PURPOSE OF THIS GUIDE

ACCIDENT/INCIDENT
INVESTIGATIONS

Sources of Information
Workplace Health, Safety and
Compensation Commission
Prevention Services
Phone: (709) 778-1552
Toll free 1 800 563-9000
or
Department of Government Services
Occupational Health and Safety Branch
Phone: (709) 729-2706
Toll free 1-800-563-5471
or
Human Resources and Social
Development
Labour Program, Newfoundland and
Labrador office
Phone: (709) 772-5022
(call collect outside St. Johns)

www.safeworknl.com
May 2006

ACCIDENT/INCIDENT INVESTIGATIONS

The
Workplace
Health, Safety and
Compensation
Commission is developing
resource materials to help
workplace parties employers,
workers including supervisors and
managers, and occupational health
and safety committees to carry out
their responsibilities for health and
safety in the workplace. This specific
booklet, Accident/Incident Investigations, is
designed to provide workplace parties
with an understanding of their role in
effective accident/incident investigations.
It includes an outline for planning and
the six steps involved in conducting
accident/incident investigations. A
sample accident/incident report
form and a sample
accident/incident
investigation form are also
included in this booklet.

Disclaimer
The Workplace Health, Safety and Compensation Commission (the Commission) provides
information and health and safety advisory services for most aspects of occupational
health and safety programming.
The information presented is subject to a disclaimer. It is intended to provide examples of
general use and may not apply to every circumstance. While all reasonable efforts have
been made to ensure the accuracy of the information presented, the Commission does not
and cannot guarantee the accuracy thereof. The Commission does not warrant or assume
any legal liability or responsibility for the accuracy, completeness, or usefulness of the
information presented nor for any actions taken in reliance thereon. The Commission
shall not be liable for any damage or loss arising out of the use of the information or the
application of the concepts contained therein. All those using the information do so at
their own risk and shall be deemed to indemnify the Commission from any loss or
damage arising from the use of the information.
The information presented is subject to jurisdictional variation and is always subject to
change. Individuals or organizations responsible for working with the information
presented are responsible for ensuring that all applicable standards and regulations are
fulfilled. The information presented cannot and should not be considered a definitive
guide to government regulations nor does it relieve individuals or organizations using the
information from their responsibilities under any or all applicable legislation.

May, 2006
Legislative Requirements
The legislation is a minimum guide for developing occupational health and safety (OH&S) policies and procedures in
workplaces. However, best practices should be incorporated into all areas of businesses/organizations to increase
the effectiveness of the OH&S program.
The majority of employers in Newfoundland and Labrador must follow provincial legislation for occupational health
and safety:
Occupational Health and Safety Act
Occupational Health and Safety Regulations
For official copies of the Occupational Health and Safety Act and the Occupational Health and Safety Regulations please
contact the following:
Office of the Queen's Printer
Ground Floor
Confederation Building, East Block
St. John's, Newfoundland and Labrador
A1B 4J6
Telephone: (709) 729-3649
Unofficial copies are available on-line at: http://www.gs.gov.nl.ca/ohs/legislation.stm
Some employers fall under federal jurisdiction and must follow the Canada Labour Code-Part II (Code). The Code
applies to the following inter-provincial and international industries:
railways;
highway transport;
telephone and telegraph systems;
pipelines;
canals;
ferries, tunnels and bridges;
shipping and shipping services;
radio and television broadcasting and cable systems;
airports;
banks;
grain elevators licensed by the Canadian Grain Commission, and certain feed mills and feed warehouses,
flour mills, and grain seed cleaning plants;
the federal public service and persons employed by the public service and about 40 Crown corporations and
agencies;
employment in the operation of ships, trains and aircraft; and
the exploration and development of petroleum on lands subject to federal jurisdiction.

Note: Part II of the Canada Labour Code, Part II does not apply to certain undertakings regulated by the Nuclear Safety
and Control Act.
For an official copy of the Canada Labour Code please contact:
Canadian Government Publishing, Communication Canada
Ottawa, ON K1A 0S9
Telephone: (613) 941-5995 or 1-800-635-7943
FAX: (613) 654-5779 or 1-800-565-7757
Internet: http://publications.gc.ca
Unofficial copies are available on-line at: http://laws.justice.gc.ca/en/l-2/17632.html

Introduction ..........................................................1

More Information .................................................2

Inside this Guide

Accident/Incident Investigations ......................3

Requirements .....................................................3
Definitions ..........................................................4
An Accident .................................................4
An Incident ..................................................4
An Accident/Incident Investigation...............4

Step 3 - Analyze the information to

determine the root cause .............................14
Contributing Factors ...................................14
Immediate/Direct Cause(s) .........................15
Root/Basic Cause(s) ....................................16

