Module six:

Investigating incidents

Key learning points

1. Why investigate incidents?
2. How do incidents happen?
3. How do you carry out an incident investigation?

Notes:

Why investigate incidents?

For most of this course, we’ve been raising your awareness of the things you need to
do to manage safety and health and to minimise the chances of things going wrong (by
introducing risk controls, for example). But while you can minimise the chances of injury

So we need to know what to do on occasions when things do go wrong and how to learn
from them.

That’s why we need to discuss incident investigation.

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Incident – an incident is an undesired event
that has caused or could have caused
damage, death, injury or ill health.

An incident can be categorised as a ‘near

miss’ or ‘accident’.

Near miss – a near miss can be described as an

incident that results in no injury or damage, but
which has the potential to do so.

Accident – an accident is an incident which results

in injury to someone or damage to property.

There are a number of reasons to investigate incidents, including:

• to collect the information you need to pass on to the enforcing authority

• to identify the cause of the incident to stop it happening again

• to get information needed for an insurance claim

• to identify any other hazards/risks and training requirements

• to ensure legal compliance.

happened so that you can stop it happening again. It’s also important to do this with an
open mind. An investigation provides a snapshot of how work is really done – it may

controls and opportunities for improvement.

Notes:

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 Notes:

While there are good reasons to investigate incidents, investigating them will also bring

• making a safer work environment

• improving worker morale
• preventing further business losses from disruption and down-time
• developing useful skills and knowledge that can be applied throughout the
organisation

Remember:

Incidents that don’t result in any loss, such as an injury or damage to

equipment, also need to be reported and investigated. This is because these
incidents could cause injury or loss next time they happen.

As an example, a painter working on a platform might drop a tool, which

simply falls to the ground, causing nothing more than the inconvenience of
having to go and get it later. On the other hand, the tool might hit another
worker or a member of the public, causing a serious head injury.

Did you know…?

In many cases, investigations into major incidents reveal that a similar event
had occurred in the past without resulting in serious consequences

a larger sample of near misses that you can use to identify trends or
repetitions.

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How do incidents happen?

an incident. However, incidents are rarely caused by a single factor – there are usually
several contributory factors. Also, these factors will include obvious and immediate
causes and less obvious underlying causes.

• Immediate causes – unsafe actions or lack of action (for example, operating

equipment with missing guards and bypassing interlocks, using the wrong personal
protective equipment) and unsafe conditions (for example, damaged tools and
equipment, or high noise and low lighting levels)

• Underlying causes – factors that allow the unsafe actions and conditions to happen.
The majority of these are related to the way the organisation manages safety and
health and how people perceive risk.

Among the many contributory factors to an incident, there’ll be root causes. A root
cause is a factor that may cause conditions that could result in an undesirable event. If
the problem were corrected, it would prevent the undesirable event from happening. In
other words, a root cause is an event from which all other causes spring.

incident to have just a single root cause.

For example:

You’re the manager of a distribution depot. It’s Friday afternoon,

close to the end of the working day.

One of your warehouse operatives has had enough for the day
and decides to pack up early. Meanwhile, in the warehouse

work, is driving his truck loaded with boxes of paint. The forklift
truck turns a corner and heads at speed along the aisle towards
the loading bay.

At that very moment, the warehouse operative comes out of an unauthorised access

park.

The forklift truck driver sees the man at the last minute
and brakes hard, but skids on a patch of oil left by a
leaking forklift. He comes to an abrupt stop and the load
falls onto the warehouse operative, breaking his arm and
bruising his leg.

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In this example the immediate causes are:

• struck by the load

• load falling
• forklift skidding
• patch of oil
• braking hard
• using the unauthorised aisle
• speed.

The underlying causes are:

• forklift leaking
• rushing to get the job done
• speed limiter removed
• lack of maintenance or inspection
• taking a short cut
• leaving work early.

The root causes are:

• lack of supervision
• work pressures
• poor custom and practice.

other facts.

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How do you carry out an incident investigation?

You’ll need to have a system in place and to develop this you’ll need to think about the
following factors:

Make sure the injured person is looked after

When someone’s injured in an accident, it’s essential that they get the treatment they
need as soon as possible. First aid is the initial management of the injury until expert
medical attention is available. First aid aims to preserve life, prevent deterioration and
promote recovery. You’ll need to provide enough equipment, facilities and personnel

become ill at work.

Preserving the scene of an incident

An effective investigation depends on getting all

possible evidence together, so it’s essential to secure
the incident scene as soon as possible after the
accident. Other areas separate from the main scene
but relevant to the investigation may also need to be
secured.

Notes:

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Reporting the incident

As soon as possible after the incident, you should tell the

injured person’s line manager, who should then start the

reporting forms and the accident book (which is a statutory

requirement in some countries such as the UK).

To record this information, you can use the incident report form
like the one in the appendix on pages 150 - 153.

Find out what forms are used in your organisation.

In most organisations, the reporting process depends on the severity of the injury
or potential severity of the incident. For example, in organisations, fatal and major
accidents will be reported to senior management immediately.

If the incident needs to be reported to the enforcing authority, someone needs to contact

Depending on legal requirements and other requirements in your country, you may need
to report incidents such as:
• worker or non-worker deaths
• some types of worker injury
• dangerous occurrences
• occupational diseases

As well as reporting to the enforcing authority, remember that you may need to tell
several other people, such as:

• the family of the injured person

• the owner of any property that was damaged
• the organisation’s insurance company
• the organisation’s safety and health and human resources departments
• safety or worker representatives.

Did you know…?

According to the ILO, every 15 seconds, 153 workers have a

work-related accident.

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Who carries out the investigation?

