4.

2 Investigating, Recording and Reporting Incidents

Investigating, Recording and Reporting Incidents

IN THIS SECTION...
• Incidents should be investigated for several reasons, perhaps the most important of which is to discover the
causes so that corrective action can be taken to prevent similar incidents from happening again.
• Incidents can be categorised in terms of their outcome: near miss, accident (injury and/or damage), dangerous
occurrence and ill health.
• The level of investigation used should be determined by considering the foreseeable consequences of the
incident should it happen again, and not simply by looking at the actual outcome that occurred on this occasion.
• Basic incident investigation procedure is to:
–– Gather factual information about the event.
–– Analyse that information to draw conclusions about the immediate and root causes.
–– Identify suitable control measure.
–– Plan the remedial actions.
• Arrangements should be made for the internal reporting of all work-related incidents, and workers should be
encouraged to do so.
• Records of work-related injuries should be kept.
• Certain types of incident – such as fatalities, major injuries, occupational diseases and some dangerous
occurrences – have to be reported to external agencies.

Introduction to Incident Investigation

Unfortunately, in spite of an organisation’s best efforts, accidents do
happen. When they happen, it is important that the incident is reported,
recorded and investigated in an appropriate and timely manner.

There are many reasons for conducting investigations, but one of the most
important is that having happened once, an incident may happen again;
and when it happens again the outcome may be as bad as, or worse than,
it was the first time. It is therefore important to understand exactly why
the incident occurred so that corrective action can be taken to prevent a
recurrence. Often the only thing that separates a near-miss or a minor-injury
accident from a serious-injury accident is luck (or chance). The place where
one worker trips and stumbles on the steps one day, may be the place
where another worker will trip, fall and break their arm the next. It follows
that all incidents should be examined to determine the potential for serious harm, injury or loss. Where this potential
exists, a thorough investigation should be carried out to prevent that potential from becoming actual.

It is also likely that if near-miss events are rigorously reported there will be a far greater number of events to consider,
providing more data, which can help highlight the deficiencies in the safety management system.

This is not to say that all incidents should be thoroughly investigated in great depth and detail – that would be a waste
of time and effort in many cases – but that all incidents should be examined for potential so that a decision can be
made as to whether a more detailed and thorough investigation is required. This idea is sometimes formalised into an
organisation’s investigation procedures.

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TOPIC FOCUS
Reasons for investigating incidents:

• To identify the immediate and root causes – incidents are usually caused by unsafe acts and unsafe
conditions in the workplace, but these often arise from underlying, or root causes.
• To identify corrective action to prevent a recurrence – a key motivation behind incident investigations.
• To record the facts of the incident – people do not have perfect memories, and accident investigation
records document factual evidence for the future.
• For legal reasons – accident investigations are an implicit legal duty imposed on the employer, in addition
to the duty to report incidents.
• For claim management – if a claim for compensation is lodged against the employer, the insurance
company will examine the accident investigation report to help determine liability.
• For staff morale – non-investigation of accidents has a detrimental effect on morale and safety culture
because workers will assume that the organisation does not value their safety.
• To enable risk assessments to be reviewed and updated – an incident suggests a deficiency with the
risk assessment, which should be addressed.
• For disciplinary purposes – though blaming workers for incidents has a negative effect on safety culture
(see Element 3), there are occasions when an organisation has to discipline a worker because their
behaviour has fallen short of the acceptable standard.
• For data-gathering purposes – accident statistics can be used to identify trends and patterns; this relies
on the collection of good quality data.

Types of Incident
Incidents can be categorised according to their nature and outcome:

Accident

DEFINITION
ACCIDENT

An unplanned, unwanted event which leads to injury, damage or loss.

For example, a worker on the ground is struck on the head and killed by a brick dropped by another worker on a
5m-high scaffold; or, a lorry driver misjudges the turning circle of their vehicle and knocks over a barrier at the edge
of a site entrance, crushing the barrier beyond repair. Note that in both of these examples the acts are not carried out
deliberately. An accident is unplanned. Any deliberate attempt to cause injury or loss is therefore not an accident.

Accidents can be further subdivided into:

• Injury accidents – an unplanned, unwanted event which leads to personal injury of some sort.
• Damage-only accident – an unplanned, unwanted event which leads to damage to equipment or property.

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4.2 Investigating, Recording and Reporting Incidents

Near Miss

DEFINITION
NEAR MISS

An unplanned, unwanted event that had the potential to lead to injury, damage or loss, but did not, in fact,
do so.