Reporting and Investigating

Accidents/Incidents............................................4

Step 4 - Make recommendations ...................17

Benefits of an Effective Accident

/Incident Investigation ........................................5
Procedures.........................................................5
Roles in Accident/Incident Investigation .............6
Employers ....................................................6
Investigation Team........................................7
Workers Including Managers and
Supervisors ..................................................7
OH&S committees.......................................7

Planning Accident/Incident
Investigations .......................................................8
Needs of the Investigation Team ........................8

Step 5 - Write the accident/incident

investigation report ........................................18
Step 6 - Follow-up ..........................................19

Role of OH&S Committees ...............................20

Accident/Incident Investigations and

the OH&S Program ............................................21

Conclusion ...........................................................22

Appendix A - Glossary .....................................24

Materials Needed for the Investigation ..............9

The Investigation Kit ...........................................9

Steps in Accident/Incident
Investigations .......................................................9
Step 1 - Immediate response to the
accident/incident ............................................10
Step 2 - Gather information ...........................11
Taking Notes ..............................................11
Conducting Interviews ...............................11
Interviewing Tips ........................................11
Sample Interview Questions.......................12
Tips for Taking Pictures for Evidence ..........12
Suggestions for Collecting Samples ...........12
Reviewing Documentation..........................13

Appendix B - References to Legislation ........28

Appendix C - Hazardous Occurrence

Investigation Report........................................35

Appendix D - Sample Accident/Incident

Report Form .......................................................36

Appendix E - Sample Accident/Incident

Investigation Form ...........................................37

Accident/Incident Investigations

Introduction
As part of the internal responsibility system, all workplace parties employers,
workers, including managers and supervisors, and occupational health and
safety (OH&S) committees have a shared responsibility for the OH&S program
to the extent of each partys authority and ability to be involved. This means
everyone works co-operatively, shows ownership for the program and is
committed to preventing injury, illness and property damage in the workplace.
Under provincial legislation, where 10 or more workers are employed in a
workplace, the employer is required to establish and maintain an OH&S
program in consultation with the OH&S committee. In workplaces where less
than 10 workers are employed, the employer is required to ensure a worker
health and safety (WH&S) representative is in place to monitor the health,
safety and welfare of workers. And, in workplaces with less than six workers
employed and where it is impractical to assign a WH&S representative, the
employer may designate a workplace health and safety designate to monitor
the health, safety and welfare of workers.
For federally regulated workplaces, employers are responsible for developing,
implementing and monitoring a prescribed program for the prevention of
hazards in the workplace in consultation with the health and safety committee,
policy committee or the health and safety representative.
For the purpose of this booklet, the duties and responsibilities of the OH&S
committee will also include those of WH&S representatives and workplace
health and safety designates in provincially regulated workplaces and health
and safety representatives in federally regulated workplaces.
This booklet is designed to assist those responsible to carry out effective
accident/incident investigations in the workplace. It provides basic information
about accident/incident investigations including the role of workplace parties,
planning the investigation, and the steps involved in conducting the
investigation.
Best practice is a standard that exceeds minimum legislative requirements and
supports working in the safest possible way. Carrying out investigations on all
accidents and incidents, finding root causes, and implementing corrective
actions demonstrate best practices.
For commonly used OH&S terms, please refer to Appendix A Glossary.

Accident/Incident Investigations

More Information
For more information on building a health and safety program, there are
several booklets and information resources available in this series.

Fact Sheets:
Introduction to an OH&S Program
Leadership and Administration
OH&S Committees
Education & Training
Safe Work Practices and Procedures
Hazard Recognition Evaluation and Control
Workplace Inspections
Accident and Incident Investigation
Disability Management
Ergonomics and the OH&S Elements
Worker Health and Safety Representative/Workplace Health and
Safety Designate

Look for these fact sheets in the near future:

Communication
Emergency Preparedness

Booklets:
Guide to Writing an Occupational Health & Safety Policy
Occupational Health & Safety Committees
Introduction to an Occupational Health and Safety Program
Workplace Inspections
Accident/Incident Investigations

Look for these booklets in the near future:

Communication
Emergency Preparedness

Accident/Incident Investigations

Accident/Incident Investigations
Accident/incident investigations are an important part of the OH&S program.
They include a process of fact finding to identify the root (basic) cause of
accidents/incidents as a means of preventing further occurrences. Ergonomic
considerations should always be part of accident/incident investigations.
Including investigations in the OH&S program strengthens the internal
responsibility system and is essential to building a positive health and safety
culture in the workplace.