A team carrying out an incident investigation will need a range of knowledge, skills and
experience. The team should be led by someone with enough authority and knowledge
to make authoritative recommendations. An ideal team may include:

• someone familiar with the work location

• a supervisor or manager from the work location

• a safety and health expert

• a worker representative
• a person involved in the incident (if possible)
• a technical expert, for example, an engineer or
medical practitioner, if necessary

It’s your responsibility to make sure that the investigator is competent in a range of
analytical, interpersonal, technical and administrative skills.

these roles. For example, a senior manager or line manager with safety and health
responsibilities would take part in the investigation as it’s unlikely the organisation will
have a safety and health specialist. Senior managers are more likely to be part of the
team for more serious accidents.

Notes:

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Investigation process

You’ll need to decide how you’ll carry out the investigation. You’ll also need to decide
what level of investigation is needed – all incidents need to be reported, but not all
need the same level of investigation. Clearly, the more serious ones need deeper
investigation. But also think about the likelihood of the undesired event occurring again
and its worst potential consequences. For example, a tool falling off the scaffold may not
have caused any injuries, but it has the potential to cause a major injury.

Minimal investigation – a supervisor looks at the circumstances of the undesired event

and tries to identify how to prevent other similar events.

Low-level investigation – a supervisor or line manager does a short investigation into the
circumstances and looks at the immediate, underlying and root causes of the undesired
event to try to prevent it happening again.

Medium-level investigation – a more detailed investigation, involving a safety and health

practitioner and worker representatives.

High-level investigation – the highest level of investigation, using a team-based

approach that may include line managers, supervisors, safety and health practitioners
and worker representatives; and led by a senior manager.

Did you know…?

An explosion on the North Sea oil production platform, Piper Alpha,

in 1988, killed 167 people and cost more than £2 billion (www.hse.gov.uk).

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Structured approach to investigation

A good investigation has a structured approach.

Information gathering:
and when the incident happened and who was
involved, how it happened and what happened. This
will involve gathering evidence (such as broken parts
and debris), taking photos and witness statements,
and looking at documented information (which
includes electronically processed information) such
as risk assessments. You need good interpersonal
skills to interview witnesses.

Analysis: At this stage you need to look at all the

information you’ve gathered to identify what happened
and why. There are several ways to do this, but it’s
essential to do the analysis carefully and systematically.

were part of the cause, you’ll need to discover whether

someone forgot, didn’t know or deliberately ignored
a rule. This will help when considering how to avoid it
happening again.

Reviewing risk control measures: At this stage you’ll be

able to identify where changes need to be made to risk
control measures to prevent the incident happening
again. You’ll need to evaluate the possible options
carefully. Consider also whether you need to make
similar changes elsewhere in the organisation.

Action planning: This is about deciding what changes

are going to be made, by when and by whom. It’s
essential that someone in authority is responsible for
delivering the action plan.

Sharing and communicating: Announcing the

suggested improvements following the investigation
can show the workforce that the organisation cares
and can improve the workers’ engagement.

To record this information, you can use an

investigation form like the one in the appendix on
pages 150 - 153.

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External relations

You’ll need to have plans in place for dealing with external bodies – for example, the
enforcement authorities, media and local residents and businesses. It’s essential that
only designated people release information to these parties and that this happens when
it’s clear what’s happened and what’s going to happen.

Enforcement authorities have the right to enter

all workplaces under their jurisdiction in order to
carry out their duties outlined in local safety and
health law so it’s an offence to refuse entry to
an enforcement inspector. Inspectors can gather
copies of documents, take samples and photos
and ask questions.

Always treat inspectors with the respect that

their position deserves

If it is found that an offence has been committed, they’ll issue a caution to a designated
representative of the organisation.

In larger organisations there are more likely to be procedures for dealing with
enforcement visits. When organisations don’t have procedures, it’s a good idea to have
a nominated individual to act as the main contact for such visits.

Find out what procedures are in place in your organisation.

Notes:

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Getting it right
•

• While we think it may never happen to us and our organisation, having plans and
procedures in place for investigating incidents before they occur will help to make the
investigation process as effective as possible if the worst happens.

as possible. Different people in the organisation will need different levels and types
of information. For example, workers using similar processes to those involved in the
incident will need detailed information on how to avoid the conditions that led to the
accident, but a senior manager will need only summary information.

Notes:

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Case study
Exciting Technologies Ltd were busy negotiating a lucrative contract with the large
multi-national company World Widgets Ltd. The contract would make them a very

which were in desperate need of refurbishment.

A few weeks before this, a member of staff tripped on a section of worn out carpet
on the main staircase. Fortunately, the worker was holding the handrail which
was a company rule when using any staircase in the building, so they didn’t injure

Mr Steel was under a considerable amount of pressure to secure the contract with
World Widgets Ltd and as no harm had come to anyone in the incident, he took no
further action. After all, replacement carpets would be part of the refurbishment and
then the problem would disappear.

Delphine had only worked for Mr Steel for a month and he hadn’t yet had the
chance to give her the company induction training that should have occurred

tell her that the rules included holding staircase handrails and not using personal

extra hours to help pay for her wedding later in the year which she was arranging
herself, and her supervisor often saw her calling wedding suppliers during the day.
The supervisor didn’t see this as a problem after all most staff used their phones at
work, including himself.

At 6:15pm on April 1st Delphine needed to call her wedding planner to resolve
a problem. Mr Steel asked her to take some overdue paperwork downstairs to

to go down the main staircase holding the paperwork in one hand, using her other
hand to hold her phone whilst making the call. She didn’t notice when the heel of

of stairs. Delphine was taken to hospital and was found to have broken her ankle
and dislocated her foot.

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Notes:

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Summary

1. You need to investigate incidents because…

2. Incidents happen because…

3. You can carry out an incident investigation by...

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