Incident reporting and investigation duties

At 7:52 on the Monday morning of the level 5 fall, Jordan Pike called Ben Nakamura on the radio: 'Man down on five, by the shaft.' Within ten minutes, a Tallgrass first aid attendant was with the injured worker, an ambulance had been called and directed to the north gate, and Ben had stopped work on level 5 and taped off the area around the opening. Within the hour, the incident had been reported to the regulator. Within the week, a joint investigation by Tallgrass, the three subcontractors involved and the worker co-chair of the committee had found five failed layers of protection, as lesson 1 described, and agreed on the fixes in lesson 7.

This lesson sets out what must be reported, to whom and when, and how a general contractor leads an investigation on a site with many employers.

The first hour

Whatever the jurisdiction, the first priorities after a serious incident are the same, and Tallgrass's emergency plan lists them in order.

• Care for the injured. First aid, emergency services, and someone to meet the ambulance at the gate.
• Make the area safe. Stop the work, control any continuing hazard, and keep others out without putting rescuers at risk.
• Preserve the scene. Leave things as they are, except to rescue or to prevent further harm. Tape it off and post someone to keep people out.
• Notify. Inside the company and the subcontractor, and to the regulator and others as the law requires.
• Record. Names of witnesses, the time, photographs of the scene before anything is moved, and the conditions: weather, lighting, equipment in use.

What must be reported in Manitoba

Manitoba's Act and regulation require the employer to notify the Branch immediately of a serious incident, which includes a death and a range of serious injuries such as injuries requiring admission to hospital, fractures of certain bones, amputations and loss of consciousness, as well as dangerous occurrences that could have caused serious injury even if no one was hurt, such as the collapse of a crane, a structure, scaffold or excavation, or an uncontrolled explosion or fire. Except to rescue people or prevent further injury, the scene must not be disturbed until an officer gives permission. The employer must also investigate incidents, prepare a written report setting out what happened, the causes and the corrective actions, and give it to the committee or representative. Separately, injuries that need medical treatment or cause time off work must be reported to the WCB within the time limits it sets, and workers must report injuries to their employer promptly.

Who reports on a multi-employer site

The legal duty to report usually falls on the employer of the injured worker. On a construction site, the prime contractor also needs to know immediately, because it controls the site, must coordinate the response and may itself have duties. Tallgrass's subcontracts require every subcontractor to report any injury, near miss or dangerous occurrence to Tallgrass immediately, and Tallgrass makes the call to the Branch jointly with the employer for serious incidents, so that nothing is missed and the regulator hears one consistent account. For the level 5 fall, Pinecrest's office and Owen called the Branch together, nineteen minutes after the fall.

Near misses

A near miss is an event that could have caused injury or damage but did not, such as a tool dropped from a height that landed in an empty area, or a worker who slipped at an edge and caught a guardrail. Near misses are free lessons: the causes are the same as those of injuries, but no one has been hurt. Tallgrass asks every worker to report near misses, by telling their foreman, by a card in the lunchroom box or through the site app, anonymously if they prefer. Near misses with serious injury or fatality potential are investigated with the same depth as injuries.

Leading the investigation

An investigation has one purpose: to understand why the event happened so that it does not happen again. It is not a search for someone to blame, and an investigation that becomes one will not get honest answers. On a multi-employer site, Tallgrass leads or coordinates investigations of serious events, with the employers involved and a worker member of the committee. The level 5 investigation team was Owen, Ben, the safety leads from Pinecrest, Keystone Mechanical Ltd. and Highline Scaffold Ltd., and Lena Petrov.

The team followed Tallgrass's five-step method.

• Gather facts. Photographs, measurements, the condition of equipment, records (the opening register did not yet exist, but the mechanical contractor's work order showed the opening cut on Friday), and interviews with the injured worker, witnesses, foremen and the people who last worked in the area.
• Build a timeline. What happened, in order, from the cutting of the opening on Friday to the fall on Monday.
• Find the causes. For each event in the timeline, ask why it happened and keep asking until the answers reach the system: the procedures, training, supervision, planning and coordination that should have prevented it.
• Decide corrective actions. Use the hierarchy of controls, give each action an owner and a date, and prefer fixes that do not depend on people remembering.
• Share and follow up. Tell the site what happened and what has changed, check that the actions are done and working, and close the investigation.

