Incident Investigation

UNIVERSITY WIDE GUIDELINES

Occupational Health and Safety
- Incident Investigation -

1. Why Investigate Incidents?

The main aim of investigating incidents is to:

prevent similar incidents recurring in the future;
identify any new hazards; and
identify and choose suitable controls.

We want to reduce the cost in pain, suffering, disruption to work and studies and loss of earnings of injured workers and students. We also wish to reduce the costs of incidents to the University. Therefore, we need to investigate fully and accurately the circumstances and causes of incidents.

2. When to Investigate Incidents?

It is important that any investigation occurs as soon as possible. The less time between an incident and the investigation, the more accurate the information that can be obtained. While concern for an injured worker should take precedence over everything else, when incidents involving injury or illness occur, early investigation is essential.

3. What to Investigate?

Obviously, any incident in which injury or significant property damage occurs should be investigated. There will also be events usually referred to as 'near misses'. Most of us will remember incidents in which we have been 'lucky' to escape injury. Such near misses have the same causes and actions as more serious incidents, only the outcomes vary. Study of near misses can therefore be used to prevent more serious incidents.

4. How to Conduct an Investigation

It is important to examine the causes and results of any incident objectively. The investigator must begin the investigation with an open mind. No assumptions should be made and any judgement should be based on information that is known to be full and accurate.

It is important to ask open-ended questions and not to put words into witnesses' mouths. It is also important not to blame people but rather to emphasise the importance of seeking the reasons for the incident to prevent a recurrence.

It is far less effective to attempt to change people, to ask them to be better, to be less human, than it is to change their environment so that the consequences of an error on their part are either eliminated or reduced. Rather than an emotive discussion of patterns of behaviour, a more positive approach attempting to modify the environment is needed. That is, it is more effective to alter the situations producing an error than to attempt to change human nature.

For example, if material is poorly stacked on a high shelf and it falls off, the immediate obvious cause could be poor housekeeping. However, possible underlying causes could include the employee not realising the hazard of the action, the shelving being unsuitable for the task or being poorly maintained. Therefore, the true basic causes could identify the need in this case for:

further operator training;
better planning, layout and or access; or
new equipment or methods.

An investigation may require photographs, sketches or another's technical expertise before the final causes of an incident can be determined and adequate controls considered and chosen.

When commencing the investigation:

(a) Make sure any injured person is given appropriate medical attention without delay.
(b) Control the incident scene, place barriers, turn power off, etc.
(c) Start the investigation as quickly as possible. Conduct interviews at the scene of the incident if possible. Ensure that the witnesses discuss the incident in relative privacy. Begin with those who can contribute most.
(d) After each interview, repeat the witness' statement as you understand it to ensure that you have correctly understood.
(e) Close each interview on a positive note.
(f) Take immediate corrective action where warranted.
(g) Complete report with recommendations.
(h) Ensure follow-up action occurs.

5. Key Questions to Ask

Who? Get the names of everyone involved, near, present or aware of possible contributing factors.

What? Describe materials and equipment involved, check for defects, get an exact description of chemicals involved, etc.

Where? Describe exact location, note all relevant facts, i.e. lighting, weather, floor conditions, etc.

When? Note exact time, date and other factors, i.e. shift change, work cycle, break period, etc.

How? Describe usual sequence of events and actual sequence of events before, during and after the incident.

Why? Find all possible direct and indirect causes AND how to keep it from happening again.

6. Fundamental Concepts

6.1 Causes of incidents are rarely simple when circumstances are examined closely. Behind every incident there are many contributing factors and causes. The key is to identify those that can be most effectively acted upon to prevent recurrences in the long term.

6.2 Incident investigations should emphasise the long-term elimination of injury, loss or damage. The focus should be on systems deficiencies in preference to human factors.

6.3 After identifying causes and factors, suitable improvement actions must be identified and implemented.

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Warning - Uncontrolled when printed! The current version of this document is kept on the UB website.

Authorised by: University Health and Safety Policy Committee
Maintained by: Manager - Workplace Support
Review Date: Dec-2007

Original Issue: 08/05/2000
Current Version: 21/01/2005