For example, a worker drops a brick from a 5m-high scaffold and it narrowly misses another worker standing on the
ground. No injury results and the brick is not even broken. The only thing that separates accidents and near misses is
the outcome of the event. An accident causes loss, a near miss does not.

Dangerous Occurrence

DEFINITION
DANGEROUS OCCURRENCE

A specified event that has to be reported to the relevant authority by statute law.

For example, under the UK’s Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013
(RIDDOR) certain types of event have to be reported to the relevant authority, even though no injury or ill health
may have resulted. For example, the failure of the load-bearing parts of a crane is a dangerous occurrence. No person
has to be injured by the failure, the failure itself is reportable. This topic is dealt with in more detail later in this
element.

Reporting of these dangerous occurrences to the relevant authorities is usually a requirement of law in most countries
and regions around the world.

Work-Related Ill Health

DEFINITION
WORK-RELATED ILL HEALTH

Diseases or medical conditions caused by a person’s work.

For example, dermatitis is a disease of the skin often caused by work

activities, especially when the handling of solvents, detergents or irritant
substances is involved.

Work-related ill health includes diseases and conditions related to exposure

to:

• Toxic substances (e.g. lead poisoning caused by exposure to lead fumes).

• Harmful biological agents (e.g. Legionnaires’ disease caused by exposure
to Legionella bacteria).
• Physical or ergonomic hazards (e.g. noise-induced hearing loss caused by
exposure to excessive noise).
Dermatitis

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• Ergonomic hazards (e.g. upper limb disorder caused by repetitive handling).

• Psychological hazards (e.g. clinical depression caused by excessive pressure).
Ill health can result from a single incident. For example, it is possible to develop dermatitis as a result of a single
exposure to an irritant substance. However, many forms of ill health do not result from a single incident but from
ongoing or long-lasting working conditions or multiple exposures.

Level of Investigation
The amount of time, money and effort put into an incident investigation should be proportionate to the risk
associated with the incident should it happen again. This risk estimation must be made based on the foreseeable and
possible severity of harm or loss associated with the incident. It must not be based solely on the actual severity of
harm or loss associated with the incident this time.

So, for example, the effort put into investigating an accident that resulted in a worker breaking their arm should not
be determined simply by looking at the fact that the outcome was a broken arm (which is, of course, a serious injury).
The foreseeable and possible severity of harm associated with a repeat event must be taken into account. If a fatal
injury is a very likely outcome from this event (and the worker was lucky to escape with just a broken arm on this
occasion) then more time, money and effort must be dedicated to the investigation process.

Similarly, the effort put into investigating a near miss must be determined by the foreseeable possible harm or loss
if the event happens again. Not simply on the basis that the near miss did not cause any harm or loss. So a near miss
that might foreseeably result in a lost-time injury should be investigated with a proportionate level of investigation.

When determining what level of investigation to apply the risk associated with each incident can be estimated
in order to allocate appropriate resources. As we know from Element 3, risk can be estimated by considering the
likelihood of occurrence and foreseeable severity of harm or loss.

This can be used to determine whether an investigation should be:

• Minimal – immediate line manager and not excessive time or effort.

• Low – line manager perhaps with some support and more time and effort involved.
• Medium – middle manager with support and significant time and effort.
• High – senior management oversight with team based approach and significant time and effort.

MORE...
For more information on types of incident, refer to HSG245 at:

hse.gov.uk/pubns/hsg245.pdf

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4.2 Investigating, Recording and Reporting Incidents

Basic Investigation Procedures

When investigating an accident or other type of incident, there are some basic principles and procedures that can
be used:

• Step 1: Gather factual information about the event.

• Step 2: Analyse that information and draw conclusions about the immediate and root causes.
• Step 3: Identify suitable control measures.
• Step 4: Plan the remedial actions.
However, before the investigation can begin, there are two important issues that should be considered:

• Safety of the scene – is the area safe to approach? Is immediate action needed to eliminate danger even before
casualties are approached?
• Casualty care – any injured people will require first-aid treatment and may need hospitalisation. This is, of course,
a priority. It is also worth considering the welfare of uninjured bystanders who may be in shock.
Once immediate danger has been eliminated and casualties have been attended to, a decision has to be made about
the type or level of investigation as outlined above.

It may be useful for an organisation to develop a checklist to guide the investigator through the process and act as a
memory aide.

TOPIC FOCUS
Items that could be included on an accident investigation checklist:

• Personal details of the person involved.