Requirements
Specific OH&S requirements for employers who are provincially regulated can
be found in the Occupational Health and Safety Act and Regulations. Requirements
for federally regulated employers can be found in the Canada Labour Code, Part II
and the Canada Occupational Health and Safety Regulations. Contact
information for obtaining provincial and federal OH&S legislation can be found
at the beginning of this booklet and in Appendix B References to
Legislation.
The legislative references in Appendix B refer to the content in this booklet
and may not be complete. Workplace parties must refer to the appropriate
legislation to find complete information regarding legislative requirements
for developing an OH&S program.
Employers must also comply with industry-specific or hazard-specific
legislation. Examples include: Asbestos Abatement Regulations; Asbestos
Exposure Code Regulations; OH&S First Aid Regulations; Workplace Hazardous
Materials Information System (WHMIS) Regulations; Radiation Health and Safety
Act and Regulations; Mines Safety of Workers Regulations; and Workplace Health,
Safety and Compensation Act and Regulations. Employers should be aware of
legislation that relates to their industry and specific hazards in their workplaces.
Appendix B References to Legislation contains details of the following
legislation.
OH&S Act

OH&S
Regulations

Canada Labour
Code Part II

Sections
4
41 (1)
42.1 (1)
54

Sections
4(1) (f) (iv)
4 (1) (j)

Sections
134.1 (1) and (4)
(d)
135 (1) and (7)
(e)
136 (1)
136 (2)

Canada
OH&S Safety
Regulations
Sections
15.3, 15.4,
15.5, 15.6,
15.7, 15.8,
15.9

Workplace Health,
Safety and
Compensation
Act
Sections
56

Accident/Incident Investigations

Definitions
An Accident
An accident is an unplanned/undesired event that results in a personal
injury or illness, or in damage to property, process or the environment.
An Incident
An incident is an unplanned/undesired event that has the potential to
result in an injury, illness, or property damage.
An Accident/Incident Investigation
An accident/incident investigation is a well planned analysis of an event
that identifies the root cause and recommends corrective action to
prevent the event from happening again. Despite what many people
think, workplace accidents/incidents dont just happen; they result from a
series of events that usually stem from an ineffective OH&S program.
The aim of an OH&S program is to prevent accidents and incidents;
however, as part of the internal responsibility system, when
accidents/incidents do happen, there should be a process in place to find
the root cause of these events.

Reporting and Investigating Accidents/Incidents

Employers must immediately report accidents resulting in serious injury or
death or the potential for serious injury or death to the assistant deputy
minister and the OH&S committee (OH&S Act, section 54). Employers must
also report an injury to a worker for which the worker is disabled from
earning full wages or the worker is entitled to medical aid (Workplace Health,
Safety and Compensation Act, section 56).
Federally regulated workplaces have reporting and investigation
requirements in cases of work-related injuries or illnesses. Please refer to
Appendix B References to Legislation under the heading Canada
Occupational Health and Safety Regulations for these requirements.
Appendix C Hazardous Occurrence Investigation Report contains a copy
of the form employers are required to complete. A copy of this form may be
found on the Human Resources and Social Development web site:
+
+
+
+

Go to www.sdc.gc.ca
Click Forms
Click List of Forms
Under the heading Occupational Health and Safety, find number
LAB1070 Hazardous Occurrence Investigation Report.

When developing accident/incident investigation procedures for workplaces,

best practices would include an internal process for reporting and
investigating all accidents and incidents. Incidents are warnings that

Accident/Incident Investigations

something is wrong in the workplace. If incidents are investigated

and the root cause found, accidents can be prevented. Please refer to
Appendix D Sample Accident/Incident Report Form.

Benefits of an Effective Accident/Incident Investigation

employers demonstrate their commitment to health and safety
to their workers and the public;
workers on the investigation team are trained in investigation
techniques;
workers are trained in the importance of reporting
accidents/incidents;
accidents/incidents are promptly reported;
accidents/incidents are immediately investigated;
root causes are identified;
corrective actions are implemented, monitored and evaluated;
workers are trained in how to prevent similar
accidents/incidents;
pain and suffering are reduced;
findings can be used to identify accident/incident trends; and
associated costs of accidents and property damage are
reduced.

Procedures
Accident/incident investigations are a mandatory part of an OH&S
program and should have procedures to ensure their effectiveness.
Accident/Incident investigation procedures are the step by step way
for completing an accident/incident investigation. All workplaces are
different; therefore, the procedures should be developed with the
specific workplace in mind. For example, in some workplaces, the
procedures may outline the duties of groups of workers in a specific
department while another workplace may outline the duties of
groups based on their job titles. Duties and responsibilities depend on
what works best for the individual workplace.
Accident/incident investigation procedures should include a process
for planning and the six steps for conducting the investigation. They
also identify those responsible for each step in the procedure and
those responsible for communicating the results of the investigation.
Ergonomic considerations should be included in accident/incident
investigations procedures.

