Incident Investigation Overview

Incident Investigation Overview

• Incident investigation aims to understand how and why incidents happen.
• The goal is not blame but to uncover contributing factors and root causes.
• Investigations benefit organizations by identifying unsafe conditions.
• Investigations prevent similar incidents by implementing corrective actions.

Benefits of Incident Investigation

• Strengthens internal responsibility systems.
• Fosters positive health and safety (OHS) cultures.
• Prevents future incidents by identifying root and contributing causes.
• Supports regulatory compliance.
• Aids in identifying systemic issues through trend analysis.

Management System Failure

• Incidents can arise from various management system failures.
• Inadequate practices, procedures, and training for safety-critical operations can be contributing factors.
• Insufficient assessment of tasks or objects requiring mechanical assistance instead of manual handling.
• Lack of pre-job assessments or monitoring in the management system.

Incident Investigation Terminology

• Incident: An unplanned event or sequence of events that disrupts a work process or routine and causes injury or damage.
• Near Miss: An unplanned event with the potential for injury or damage but no actual harm.
• Unsafe Act: An activity performed in a manner that endangers the health or safety of individuals. Examples include using defective equipment, operating machinery when unqualified, or bypassing safety devices.
• Unsafe Condition: Situations in the workplace that are likely to cause injury or damage. Examples include defective tools, congestion, and inadequate safety systems, inadequate guards or warnings, or spills and leaks. (e.g. of hydrocarbons).
• Direct Cause: The immediate cause of an event, the action or condition that triggered an incident. It is usually an unsafe condition or act.
• Programmatic Cause: A cause that contributed to an incident but would not have caused the event by itself. This is a deeper systemic issue in management or policies.
• Root Cause: The fundamental reason an incident occurred. This is the ultimate cause, if addressed, would prevent similar incidents. A root cause is often a failure in management systems.

Incident Investigation Procedure

• Step 1: Manage the Incident Scene: Immediately control immediate hazards. Secure the area, render first aid, alert responders (police, fire, paramedics), de-energize equipment, stop leaks or fires.
• Step 2: Gather Information: Collect information from witnesses, involved personnel, supervisors, etc.
• Step 3: Analyze Information and Determine Causes: Define the sequence of events leading to the incident; analyze factors (equipment, materials, environment, humans, task control, organizational factors, operations).
• Step 4: Determine Corrective Actions: Implement corrective measures to eliminate identified causes. Be specific and practical, involve relevant personnel.
• Step 5: Write Incident Investigation Reports: Create a detailed report that documents the incident's conditions, causal factors, corrective actions, and follow-up procedures. Include supporting documentation (photos, witness statements, etc).
• Step 6: Follow-Up: Monitor implemented measures to ensure effectiveness and take further actions depending on need. Review if additional measures are needed. Ensure that recommendations are implemented, responsibilities are assigned, and timelines are met.

OHS Committee and Incident Investigation

• OHS committees play a vital role in incident investigations by helping determine safe procedures and improving the quality of the processes needed to reduce the risk of incidents.
• A committee should be versed in the roles of the respective members' roles in incident investigation.
• The OHS Committee members should follow investigation procedures as defined by the OHS Committee members (and/or by their institutions).

This quiz covers the fundamentals of incident investigation, aiming to understand the causes of incidents without placing blame. It highlights the benefits of conducting thorough investigations, such as identifying unsafe conditions and fostering a positive safety culture. Learn how effective investigations can prevent future incidents and support compliance.