• Time and location of the accident.
• Type and severity of the injury sustained.
• Whether the injured person had been given first aid, had returned to work or had been sent to hospital.
• Underlying medical condition of the injured person.
• Task being undertaken at the time of the accident.
• Working environment as far as weather, standard of lighting and visibility were concerned.
• Condition of the floor or ground.
• The type and condition of any personal protective equipment that was being worn.
• Details of the training and information received.
• Details of any relevant risk assessments that had been carried out.
• Any previous similar accidents that had occurred.

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Step 1: Gathering Information

• Secure the scene as soon as possible to prevent it being altered.
• Collect witnesses’ details quickly, before they start to move away. In
some cases it may help to remove witnesses from the scene and ask
them to wait in a separate area. If there are many witnesses it may
be better to separate them from each other to prevent them from
conferring with each other and developing an ‘agreed’ story.
• Collect factual information from the scene and record it. This might be
done by means of:
–– Photographs.
–– Sketches.
–– Measurements. Accident investigator taking
measurements
–– Videos.
–– Written descriptions of factors such as wind speed, temperature, etc.
–– Physical evidence such as samples, or the equipment that has failed.
–– Marking up existing site/location plans.
The investigator should come prepared with the appropriate equipment to record this information.

• Once the scene has been thoroughly examined, move on to the second source of information: witnesses.
Witnesses often provide crucial evidence about what occurred before, during and after incidents. They should be
interviewed carefully to make sure that good-quality evidence is gathered.

TOPIC FOCUS
Good witness interview technique requires that the interviewer should:

• Hold the interview in a quiet room or area free from distractions and interruptions.
• Introduce themselves and try to establish rapport with the witness using appropriate verbal and body
language.
• Explain the purpose of the interview (perhaps emphasising that the interview is not about blaming
people).
• Use open questions (such as those beginning with What, Why, Where, When, Who, How, etc.) that do
not put words into the witness’ mouth and do not allow them to answer with a ‘yes’ or ‘no’.
• Keep an open mind.
• Take notes so that the facts being discussed are not forgotten.
• Ask the witness to write and sign a statement to create a record of their testimony.
• Thank the witness for their help.

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4.2 Investigating, Recording and Reporting Incidents

• Once witnesses have been interviewed, move on to the third source of information: documentation. Various
documents may be examined during an accident investigation, such as:
–– Company policies.
–– Risk assessments.
–– Training records.
–– Safe systems of work.
–– Permits to work.
–– Maintenance records.
–– Site plans, area layout plans.
–– Previous accident reports.
–– Sickness and absence records.

Step 2: Analysing Information

The purpose here is to draw conclusions about the immediate and root causes of the incident.

Immediate causes are the obvious causes that gave rise to the event itself. These will be the things that occurred at
the time and place of the accident. For example, a worker slips on a patch of oil spilt on the floor, injuring their back
as they fall backwards and hit the ground. The immediate cause of the back injury is hitting the ground, but there are
many contributors to this cause. It is common to think of these in terms of unsafe acts and unsafe conditions. So here,
for example, we might have the slippery oil (unsafe condition), and the worker walking through it (unsafe act).

Underlying or root causes are the things that lie behind the immediate causes. Often, root causes will be failures in
the management system, such as:

• Failure to adequately supervise workers.

• Failure to provide appropriate PPE.
• Failure to provide adequate training.
• Lack of maintenance.
• Inadequate checking or inspections.
• Failure to carry out proper risk assessments.
For example, with the slip we described above, the root causes might
be a poorly maintained machine that has leaked oil onto the floor, and a
poorly inspected and maintained workshop with broken light fittings and
inadequate lighting levels. Here, the worker might be blameless on the basis
that, given those conditions, the accident was bound to happen eventually.

Many of the accidents that happen in workplaces have one immediate

cause and one underlying or root cause. If that one root cause is identified
and dealt with, then the accident should not happen again. For example, if
a worker twists their ankle in a pothole in the pavement, then the obvious
solution is to fill the pothole in. It might also be worth asking how long the
pothole had been there. If it had been there for a long time, why was it not
spotted sooner? And if it had been spotted, why had it been left unrepaired
There may be more than one cause
with no interim measure being taken to protect people?
for an accident

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These questions might identify an underlying cause, such as inadequate inspection and maintenance, or failure to put
interim measures in place while waiting for maintenance work to be carried out.

In contrast to this single-cause idea, some workplace accidents are complex and have multiple causes: there are
several immediate causes for the accident and each of these has underlying, or root causes. For example, a worker
might be struck by a load being carried by a forklift truck. Immediate causes for such an accident might be:

• Failure to secure the load on the pallet.