Accident/Incident Investigations

Roles in Accident/Incident Investigation

In keeping with the internal responsibility system and with best practice,
workplace parties have a role in accident/incident investigations. To meet
their legislative requirements for establishing and maintaining an OH&S
program and conducting accident/incident investigations, employers should
ensure accident/incident investigation procedures outline the responsibilities
of all workplace parties. Following are examples of roles and responsibilities
based on legislative requirements and best practice.
Employers
must immediately report accidents resulting in serious injury or death
or the potential for serious injury or death to the assistant deputy
minister and the OH&S committee;
must report an injury to a worker for which the worker is disabled
from earning full wages or the worker is entitled to medical aid;
provide the resources human and financial to carry out
accident/incident investigations;
ensure accident/incident investigation procedures are developed and
followed;
ensure all workers are provided with the education and training
needed to understand their responsibility to report
accidents/incidents and to cooperate with those conducting
investigations;
review accident/incident investigation reports;
ensure corrective action is implemented, monitored, evaluated and
communicated; and
review accident/incident investigation procedures at least every three
years.
Investigation Team
Managers and supervisors are often the ones that carry out
accident/incident investigations. However, it is a good practice, when
possible, to include other workers and members of the OH&S
committee on investigation teams. This practice would promote the
internal responsibility system in the workplace. Those conducting the
investigation are to:
conduct the investigation as soon as possible after the
accident/incident;
follow accident/incident investigation procedures;
put emphasis on finding the root cause not on finding fault or placing
blame;

Accident/Incident Investigations

consider multiple causes to find all factors contributing to the event;

do not jump to the obvious answer keep looking; and
ensure the results of the investigation are communicated to workplace
parties.
Workers Including Managers and Supervisors
report accidents/incidents to their supervisors immediately;
co-operate with the accident/incident investigation team;
participate as members of the investigation team when requested;
make suggestions for corrective actions to the investigation team; and
take part in training required as the result of the investigation.
OH&S committees
are a resource to the accident/incident investigation team;
may participate as members of the investigation team;
review all accident/incident investigation reports to identify trends in
injury, illness and property damage;
monitor implementation, follow-up, and evaluation of corrective actions;
review training required as the result of the accident/incident
investigation; and
regularly evaluate this element of the OH&S program.

Planning Accident/Incident
Investigations
Accident/incident investigation procedures should identify the members of the
investigation team, their training requirements, and their responsibilities. It is
beneficial to have a core team of trained individuals to carry out an
investigation. Depending on the accident/incident and the potential for it
recurring, the team may differ in size. Having more than one person
investigating means there is less of a chance to overlook something.

Needs of the Investigation Team

The accident/incident investigation team should
be trained in investigation techniques including
+ gathering information
+ interviewing skills

Accident/Incident Investigations

+
+
+
+
+
+

collecting samples
analysing information
contributing factors of accidents/incidents
identifying immediate/direct causes
identifying root/basic causes
writing recommendations

+ writing reports;

know what is expected of them in the investigation process;

keep an open mind about the cause;
never jump to a conclusion before all the information has been
analyzed;
be impartial;
understand that there is rarely only one cause of an accident/incident;
be familiar with
+ work processes,
+ the people that work in the workplace, and
+ practices and procedures;
have knowledge of OH&S legislation, standards, codes of practice,
manufacturers specification, etc.;
know the layout of the workplace;
be objective and honest; and
possess interviewing, analytical, organizational and report-writing
skills.

Materials Needed for the Investigation

The accident/incident investigation procedure should include a list of the
materials needed for an investigation plus the materials in the investigation
kit.
The accident/incident investigation procedure should identify
required materials, equipment, and personal protective equipment
(PPE);
names and phone numbers of personnel such as the investigation
team, first aid responders, members of the OH&S committee,
management personnel, maintenance staff, security staff, etc.; and
items to be included in an investigation kit.

Accident/Incident Investigations

STEPS

in

Accident/incident
investigation procedures
should outline a step-bystep process for carrying
out each of the six steps in
the investigation:

Step 1
Immediate response to the
accident/incident

Step 2
Gather information

Step 3
Analyze the information to
determine the root cause

Step 4
Make recommendations

Step 5
Write the accident/incident
investigation report

Step 6
Follow-up

Accident/Incident
Investigations
The Investigation Kit
Items usually found in an
accident/Incident investigation kit
+ accident/incident investigation
forms
+ 'Do Not Enter' tape
+ clip board
+ tape measure and ruler
+ camera, batteries, film (or video
camera)
+ flashlight and batteries
+ plastic bags and containers for
samples
+ labels and permanent marker for
labelling samples
+ pens/pencils
+ eraser
+ notebook and graph paper
CAUTION:
Some workplaces may not permit
the use of devices such as cameras,
flashlights, etc. because,
depending on the workplace and
the accident, they may pose a
hazard to the investigation team.
Therefore, the above items should
be evaluated to ensure they do not
create additional hazards.

