Incident Investigation

When an incident occurs, the most important thing to do is provide the necessary help in the form of first aid or other medical assistance to any injured workers on site. Only after this should you look at starting your investigation.

The first step in the investigation is to secure the incident scene and preserve any physical evidence using cones or other barriers to protect sensitive areas. If the investigation team has to travel a long distance to reach the scene, on-site management should be instructed to carry out this step. The investigation team should also make sure to follow any safety guidelines required by the site, wearing personal protective equipment (PPE) if necessary.

Once the scene is secured, start documenting the scene by taking photos or videos of the scene, and collecting any perishable physical evidence including CCTV tapes and samples. Depending on the nature of the incident, it might be useful to record what equipment was being used when the incident occurred, weather conditions at the time of the incident, positions and use of machine guards, controls, and safety devices, and other relevant information.

Once you have secured the scene and recorded immediate information and evidence, it is time to plan the investigation. A systematic investigation plan helps ensure that it is comprehensive and thorough. In this step, you need to decide whom to involve in the investigation, gauge how long it will take, and estimate what resources will be required.

In addition, it is recommended to prepare a kit with all the relevant documents and equipment so that the actual investigation is smooth and efficient. Depending on the circumstances, possible inclusions in the kit could be:

Cones and barricade markers.

Warning tags or padlocks for really sensitive areas.

PPE

Measuring tape.

Interview forms.

Investigation forms.

Sample containers.

It might be prudent to carry some of these, like the sample containers, cones, etc. to the incident scene when you are going to secure the scene as well.

The next step is to collect all the relevant information related to the incident. Such information is available from various sources, including the people involved, witnesses (whom you should interview), equipment on the scene, and documents such as maintenance logs, inspection reports, and training histories.

Interviewing the people involved and any witnesses to the incident is a crucial step in collecting the information you need, as they can let you know what exactly happened. The information collected through these interviews might include:

Details about the worker

Details about any injuries or property damage

A narrative description of the events that took place (including location of the incident, the sequence of events leading up to the accident or near miss, equipment or objects involved, conditions under which the incident took place, the task being performed when the incident occurred, and other details)

Information about supervision at the time of the incident

Causal factors related to the incident

To ensure that the interviews are effective, reduce your employees' possible fears and anxieties and make them feel at ease by assuring them that the purpose of the investigation is to find the cause rather than point blame.

Let them know that they can have a labor representative present if they wish.

For the best possible data collection, follow best practices like asking open-ended questions, listening to the interviewees without interrupting, asking clarifying questions and correcting inconsistencies, interviewing the witnesses in the place where the incident occurred to help jog their memories, taking notes and, if possible, recording the interview.

Another way to enrich your data is to ask the workers for their opinions on how they think the incident could have been prevented.

Once you have collected all the required data, it is essential to summarize and document it all by completing an incident investigation form.

After the data is collected, it must be analyzed. The goal here is to find the root cause of the incident so that this and similar incidents can be prevented in the future.

Incidents are usually caused by a chain of events rather than a single event, so understanding the sequence of events is crucial to find the root cause. This can be done by performing a root cause analysis, which helps you uncover underlying or systemic issues rather than surface causes of the incident (like human error). A simple but effective technique is the "Five Whys" method, outlined in OSHA's root cause analysis fact sheet.

It is important to remember here that while finding and rectifying the immediate cause might fix the symptom of the problem (that specific incident) but not the issue itself. Also keep in mind that the root cause is unlikely to be a simple human error. It's likely that there are numerous contributing factors including equipment, environment, organizational management systems, mental or physical abilities of the worker(s) involved, and more. Discovering every contributing factor related to the incident is the only thing that will help you prevent future incidents.

Of course, identifying the root cause of the incident is not enough. To ensure that the incident investigation was useful and not a waste of time, corrective action must be implemented.

Create an action plan to resolve the causes of the incident, both immediate and underlying, assign people to implement the actions, and ensure that the plan is acted upon. Make sure you track the progress of the corrective action plan because if you don't, the actions might never get implemented.

It isn't easy to keep track of such a plan, especially if there are multiple corrective actions with varied people implementing them, or even worse, if there are multiple such incidents to act upon.

Submit Report

To find root causes and prevent recurrence, uncover gaps in existing controls, support legal and insurance claims, and show employees and clients your commitment to safety.

At the scene, as soon as possible after the incident, so evidence that helps find the root cause is not lost.

Ideally people with formal training in investigation, knowledge of legal and organisational requirements, and an understanding of the work processes involved. Serious incidents may need a multi-disciplinary team.

Secure the scene, plan the investigation, collect all relevant information, analyse the data to find the root cause, implement corrective actions, and document and share the results.

First aid and medical help for anyone injured. Only then should the scene be secured and evidence preserved.