• Poor road positioning of the truck close to a pedestrian exit.
• Aggressive braking by the truck driver.
• An inattentive pedestrian stepping out in front of the truck.
On investigation, each of these immediate causes might have their own separate root causes, such as:

• No training for the driver, who is new to the workplace, has not worked with this type of load before and is
unaware of the load-securing technique required.
• Lack of segregation of pedestrian and traffic routes; no barriers and no markings to separate the two.
• Lack of proper driver induction into their new workplace so they are unaware of the layout and position of
pedestrian exits, etc.
• Poor maintenance of the truck.
• No refresher training for existing staff, meaning that experienced staff have become complacent.
If there are multiple causes for the accident, then it is important that each of these causes is identified during the
investigation – otherwise, incomplete remedial action will be taken and similar accidents may happen in the future.

Step 3: Identifying Suitable Control Measures

Once the immediate and underlying causes of the accident are known, appropriate control measures can be
identified. It is important that the correct control measures are established – otherwise, time, money and effort will
be wasted on inadequate and unnecessary measures that will not prevent similar occurrences in the future.

Control measures must be identified to remedy both the immediate and underlying causes. Immediate causes are
usually easy to identify – if there is a spill of oil on the floor, clean it up; if the guard is missing from the machine,
reattach it.

Underlying causes can be harder to determine because they reflect failure of the management system. However, it
is essential that the correct control measures to remedy the failure of the
management system are identified because this will help prevent similar
accidents occurring in similar circumstance across the entire organisation.
For example, if a worker slips on some oil that has leaked out of a vehicle in
the distribution depot, an employer may:

• Clean up the oil leaking out of the vehicle (the immediate cause),
but fail to deal with the underlying cause (lack of inspection and
maintenance). This could lead to more leaks, which in turn may lead to
more pedestrian slips (and perhaps vehicle skids).
• Clean up the oil leaking out of the vehicle and deal with the underlying
cause (by introducing a proper inspection and maintenance system).
In this instance, there is a good chance that most oil leaks will be Control measures mean accidents
prevented in the future for all vehicles in the fleet at all locations. are less likely to recur

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4.2 Investigating, Recording and Reporting Incidents

Perhaps the most important questions to ask when identifying control measures are:

• If this action is taken, will it prevent the same accident from happening in exactly the same way at this location?
• If this action is taken, will it prevent other similar types of accident from happening in similar locations in the
future?
If the answer to both of these questions is ‘no’, then you need to identify other control measures.

Step 4: Planning the Remedial Actions

An incident investigation should lead to corrective action being taken, in just the same way as a workplace inspection
will. Remedial actions can be presented in an action plan:

Recommended Action Priority Timescale Responsible Person

Introduce induction Medium 1 month Warehouse manager
training for all new drivers

When the action plan is being prepared, appropriate immediate and interim control measures must be given suitable
priorities and timescales.

Unsafe conditions must not be allowed to persist in the workplace. Dangerous practices and high-risk activities must
be dealt with immediately. This means that immediate action must be taken to remedy these circumstances when
they are discovered. Machinery and equipment may have to be taken out of action, certain work activities suspended,
and locations evacuated. These responses cannot be left until the investigation has been completed. They will have to
be implemented immediately to ensure safety while the investigation is in progress.

There may be interim control measures that can be introduced in the short-
to medium-term to allow work to proceed while longer-term solutions are
being worked out. For example, hearing protection might be introduced as
a short-term control measure until the maintenance of a piece of machinery
that is producing excessive noise has been completed. A perimeter guard
might be fitted around an overheating machine that would ordinarily be
protected with a fixed enclosed guard while new cooling units are sourced
and delivered.

Underlying causes will often demand significant time, money and effort to
remedy. It is essential, therefore, that the remedial actions that will have the
greatest impact are prioritised and timetabled first. There may be actions
that have to be taken (to address a management weakness, or to achieve
legal compliance) that will not be as effective in preventing future accidents. Hearing protection could be a short-
These actions should still be taken, but with a lower priority. term control measure

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TOPIC FOCUS
The contents of a typical incident investigation report may include:

• Date and time of the incident.

• Location of the incident.
• Details of the injured person/persons involved (name, role, work history).
• Details of injury sustained.
• Description of the activity being carried out at the time.
• Drawings or photographs used to convey information on the scene.
• Details of witnesses and witness statements.
• Immediate and underlying/root causes of the incident.
• Assessment of any breaches of legislation.
• Recommended corrective action, with suggested costs, responsibilities and timescales.
• Estimation of the cost implications for the organisation.

Recording and Reporting Requirements

DEFINITIONS
REPORTING

The process of informing people that an incident has occurred – this can be internally within the organisation
or externally to enforcing authorities or insurers, etc.