Accident/Incident Investigations

STEP1
Immediate response
to the accident/incident
CAUTION: The investigation team members must ensure that:
the equipment they bring to the accident site does not endanger
themselves or others; and
they take particular care and follow safe work procedures so as
not to be exposed to workplace hazards such as confined space,
invisible gases, electrocution, engulfment, etc. as the result of
helping injured workers or conducting the investigation.
The steps to be taken immediately in case of an accident/incident are:
eliminate immediate hazards to ensure no one else is injured;
provide emergency care to the injured;
secure the accident site:
+ use ropes, barrier tape and/or cones or human guards if required,
+ remove nothing from the site without permission, and
+ maintain site until all information is collected;
notify proper authorities governmental agencies, Workplace Health,
Safety and Compensation Commission (the Commission), etc.
Note: When an injury occurs in the workplace and a worker requires medical
care, the employer is required to notify the Commission in writing within
three days.1
The amount of information gathered and the resources needed depend on the
specific accident/incident.

If a worker is injured and requires medical care, the worker must complete a Form 6 Worker's Report of
Injury, and the employer must complete a Form 7 Employer's Report of Injury. These forms are available
at: http://www.whscc.nf.ca/form.htm.

10

Accident/Incident Investigations

STEP2
Gather information
Taking Notes

Notes should include:

Keeping notes in a notebook

throughout an investigation
process keeps information
together and organized. Notes
should be neat and detailed,
yet concise; and they should
answer who, what, when,
where, why and how. Good
notes help to recall facts and
are useful when analyzing
information to determine the
root cause.

dates and times;

names and addresses;
information from interviews;
observations;
action taken by you and others;
description of site and environmental
conditions;
reference to pictures, if taken;
measurements;
sketches and diagrams; and

information about evidence gathered.

+
+
+
+
+
+
+
+

Conducting Interviews
Interview promptly and separately
injured workers;
witnesses to the event;
immediate supervisor;
staff from departments such as maintenance, purchasing or supplies (if
necessary); and
anyone else who can provide information; for example, a representative
of the manufacturer or a company trainer.

Interviewing Tips
maintain privacy and put the person at ease;
explain why the interview is being conducted;
emphasize the investigation is for fact finding, not fault finding;
ask people to explain what happened in their own words;
let people tell what happened dont lead the witness;
try not to interrupt;
ask specific questions to clarify and fill in the gaps;
repeat what is reported to verify your understanding;

11

Accident/Incident Investigations

thank people for their co-operation; and

write-up a complete account as soon as possible after the interview to
ensure the details are accurate.

Sample Interview Questions

Where were you when the accident (incident) happened?
What were you doing at that time?
What did you see?
What did you hear?
Who else was around at the time?
Is there a standard procedure for the task?
Are workers trained in the standard procedure?
Was this the first time this task was done?
Was the work being supervised at the time?
Is there anything else youd like to
add?

for Taking
Pictures
for
Evidence

Suggestions for Collecting Samples

use a diagram of the area to note
where samples were found;
keep people away from area;
ensure evidence is not damaged;
place samples in a bag or container,
seal it, and label with a permanent
marker;
label the evidence with
+
+

+ use adequate lighting;

+ ensure unobstructed
view of the area or
object;
+ date the photograph;

keep evidence in a secure place; and

+ reference the
measurement (i.e. place
a ruler, measuring tape,
another object or
person, etc. next to the
area or object); and

keep a record if evidence is moved.

+
+

12

a reference number
the date and time evidence was
collected
the specific location evidence was
found
the collectors name;

The following tips will

ensure pictures can be used
as evidence:

keep the negatives.

Accident/Incident Investigations

Reviewing Documentation

Examples of documentation that may

need to be reviewed
log books
work schedules
files
policy and procedure manuals
specific legislation
manufacturers specification
check lists
training records
formal workplace inspection reports
previous records of this kind of event
previous accident/incident investigation reports

Once all information about the accident/incident is gathered, it must be reviewed

to determine the root cause. The information should be organized into a logical
sequence of events, working back from when the accident/incident occurred. All
possible causes should be listed at each step and checked to see if they are
supported by the evidence. If gaps in the evidence are discovered, there may be
a need to re-interview witnesses, review the documentation again, or gather
further information.

