation purpose is to learn from what happened and prevent recurrence - not to assign blame.

Core Principle: Every incident is opportunity to improve. We investigate to learn, not to punish.

Why Investigate: Prevent similar incidents in future; identify root causes, not just symptoms; improve safety programs/procedures; demonstrate due diligence/regulatory compliance; support injured workers; reduce costs (injuries, damage, downtime).

What We Investigate: All injuries (no matter how minor); near misses (incidents that could have caused injury); property damage; environmental releases; dangerous conditions/practices; regulatory violations.

Regulatory Compliance: WorkSafe BC requires investigation of all incidents; serious incidents reported to WorkSafe BC within prescribed timeframes; investigation demonstrates due diligence; failure to investigate/correct can result in penalties.

9.1 Incident Reporting¶

9.1.1 What Must Be Reported¶

All of the following reported immediately to supervisor:

Injuries: Any injury requiring first aid (even minor cuts, bruises, splinters); medical treatment (doctor visit, stitches, x-rays); lost time injuries (unable to work next shift); serious injuries (hospitalization, fractures, amputation, permanent impairment); occupational illness/disease; aggravation of pre-existing injury/condition.
Near Misses: Incidents that could have resulted in injury but didn't (by luck or last-second avoidance); examples: equipment failure that could have caused injury, fall caught by fall protection, atmospheric hazard detected before entry, close call with mobile equipment.
Property Damage: Damage to 4Core equipment/tools; damage to client property/equipment; vehicle accidents/damage.
Environmental Releases: Spills of thermal oil, chemicals, or hazardous materials; releases to soil, water, or air; exceeding permit limits/environmental thresholds.
Hazardous Conditions: Unsafe equipment/conditions discovered; violations of safety procedures; missing/inadequate controls.

"When in doubt, report it." Better to report something that turns out minor than fail to report something serious.

9.1.2 Reporting Process¶

Report Timing	Incident Type	Report To
Immediate (Within 1 Hour)	Serious injuries/fatalities; incidents requiring 911 response; environmental spills/releases; dangerous incidents (CS emergency, fall from height, structural collapse, major equipment failure); any incident requiring WorkSafe BC notification	Supervisor, Safety Officer, Management; Client emergency coordinator (at client sites); Call 911 first for medical emergencies
Same Shift (Within Hours)	Injuries requiring medical treatment; near misses with high potential consequence; property damage >$5,000; equipment failures creating hazards	Supervisor, Safety Officer
Within 24 Hours	All other injuries (including first aid only); low-consequence near misses; hazardous conditions discovered; minor property damage	Supervisor

After-hours/emergency: Management on-call number: [Number]. For medical emergencies, call 911 first, then notify supervisor.

9.1.3 Incident Report Form¶

Written incident report required for all reportable incidents. Worker or supervisor completes incident report form within 24 hours.

Incident report includes: Date/time/location of incident; injured person (name, position, years of experience); witnesses (names/contact info); description of what happened (step-by-step sequence); immediate causes (what directly caused incident); injuries sustained; first aid/medical treatment provided; property damage (description, estimated cost); environmental impact; supervisor notified (when, how); corrective actions taken immediately; photos (if applicable); worker signature/date; supervisor signature/date.

Report submitted to: Safety Officer for review/investigation coordination; Management for review; Workers compensation (if lost time injury).

9.2 WorkSafe BC Notification Requirements¶

9.2.1 Immediate Notification (Within 1 Hour)¶

WorkSafe BC must be notified immediately (phone: 1-866-922-4357) for: - Fatality - Serious injury (hospitalization, amputation, major fracture, loss of consciousness, serious burns, acute poisoning) - Dangerous incident even if no injury (major structural failure/collapse, explosion/fire, uncontrolled release of hazardous substance, failure of lifting equipment/overturning of equipment, diving incident, geotechnical failure)

Notification made by: Management or Safety Officer; supervisor if others unavailable; person making call documents: date/time of call, who they spoke to, WorkSafe BC file number assigned, follow-up requirements.