RECORDING

The process of documenting the event.

Work-related incidents should be reported internally by workers to

management. The system put in place by an organisation to allow for this
should be described in the Arrangements section of the organisation’s
safety policy.

It is standard practice for workers to verbally report incidents to their

immediate line manager, followed by completion of an internal incident
report form. There are occasions when this simple verbal reporting
procedure is not appropriate, and a more complex reporting procedure
then has to be introduced. For example, a lone-working contractor visiting a
client’s premises may have to report their accident to the client as well as to
their immediate line manager.

Internal reporting to line manager

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4.2 Investigating, Recording and Reporting Incidents

Internal Incident Reporting Systems

When establishing an incident-reporting policy, the organisation should be clear about the type of incident that has to
be reported by workers. It is usual to include a list of definitions in the policy so that workers understand the phrases
used. For example, if the organisation wants workers to report near-misses, it must specify this in the policy and be
clear about what the phrase ‘near-miss’ actually means.

Having established an incident-reporting policy, the organisation must encourage workers to report all relevant
incidents. Unfortunately, there are many reasons why workers do not report incidents.

TOPIC FOCUS
Barriers to reporting – reasons why workers might not report incidents:

• Unclear organisational policy on reporting incidents.

• No reporting system in place.
• Culture of not reporting incidents (perhaps due to peer group pressure).
• Overly complicated reporting procedures.
• Excessive paperwork.
• Takes too much time.
• Blame culture (where a worker feels that they may be treated detrimentally or disciplined for reporting
any accident or near miss that they were associated with).
• Belief that management does not take reports seriously.
• Concern over the impact on the company or departmental safety statistics (especially if this is linked to an
incentive scheme).
• Reluctance to receive first-aid treatment.
• Apathy.

The organisation should try to remove each of these barriers to ensure that every relevant incident is reported in a
timely manner. Most of these barriers can be dealt with by having a well-prepared, clearly-stated policy, adopting user-
friendly procedures and paperwork, and training staff in the procedures. An organisation can take disciplinary action
against workers who fail to report incidents if they have been given the training and means to do so.

If fatal or major injuries, high-cost events, high-profile incidents or environmental events occur, it will be necessary to
notify certain internal personnel immediately. Senior management, human resources, safety and/or environmental
management and worker representatives may all have to be notified. Action by these staff may then be required to
inform external parties as necessary (e.g. the family of the casualty, external authorities, insurance companies, public
relations advisers). These internal and external contact procedures, or escalation procedures, should be documented
in the incident reporting section of the safety policy.

Incident Recording
When a work-related incident is reported, a record is usually created of that event (in some instances the report is
filed in written form, so reporting and recording are one and the same thing).

As a minimum, organisations should keep a record of all work-related accidents that result in personal injury. This is
usually dictated by regional statute law and there is often a standard accident record form or book that should be
used. This record must then be kept by the organisation; the length of time that it has to be retained is usually also
subject to statute law.

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Typical contents of an internal accident record:

• Name and address of casualty.

• Location of accident.
• Details of treatment given.
• Details of any equipment or substances involved.
• Details of person completing the record.
• Date and time of accident.
• Details of injury.
• Description of event causing injury.
• Witnesses’ names and contact details.
• Signatures.

Separate forms can also take account of near misses and reports of ill health. These do not need to include standard
accident book data as there is no explicit legal requirement to keep a record of most near misses.

Organisations often have separate forms for the recording of accidents (as above) and the recording of accident
investigations. This is an important distinction to make; the accident record is the initial record of the basic facts
of the injury; the accident investigation report is the detailed examination of what caused that injury and why it
happened (immediate, underlying and root causes) as well as the corrective actions required to prevent recurrence.
These do not have to be recorded in the same document.

Reporting of Events to External Agencies

Most countries have statute law that requires certain types of event to be reported to relevant government appointed
agencies. All countries agree that fatal accidents must be reported, however the level of detail of other types of
event that need to be reported differs between countries.

Typical reportable events include:

• Accidents resulting in major injury (e.g. an amputation, such as loss of a

hand through contact with machine parts).
• Dangerous occurrences (e.g. the failure of an item of lifting
equipment, such as the structural failure of a passenger lift during use).
• Occupational diseases (e.g. mesothelioma, a form of cancer of the
lining of the lung, as might be contracted by someone exposed to
asbestos).
Other types of event often fall into this reporting regime, such as lost-time
injuries, where workers are unable to perform their normal duties for a
certain time period. Local statute law usually specifies how these reports are
Lung cancer can be caused by
made and the timescales for reporting.
working with asbestos

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