13

Accident/Incident Investigations

STEP3

Analyze the information

to determine the root cause

Contributing Factors
There are many factors that contribute to accidents/incidents; however they
can usually be broken down into four major categories: people, equipment,
materials and the environment. The following are some areas that may be
explored when investigating accidents/incidents to determine the root
cause(s).
People (management, non-management workers, contract workers, visitors)
? knowledge, experience, skill, understanding, orientation,training
? job site analyses
? communication
? safe work practices and procedures
? documentation of hazards
? equipment
? preventative maintenance
? physical capability analysis
? workload
? workplace inspections
Equipment
? design
? manufacturers specifications
? use
? preventative maintenance
? ergonomics
? job safety analysis
? safe work practices and procedures
? hazard recognition, evaluation and control
? documentation
? personal protective equipment (PPE)
Materials
? manufacturers specifications
? use
? preventative maintenance
? ergonomics
? job safety analysis
? safe work practices and procedures
? hazards recognized, evaluated and controlled
? documentation

14

Environment
? lighting
? noise
? air quality
? housekeeping practices
? weather conditions

Accident/Incident Investigations

It is widely accepted that accidents/incidents occur as a result of a chain of

events. There is rarely one cause. Causes of accidents/incidents are usually
grouped into two main categories: immediate/direct cause(s) and root/basic
cause(s).

Immediate/Direct Cause(s)
Immediate/Direct Cause(s) are events, conditions or acts that immediately
precede the accident/incident. Immediate/direct causes are usually the
symptoms of the root/basic cause, not the root cause itself.
Immediate/direct causes are usually related to uncontrolled hazards arising
from substandard conditions and/or substandard actions.

Examples of conditions:
machine guards in good
working order;
noise at acceptable levels;
planning documented;
good housekeeping
practiced; and
personal protective
equipment maintained.

Examples of actions:
safe work procedures
followed;
equipment appropriately
maintained and used;
hazards communicated;
rules followed; and
personal protective
equipment properly used and
maintained.

15

Accident/Incident Investigations

Root/Basic Cause(s)
Root/Basic Cause(s) are real or underlying cause(s) of
accidents/incidents. They are not always immediately evident.

Examples of job factors:

design of equipment;
knowledge of workplace
parties;
communication practices;
workplace inspections
scheduled and conducted; and
appropriate equipment
available and used.

Examples of personal factors:

orientation;
communication and
understanding of safe work
practices and procedures;
pace of work;
education and training; and
performance feedback.

Analyzing all information contributing factors and the immediate/direct

causes increases the likelihood of finding the root cause(s). Finding the root
cause(s) and implementing corrective actions will in turn prevent similar
accidents/incidents in the future.

16

Accident/Incident Investigations

STEP4
Make recommendations
Once the root cause of the accident/incident is identified, a set of well thoughtout recommendations should be developed as a means of preventing a similar
event in the future. The accident/incident investigation procedures should
outline the criteria for writing recommendations.

Recommendations should:
be clearly written;
be as specific as possible what, when and where;
identify target dates for implementation and follow-up; and
list the resources required for implementation (i.e. human,
financial, equipment, materials, etc.).

17

Accident/Incident Investigations

STEP5

Write the
accident/incident
investigation report

The purpose of the accident/incident investigation report is to communicate

the investigation information and document recommendations for corrective
action. Accident/incident investigation reports may be used as evidence
during legal proceedings; therefore, it is important that it is fully completed.
The accident/incident investigation procedures should identify who is
responsible for distributing the written report and who is responsible for
communicating its findings to the appropriate workers.
Please refer to Appendix E Sample Accident/Incident Investigation Form.
When writing an investigation
report, remember to:
keep the report well organized,
clear and to the point;
describe what happened
including the sequence of events
and timelines;
write a short description of the
investigation methods used; and
describe the analysis of the
cause including the
immediate/direct causes and the
root cause(s).

The accident/incident investigation

report should include:
supporting documentation and
other evidence; for example,
summaries of interviews, pictures
and analysis of evidence;
recommendations for corrective
actions;
outline of the follow-up
procedure;
signatures of the investigation
team; and
date the report is submitted to
the employer.

The accident/incident investigation procedures should identify:

those responsible for distributing the investigation report;
those who should receive the report or the findings of the investigation;
and
a mechanism for communicating the findings to appropriate staff.
The report should be distributed to senior management, the OH&S
committee, and the management in the appropriate work areas.

All confidential worker information should be removed

before distribution of the investigation report and before
communicating the investigation findings.
18

Accident/Incident Investigations

STEP6
Follow-up
Accident/incident investigation procedures should identify those responsible
for:
implementing corrective actions within the assigned time frame;
meeting time-lines for implementing the corrective actions;
adding the corrective actions to the workplace inspection checklist as a
means of evaluating them;
evaluating corrective actions to ensure they are effective;
sharing the investigation findings with workers; and
communicating the effectiveness of the corrective actions to senior
management, the OH&S committee, and the staff in the affected work
area.

All confidential worker information should be removed

before distribution of the investigation report and before
communicating the investigation findings.

