Please note: The term incident is used in some situations and jurisdictions to cover both an "accident" and "incident". It is argued that the word "accident" implies that the event was related to fate or chance. When the root cause is determined, it is usually found that many events were predictable and could have been prevented if the right actions were taken - making the event not one of fate or chance thus, the word incident is used.
For simplicity, we will now use the term incident to mean all of the above events. The information that follows is intended to be a general guide for employers, supervisors, health and safety committee members, or members of an incident investigation team. When incidents are investigated, the emphasis should be concentrated on finding the root cause of the incident so you can prevent the event from happening again. The purpose is to find facts that can lead to corrective actions, not to find fault.
Always look for deeper causes. Do not simply record the steps of the event. Some jurisdictions provide guidance such as requiring that the incident must be conducted jointly, with both management and labour represented, or that the investigators must be knowledgeable about the work processes involved.
Note: In some cases, other authorities may have jurisdiction, such as if a serious injury or fatality occurred. Your organization should establish, implement, and maintain a procedure to coordinate managing incidents with the authority having jurisdiction e. This coordination may include the authority taking control of the incident scene. The advantage is that this person is likely to know most about the work and persons involved and the current conditions.
Furthermore, the supervisor can usually take immediate remedial action. This situation should not arise if the incident is investigated by a team of people, and if the worker representative s and the investigation team members review all incident investigation findings and recommendations thoroughly. An investigator or team who believe that incidents are caused by unsafe conditions will likely try to uncover conditions as causes.
On the other hand, one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine all underlying factors in a chain of events that ends in an incident. The important point is that even in the most seemingly straightforward incidents, seldom, if ever, is there only a single cause. For example, an "investigation" which concludes that an incident was due to worker carelessness, and goes no further, fails to find answers to several important questions such as:.
An inquiry that answers these and related questions will probably reveal conditions that are more open to correction. As little time as possible should be lost between the moment of an incident and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses.
The tools that members of the investigating team may need pencil, paper, camera or recording device, tape measure, etc. The simple model shown in Figure 1 attempts to illustrate that the causes of any incident can be grouped into five categories - task, material, environment, personnel, and management. When this model is used, possible causes in each category should be investigated. Each category is examined more closely below. Remember that these are sample questions only: no attempt has been made to develop a comprehensive checklist.
Figure 1: Incident Categories. Here the actual work procedure being used at the time of the incident is explored. Members of the investigation team will look for answers to questions such as:. To seek out possible causes resulting from the equipment and materials used, investigators might ask:.
Again, each time the answer reveals an unsafe condition, the investigator must ask why this situation was allowed to exist. The physical work environment, and especially sudden changes to that environment, are factors that need to be identified.
The situation at the time of the incident is what is important, not what the "usual" conditions were. For example, investigators may want to know:.
The physical and mental condition of those individuals directly involved in the event must be explored, as well as the psychosocial environment they were working within. The purpose for investigating the incident is not to establish blame against someone but the inquiry will not be complete unless personal characteristics or psychosocial factors are considered. Some factors will remain essentially constant while others may vary from day to day:.
Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management and the role or presence of management systems must always be considered in an incident investigation.
These factors may also be called organizational factors. Failures of management systems are often found to be direct or indirect causes. Ask questions such as:. This model of incident investigation provides a guide for uncovering all possible causes and reduces the likelihood of looking at facts in isolation.
Some investigators may prefer to place some of the sample questions in different categories; however, the categories are not important, as long as each question is asked.
Obviously there is considerable overlap between categories; this overlap reflects the situation in real life. Again it should be emphasized that the above sample questions do not make up a complete checklist, but are examples only. The steps in the investigation are simple: the investigators gather data, analyze it, determine their findings, and make recommendations.
Although the procedures are seemingly straightforward, each step can have its pitfalls. As mentioned above, an open mind is necessary in an investigation: preconceived notions may result in some wrong paths being followed while leaving some significant facts uncovered. All possible causes should be considered. Making notes of ideas as they occur is a good practice but conclusions should not be made until all the data is gathered. Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses.
In some jurisdictions, an incident site must not be disturbed without approval from appropriate government officials such as the coroner, inspector, or police. Physical evidence is probably the most non-controversial information available.