After notification: Preserve incident scene (do not disturb unless necessary for rescue/safety); take photos before disturbing scene; await WorkSafe BC instructions (inspector may attend site); do not resume work in area until authorized by WorkSafe BC.

9.2.2 Written Report (Within 48 Hours)¶

If verbal notification made, written report submitted to WorkSafe BC within 48 hours: Online at WorkSafe BC website; includes detailed incident description, injuries, witnesses, corrective actions taken/planned; copy retained in 4Core files.

9.2.3 Workers Compensation Claims¶

All work-related injuries requiring medical treatment or lost time must be reported to WorkSafe BC for workers compensation purposes: Employer's Report of Injury (Form 7) submitted online within 3 business days of learning of injury; worker completes Worker's Report of Injury (Form 6A); copies of both forms retained in worker file; Safety Officer coordinates with workers compensation administrator.

9.3 Incident Investigation¶

9.3.1 Investigation Levels¶

Level	Incident Type	Led By	Team Members	Timeline
Level 1 - Basic	First aid only injuries; low-consequence near misses; minor property damage	Supervisor	Worker(s) involved	Within 24 hours
Level 2 - Standard	Medical treatment injuries; moderate near misses; significant property damage; regulatory violations	Safety Officer	Supervisor, worker(s) involved, subject matter expert (if applicable)	Within 3 days
Level 3 - Comprehensive	Lost time injuries; serious injuries/fatalities; dangerous incidents; high-consequence near misses; environmental releases; incidents requiring WorkSafe BC notification	Management	Safety Officer, supervisor, worker(s) involved, external specialist (if applicable), worker representative	Within 7 days

9.3.2 Investigation Process¶

5-Step Investigation Process:

Secure Scene and Gather Information:
Ensure area safe for investigation; preserve evidence (do not clean up or repair until photos taken, measurements made); take photos (overall scene, specific hazards, damage, equipment position); interview witnesses separately (as soon as possible while memory fresh); gather physical evidence (damaged equipment, materials, tools); review documentation (permits, JHAs, training records, inspection records, procedures).
Determine Sequence of Events:
Create timeline (what happened first, next, etc.); identify deviations (what was different from normal procedure or expected conditions?); use "who, what, when, where, how" questions; focus on facts, not opinions or speculation.
Identify Direct Causes:
Unsafe Acts: Procedure not followed, unauthorized action, improper use of equipment, failure to use PPE, working under influence, horseplay.
Unsafe Conditions: Inadequate guarding, defective equipment, poor housekeeping, inadequate lighting/ventilation, lack of PPE availability.
Often multiple direct causes contribute to single incident.
Identify Root Causes (5 Whys Method):
Ask "why" five times to get beyond surface causes to underlying systemic issues.
Example: Worker injured grinding in confined space without respirator. Why no respirator? Worker didn't think it was needed. Why didn't worker think it needed? Worker not trained on respiratory hazards. Why not trained? Training not scheduled. Why not scheduled? Training program gaps not identified. Why not identified? No system to track/schedule training. Root cause = inadequate training tracking system.
Common Root Cause Categories: Training inadequate/missing; supervision inadequate; hazard assessment incomplete; procedure inadequate/not followed; equipment design/maintenance issues; management system failures; communication breakdowns; fatigue/human factors.
Develop Corrective Actions:
Address root causes, not just symptoms; apply hierarchy of controls (eliminate hazard if possible, then substitute, engineer, admin controls, PPE); assign responsibility for each action (specific person); set realistic timelines; verify implementation; monitor effectiveness.

9.3.3 Investigation Report¶

Investigation report includes: Executive summary (one paragraph: what happened, why, what we're doing); incident details (date/time/location, injured person, witnesses, sequence of events); direct causes identified; root cause analysis (5 whys documented); corrective actions (description, hierarchy of controls applied, assigned to, due date, status); lessons learned; attachments (incident report form, photos, witness statements, diagrams).