From events to causes

The team built its timeline and asked 'why' at each step. Owen recorded it in a simple structure.

# Timeline and why-chain for the level 5 fall.
timeline = [
    ("Fri 15:30", "Mechanical crew cuts 1.2 m x 0.9 m shaft opening; installs guardrail"),
    ("Sat 10:15", "Scaffold crew removes rail to move material; leaves without reinstating"),
    ("Mon 07:30", "Drywall crew sent to level 5 without a floor walk"),
    ("Mon 07:52", "Worker steps back while handling board and falls through opening"),
]
whys = [
    "Why was the opening unguarded? The scaffold crew removed the rail and did not replace it.",
    "Why was it not replaced? No rule required it, and no one owned the rail.",
    "Why did no one notice from Saturday to Monday? No one walked level 5 after Thursday.",
    "Why was there no walk? The foremen's start-of-shift check was not required in writing.",
    "Why were there no such rules? Openings and shared rails had never been assigned at the coordination meeting.",
]
for t, e in timeline:
    print(t, "-", e)
print()
for i, w in enumerate(whys, 1):
    print(f"{i}. {w}")

Fri 15:30 - Mechanical crew cuts 1.2 m x 0.9 m shaft opening; installs guardrail
Sat 10:15 - Scaffold crew removes rail to move material; leaves without reinstating
Mon 07:30 - Drywall crew sent to level 5 without a floor walk
Mon 07:52 - Worker steps back while handling board and falls through opening

1. Why was the opening unguarded? The scaffold crew removed the rail and did not replace it.
2. Why was it not replaced? No rule required it, and no one owned the rail.
3. Why did no one notice from Saturday to Monday? No one walked level 5 after Thursday.
4. Why was there no walk? The foremen's start-of-shift check was not required in writing.
5. Why were there no such rules? Openings and shared rails had never been assigned at the coordination meeting.

The final 'why' pointed at the system, not at any one person: shared hazards had no owners. That is why the corrective actions were the shared-hazard list, the opening register and the guardrail removal permit, rather than only discipline for the scaffold crew or retraining for the injured worker.

One action moved up the hierarchy: for smaller openings, a bolted cover that cannot be removed without tools replaced a guardrail that could simply be lifted off. Engineering controls do not depend on someone remembering a rule.

Interviews

Most of what an investigation learns comes from people. Owen's guidance for interviews is to talk to each person separately and soon, in a quiet place, to explain that the purpose is to prevent a recurrence, to ask open questions ('Tell me what happened from when you arrived') before specific ones, to avoid suggesting answers, and to write down what the person said in their own words. The injured worker was interviewed in hospital two days later, briefly and with his consent. He said he had been told the floor was ready and had not expected an opening behind the board stack. That detail, that the drywall foreman had told the crew the floor was ready without walking it, became a key finding.

Sharing lessons

An investigation report that sits in a file prevents nothing. Within a week of the fall, Carla presented the findings at a site-wide safety meeting, without naming the injured worker or blaming any crew, and explained each new rule. The investigation summary was posted on the site board and sent to Tallgrass's other projects, two of which adopted the opening register within a month.

Owen also gave the written investigation report to the committee, as the regulation requires, and the committee reviewed whether the corrective actions were done at its next two meetings.

Caring for the people involved

A serious incident affects more people than the injured worker. The coworkers who saw it, the foreman who sent the crew up, the first aid attendant and the crew who cut the opening may all be shaken. Tallgrass's procedure after a serious incident includes offering the employee and family assistance program to everyone involved, checking in with witnesses over the following days, and making sure the injured worker's employer stays in contact with the worker and their family. On Cottonwood Place, Carla visited the injured drywall worker in hospital with Pinecrest's owner, and his return to modified work six weeks later was planned with his doctor, his employer and Tallgrass together.