An incident is inevitable if there are no controls in place. An incident will not always involve personal injury. An incident may also be property damage, environmental damage or a near miss.
Near Miss - an incident which could have caused serious bodily injury or extensive damage to property, but in the particular case did not. These are recorded so that steps can be taken to prevent a recurrence where injury or damage may occur.
It is important to investigate all incidents because
Investigation allows for the identification of incident causes to establish preventative strategies
It provides a point of reference to establish trends in incident causes.
It encourages organisations to communicate incident information and learn from past incidents
It also shows that the organisation is taking appropriate actions to prevent recurrence of the incident
Incidents may become common law cases up to three years later. If not properly investigated at the time of the incident, details fade and memories become confused.
Near Miss - an incident which could have caused serious bodily injury or extensive damage to property, but in the particular case did not. These are recorded so that steps can be taken to prevent a recurrence where injury or damage may occur.
It is important to investigate all incidents because
Investigation allows for the identification of incident causes to establish preventative strategies
It provides a point of reference to establish trends in incident causes.
It encourages organisations to communicate incident information and learn from past incidents
It also shows that the organisation is taking appropriate actions to prevent recurrence of the incident
Incidents may become common law cases up to three years later. If not properly investigated at the time of the incident, details fade and memories become confused.
Who should investigate the incidents?
This will be dependent on the seriousness of the incident and the potential or actual loss, damage or injury involved. The investigation team may include
Immediate supervisor
Workplace Health and Safety Representative/Officer
Person/s involved
Head of School/Element
Health and Safety Specialist and
External consultant (if applicable to the incident)
This will be dependent on the seriousness of the incident and the potential or actual loss, damage or injury involved. The investigation team may include
Immediate supervisor
Workplace Health and Safety Representative/Officer
Person/s involved
Head of School/Element
Health and Safety Specialist and
External consultant (if applicable to the incident)
The Strategy of an investigation includes four stages
Gather information and establish facts
Isolate the essential contributory factors
Determine corrective actions
Carry out corrective actions
Gather information and establish facts
Isolate the essential contributory factors
Determine corrective actions
Carry out corrective actions
You need to ask 6 questions:
1. Who was involved?
This includes people both directly involved (injured or eye witnesses) and those that may be able to contribute useful information about facts surrounding the incident; eg supervisors who know what “usually” happens, trainers of persons involved, peers etc.
2. What happened?
This includes the equipment involved, the processes undertaken, systems, and what happened before and immediately after the incident. What “action” led to this incident? eg fall, slip, long-term exposure, hitting. What was happening, what task was involved?
3. When did the incident occur?
When was an incident noticed? When did the person involved start work that day? How much experience had they had in the task? It is important to identify here the date, time of day and other psychosocial issues that may have contributed to the event.
Psychosocial issues that may impact on when and incident occurs includes
- Has the person involved just worked extended hours?
- Did the incident occur at night/ on a night shift?
4. Where did the incident occur?
Have there been previous incidents in this particular area? What was the investigation outcome for previous incidents? Are there any physical aspects of the environment that may have contributed to the incident?
Look for both big and small differences and aspects of the environment.
5. How did the incident occur?
What was unusual about the event? How could the incident have been prevented? This may lead to the direct cause of the incident.
6. Why did the incident occur?
Was the person involved properly trained for the process undertaken? Were there safety procedures in place? Has a risk assessment been conducted for the task in question? Why were safety systems, procedures, training not followed? or Were systems followed but they failed?
The “atmosphere” at the time of the incident and psychosocial issues will impact on why an incident has occurred eg is it the last day before a holiday, is there some reason why the importance of safety precautions may be diminished?
Taking photos of the incident site and notes immediately after the incident occurs helps to formulate a good investigation.
1. Who was involved?
This includes people both directly involved (injured or eye witnesses) and those that may be able to contribute useful information about facts surrounding the incident; eg supervisors who know what “usually” happens, trainers of persons involved, peers etc.
2. What happened?
This includes the equipment involved, the processes undertaken, systems, and what happened before and immediately after the incident. What “action” led to this incident? eg fall, slip, long-term exposure, hitting. What was happening, what task was involved?
3. When did the incident occur?
When was an incident noticed? When did the person involved start work that day? How much experience had they had in the task? It is important to identify here the date, time of day and other psychosocial issues that may have contributed to the event.
Psychosocial issues that may impact on when and incident occurs includes
- Has the person involved just worked extended hours?
- Did the incident occur at night/ on a night shift?
4. Where did the incident occur?
Have there been previous incidents in this particular area? What was the investigation outcome for previous incidents? Are there any physical aspects of the environment that may have contributed to the incident?
Look for both big and small differences and aspects of the environment.
5. How did the incident occur?
What was unusual about the event? How could the incident have been prevented? This may lead to the direct cause of the incident.
6. Why did the incident occur?
Was the person involved properly trained for the process undertaken? Were there safety procedures in place? Has a risk assessment been conducted for the task in question? Why were safety systems, procedures, training not followed? or Were systems followed but they failed?
The “atmosphere” at the time of the incident and psychosocial issues will impact on why an incident has occurred eg is it the last day before a holiday, is there some reason why the importance of safety precautions may be diminished?
Taking photos of the incident site and notes immediately after the incident occurs helps to formulate a good investigation.
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