Report reviewed by: Management (all Level 2 and 3 investigations); Safety Officer (all investigations); Shared with workers at safety meetings (lessons learned, corrective actions); Provided to WorkSafe BC if requested.

Report distribution: Original to Safety Officer for filing; copy to supervisor; copy to management; summary to all workers (monthly safety meeting).

9.4 Corrective Actions¶

9.4.1 Immediate Corrective Actions¶

Taken at scene immediately after incident: Remove workers from danger; secure area/equipment; provide first aid/medical treatment; control spills/releases; eliminate immediate hazard if possible (shut down equipment, barricade area, ventilate space).

9.4.2 Short-Term Corrective Actions¶

Implemented within days/weeks: Repair/replace defective equipment; retrain affected workers; update procedures/JHAs; increase supervision; implement temporary controls until permanent solution in place.

9.4.3 Long-Term Corrective Actions¶

Address systemic issues (may take months): Engineering controls (equipment modifications, ventilation systems); program updates/revisions; management system changes; culture/behavior change initiatives.

All corrective actions: Documented in investigation report; tracked in centralized action item log; assigned to responsible person with timeline; status updated regularly; verified upon completion (Safety Officer or management confirms action taken and effective); effectiveness monitored (are similar incidents still occurring?).

9.5 Return to Work¶

After work-related injury: Worker provided with written instructions for medical treatment (where to go, what to tell healthcare provider); supervisor maintains contact with injured worker (check on recovery, answer questions, provide support); modified/light duties offered if medically appropriate (allows worker to continue contributing, supports recovery, maintains connection to workplace); medical clearance required before returning to full duties (written release from healthcare provider); gradual return to full duties as appropriate (don't rush recovery).

Accommodation: 4Core accommodates work-related injuries to extent possible without undue hardship; worker involved in return-to-work planning; supervisor works with Safety Officer/management to identify suitable modified duties; regular communication between supervisor and worker.

9.6 Responsibilities¶

Role	Responsibilities
Workers	Report all incidents immediately to supervisor; provide accurate information during investigation; participate in investigation as requested; cooperate with corrective actions; learn from incidents and apply lessons learned
Supervisors	Ensure all incidents reported; provide immediate response (secure scene, first aid, notifications); conduct Level 1 investigations; participate in Level 2/3 investigations; implement corrective actions assigned; follow up with injured workers; ensure lessons learned communicated to crew
Safety Officer	Coordinate all investigations; lead Level 2 investigations; support Level 3 investigations; ensure WorkSafe BC notifications made; ensure workers compensation claims submitted; track corrective actions to completion; analyze incident trends; share lessons learned across organization; maintain investigation records
Management	Provide resources for investigations; lead Level 3 investigations; review all investigation reports; approve corrective actions requiring budget; ensure corrective actions implemented; support return-to-work efforts; report serious incidents to WorkSafe BC; demonstrate commitment to learning from incidents

9.7 Records and Documentation¶

Investigation records retained permanently: Incident report forms; investigation reports; witness statements; photos/diagrams; corrective action tracking; WorkSafe BC correspondence; workers compensation claims; medical documentation.

Accessibility: Investigation records confidential; accessible to worker (own injury reports), supervisor (workers under supervision), Safety Officer (all records), management (all records), WorkSafe BC (upon request), legal counsel (if required).

Trend Analysis: Incident data reviewed quarterly and annually; trends identified (types of incidents, locations, tasks, times of day, root causes); program improvements implemented based on trends; results shared with workers.

END OF CHAPTER 9

Document Control

Field	Value
Version	0.9-DRAFT
Effective Date	December 2025
Next Review	December 2026
Approved By	[All 4 Owners]
Safety Officer	Rodney Peters

Company Information: - Business Name: 4Core Energy & Maintenance Ltd. - Address: [To Be Added] - Industry: Energy and mechanical system maintenance, retrofits and troubleshooting - WorkSafe BC Account: [Account Number]