Incident Investigations

The common practice in industrial accident/incident investigation is to look for the cause of any accident/incident.

To prevent reoccurrence of incidents, it is important to find the root causes of an incident, and identify actions to address the root causes. Root-Cause Analysis will be performed by the Investigation Team with the assistance of the Qualified Incident Investigator trained in the use of Why-Tree incident investigation and root-cause analysis tools methodologies.

Searching for a single cause of an accident/incident is restrictive. It focuses attention on only one, or at best a very few, of the essential factors while others, which may be more easily controlled, pass unnoticed.
The main objective of an investigation is prevention. A good investigation aims to establish a series of events that should have taken place and compares it to what actually happened to identify areas that need changing.

Incidents need to be reported to ensure that data is collected, an appropriate level of investigation is conducted and SMART Corrective Actions are developed to prevent recurrence of further Incidents.

SMART Corrective actions shall be developed and agreed upon by the Team and clearly described on the report. Corrective actions shall be added to the OS&H Action Tracking Register and tracked to closure.

Corrective or mitigating actions are to be developed to meet SMART Guidelines. The following information will be used to identify SMART corrective actions:

Characteristic Questions
Specific Does the action contain a verb; And, is it specific enough to be easily understood and implemented?
Measurable Can the implementation of the action be verified by others and/or can the implementation of the action be measured?
Agreed Has the action and time frame for implementation been agreed upon by the Investigation Team, the Action Owner, and Project Management?
Root Cause/s Does the action address the root cause/s for the incident?
Time Based Has a completion date been set based on the severity of the incident and the action to be implemented?

 

The most appropriate corrective actions shall be selected based on the following hierarchy of
controls (in order of action):

  1. Elimination – removal or abatement of the hazard.
  2. Substitution – the use of a safer alternative.
  3. Design / Engineering – the use of engineered controls.
  4. Administrative – the use of procedural controls or changes / improvement to procedures.
  5. Personal protective Equipment – the use of protective gear as a last line of defence.

The team approach to investigations

The type of investigation conducted depends on the seriousness or complexity of the incident, but it is best done as a team so all parties can contribute their skills and expertise to achieve the best result.
The employer is responsible for putting an investigation team together. Investigators are collectors of evidence and must base their conclusions on that evidence. Take the time to choose the right people to conduct the investigation.

The following people should be considered for the team:

  • safety representatives where they exist;
  • line manager/supervisor;
  • a safety person from the worksite; and
  • people with the relevant knowledge