It is also subject to rapid change or obliteration; therefore, it should be the first to be recorded. Based on your knowledge of the work process, you may want to check items such as:. You may want to take photographs before anything is moved, both of the general area and specific items. A later study of the pictures may reveal conditions or observations that were missed initially. Sketches of the scene based on measurements taken may also help in later analysis and will clarify any written reports.
Broken equipment, debris, and samples of materials involved may be removed for further analysis by appropriate experts. Even if photographs are taken, written notes about the location of these items at the scene should be prepared. Although there may be occasions when you are unable to do so, every effort should be made to interview witnesses.
In some situations witnesses may be your primary source of information because you may be called upon to investigate an incident without being able to examine the scene immediately after the event. Because witnesses may be under severe emotional stress or afraid to be completely open for fear of recrimination, interviewing witnesses is probably the hardest task facing an investigator.
Witnesses should be kept apart and interviewed as soon as possible after the incident. If witnesses have an opportunity to discuss the event among themselves, individual perceptions may be lost in the normal process of accepting a consensus view where doubt exists about the facts.
Witnesses should be interviewed alone, rather than in a group. You may decide to interview a witness at the scene where it is easier to establish the positions of each person involved and to obtain a description of the events.
On the other hand, it may be preferable to carry out interviews in a quiet office where there will be fewer distractions. The decision may depend in part on the nature of the incident and the mental state of the witnesses. The purpose of the interview is to establish an understanding with the witness and to obtain his or her own words describing the event:. How can safety and health representatives help improve safety and health? What are the benefits of investigating incidents?
What should an investigation report cover? Why should safety and health representatives be involved in investigations? An investigation can: yield information needed to identify trends and problem areas permit comparisons satisfy legal requirements identify the basic causes that contributed directly, or indirectly, to the unwanted event identify deficiencies in the production and management system that permitted the incident to occur suggest specific corrective action alternatives for the management system.
The report should: be developed using an accepted investigation technique e. ICAM or Taproot address the causation factors and sequence of events that resulted in the incident outline the risk reduction measures taken and safety system improvements to prevent a recurrence of the incident consider the hierarchy of control when developing risk reduction measures to provide a long-term solution to the problem be signed off by a safety representative and a company official, such as a line manager or safety professional.
A get-well card signed by co-workers, a fruit basket or flowers will send the message that the company really cares about its employees and will encourage the employee to return to work. If the employee initially declined medical treatment, the employer should confirm with the employee that no medical treatment related to the accident has been necessary.
Corrective action should be identified in terms of how to prevent a recurrence and improve the overall operations of the company. If an employee violated a major or minor safety rule, the employer will need to follow its company work rule violation policy and take the corrective action necessary.
Taking immediate corrective action will ensure workplace safety and help reduce or eliminate work-related injuries. If a company has a safety committee, members should review investigations of all accidents to help form recommendations for appropriate corrective action to prevent future reoccurrence.
Thorough investigations will help employers identify causes of accidents and will reveal any accident trends. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. Reuse Permissions. Page Content. Step 1: Assess the Injury When a workplace accident occurs, the first thing to do is to identify any injured employees and assess the severity of the injury. Step 2: Obtain Medical Treatment if Necessary If no medical attention or only first-aid is required, the employer may proceed to Step 3.
This could include some or all of the following forms: Medical treatment consent form. Questions to ask during the investigation might include: What was the employee doing at the time of the accident? Was the employee qualified to perform this operation?
Were company procedures being followed? Is the job or process new? Were proper tools or equipment being used? Was the proper supervision being provided? Where did the accident take place? What were witnesses doing at the time of the accident? Had corrective action been recommended in the past but not adopted?
Step 4: Observe Accident Scene and Analyze the Facts Next, employers should observe the accident scene and take photographs of the area, including objects, wet floors and equipment that may have contributed to the accident e.
Some questions that the HR professional may look to answer while observing the scene include: What prompted this investigation? Why did the incident occur? What should be done going forward to correct the problem? Step 6: Follow Up The employer should follow up with the employee after the accident investigation has concluded to see how the employee is doing.
Step 7: Corrective Action Corrective action should be identified in terms of how to prevent a recurrence and improve the overall operations of the company.
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