19

Accident/Incident Investigations

Role of OH&S Committees

The OH&S committee should receive all accident/incident investigation
reports. The accident/incident investigation procedures should outline those
responsible for distributing the report to the OH&S committee and those
responsible for updating the OH&S committee on implementation, follow-up
and evaluation of corrective actions.
As part of the internal responsibility system, the OH&S committee reviews all
accident/incident investigation reports to ensure:
accident/incident investigation procedures are followed;
root causes are identified;
recommendations for corrective actions are appropriate;
additional recommendations are developed and forwarded to the
employer if appropriate;
implementation time-lines are met;
corrective actions are monitored and evaluated;
communication procedures for accident/incident investigations are
followed;
trends in injury, illness and property damage are identified; and
accident/incident investigations are an effective part of the OH&S
program.
In addition to the above, the employer may ask the OH&S committee to
accept other duties such as being part of the investigation team. Just as with
other team members, these OH&S committee members should be trained in
accident/incident investigations and in hazard recognition, evaluation and
control.

20

Accident/Incident Investigations

Accident/Incident Investigations and

the OH&S Program
Accident/incident investigations are an important part of and are closely linked
to other elements of an OH&S program; for example, they:

q demonstrate the employers leadership and commitment to

preventing injury, illness and property damage by providing
necessary resources to complete accident/incident investigations;

q are an important means of hazard recognition, evaluation and

control;

q identify
+ education and training needs,
+ safe work practices and procedures that need to be
reviewed, revised or developed, and
+ injury, illness and property damage trends;

q involve the OH&S committee;

q identify items that may need to be added to the workplace
inspections checklist;

q improve communication about OH&S in the workplace;

q will need a good disability management program in place if the
accident results in an injury or illness; and

q may identify a need for review of emergency

preparedness/response equipment and procedures.

21

Accident/Incident Investigations

Conclusion
Using the information in this booklet will help workplace parties to plan
accident/incident investigations, choose the investigation team, document
the findings, identify the root cause(s), recommend corrective action,
complete the report, and follow-up on corrective action.
Accident/incident investigations are an important part of an OH&S program.
The involvement of all workplace parties strengthens the internal
responsibility system, is important to preventing similar occurrences in the
future, and is essential to building a positive health and safety culture in
workplaces.

22

Appendix A
Glossary....................................................24

Appendix B
References to Legislation ..........................28

Appendix C
Hazardous Occurrence Investigation
Report.....................................................35

Appendix D
Sample Accident/Incident
Report Form ............................................36

Appendix E
Sample Accident/Incident
Investigation Form...................................37

Appendices

Accident/Incident Investigations

Appendix A Glossary

Appendix A - Glossary

24

Accident

an unplanned event that results in a personal injury

or illness, damage or loss of property, process or
environment.

Basic/root cause

see root/basic cause

Best practice

performance standards developed by employers,

workers and OH&S professionals which exceed
basic OH&S legislative requirements and which
strive toward doing work in the safest possible way.

Controls

measures that are implemented to eliminate or

minimize hazards in the workplace. These controls
are established as either engineering (first line of
defence), administrative, or personal protective
equipment (used as a last resort).

Direct
(immediate)
cause

those unsafe objects, conditions or behaviours

which occur immediately before an accident/
incident; for example, inadequate guards and
barriers, defective tools, and improper lifting. These
are not the root cause.

Due Diligence

occurs when actions normally considered reasonable

in a particular circumstance are taken. In cases
where a serious workplace injury occurs and legal
action is taken, a due diligence defence can be
mounted if the person charged did everything a
reasonable person would do in the same situation to
prevent the injury.

Employer

a person who employs one or more workers [OH&S

Act, section 2 (f)].

Ergonomics

a science that seeks to adapt work or working

conditions to suit the worker. The aim is the
evaluation and design of facilities, environments,
jobs, training methods and equipment to match the
capabilities and limitations of workers and reduce
the potential for fatigue, error or unsafe acts.

Formal
workplace
inspections

regularly scheduled examinations carried out as a

means of preventing injury, illness and property
damage and of ensuring a safe and healthy workplace.
They are formally documented with the use of a checklist
and a report that includes recommendations for
corrective actions.

Hazard

dangerous object, event, behaviour or condition which

has the potential to cause injury, illness or property
damage.

Incident (near
miss; potential
accident)

an undesired event that could have resulted in injury,

illness or damage to property, process or environment.

Informal
workplace
inspections

daily routines used as a means of preventing injury,

illness and property damage and of ensuring a safe and
healthy workplace; for example, a supervisors walkthrough or a workers routine equipment check. Informal
inspections are usually not scheduled or documented and
do not require a checklist.

Internal
responsibility
system

a philosophy guiding OH&S legislation in all

Canadian jurisdictions. It is a system where all
workplace parties employers, workers including
supervisors and managers, and OH&S committees
share in the responsibility for workplace health and
safety to the degree of each partys authority and ability
to do so.

Occupation

employment, business, calling or pursuit but does not

include an endeavour that is not included in one of the
classes of occupations in the current Canadian
Classification and Dictionary of Occupations [OH&S
Regulations, section 2 (f)].

OH&S committee

a committee required to be established by the employer

in workplaces with 10 or more workers. The OH&S
committee must consist of representatives of the
employer and the workers at the workplace. Sections 37,
38, 38.1, 39, 40 and 45 of the OH&S Act describe the
composition and duties of the committee, and the
training and meeting requirements. Further requirements
for OH&S committees can be found in section 21 of the
OH&S Regulations.

Appendix A Glossary

Accident/Incident Investigations

25

Appendix A Glossary

Accident/Incident Investigations

26

Procedures (in
relation to the
OH&S program)

step by step way for completing of the OH&S

program components.

Risk

chance of loss based on:

(a) the probability of an injury, illness, damage or
loss of property, process or environment; and
(b) the possible severity of the injury, illness,
damage or loss of property, process or
environment.

Root/basic cause

the real cause of an accident/incident and the reason

why it occurred; for example, inadequate design, lack
of knowledge or skill, physical and physiological
stress, etc. The root cause is usually not immediately
evident and requires investigation.

Serious accident

an accident resulting in death, permanent or temporary

disability, excessive property damage, or accidental
release of pollutants with significant effects. More
specifically, serious accidents are those accidents
meriting in-depth investigation and are defined in the
OH&S Act, section 54(3).

Serious injury

a fracture of the skull, spine, pelvis, femur, humerus,

fibula, tibia, radius or ulna; an amputation of a major
part of a hand or foot; the loss of sight of a eye; a
serious internal hemorrhage; a burn that requires
medical attention; an injury caused directly or
indirectly by explosives; an asphyxiation or poisoning
by gas resulting in a partial or total loss of physical
control; or any other injury likely to endanger life or
cause permanent injury. A serious injury does not
include injures to a worker of a nature that may be
treated through first aid or medical treatment and the
worker is able to return to his or her work either
immediately after the treatment or at his or her next
scheduled shift [OH&S Act, section 54(3)].

Supervisor

includes a superintendent, foreman or other worker

authorized or delegated to exercise direction and
control over workers of an employer [OH&S
Regulations, section 2 (j)].

Unsafe act

departure from an accepted, normal or correct procedure

or practice which has actually produced injury or
property damage or which has the potential for
producing such loss.

Unsafe condition

departure from a standardized, accepted or normal

physical state to create circumstances which increase the
likelihood of an accident.

Worker

a person engaged in an occupation [OH&S Act, section 2

(m)].

Workplace

a place where a worker or self-employed person is

engaged in an occupation and includes a vehicle or
mobile equipment used by a worker in an occupation
[OH&S Act, section 2 (n)].

Workplace Health,
Safety and
Compensation
Commission

an employer-funded no-fault insurance system that

promotes safe and healthy workplaces, provides returnto-work programs and offers compensation to injured
workers and their dependants.

Workplace parties

those who perform work or are responsible for the

performance of work in a workplace. They include
employers, workers including managers and supervisors,
and the OH&S committee.

Appendix A Glossary

Accident/Incident Investigations

27

Accident/Incident Investigations

Appendix B References to Legislation

Important Note:
The legislative references included in this section are not official
versions. For official versions of the legislation, please see below.
The legislative references in Appendix B refer to the content in this
booklet and may not be complete. Workplace parties must refer to
the appropriate legislation to find complete information regarding
legislative requirements for developing an OH&S program.
Provincial legislation contact
information:

Federal legislation contact

information:

For official copies of the Occupational

Health and Safety Act and the Occupational
Health and Safety Regulations please
contact:
Office of the Queens Printer
Ground Floor
Confederation Building, East Block
St. Johns, Newfoundland and Labrador
A1B 4J6
Telephone: (709) 729-3649
Unofficial copies are available on-line at:
http://www.gs.gov.nl.ca/ohs/legislation.stm

For an official copy of the Canada Labour

Code please contact:
Canadian Government Publishing,
Communication Canada
Ottawa, Ontario K1A 0S9
Telephone: (709) 772-5571
Bookstores: (613) 954-5779
or 1-800-667-2868
Fax: (613) 654-5779 or 1-800-565-7757
Internet: http://publications.gc.ca
Unofficial copies are available on-line at:
http://laws.justice.gc.ca/en/l-2/17632.html

Appendix B - References to Legislation

OH&S Act
4. Employers general duty
An employer shall ensure, where it is reasonably practicable, the health,
safety and welfare of his or her workers.
41. Worker representative
(1) Where less than 10 workers are employed at a workplace, the
employer shall ensure that a worker not connected with the management of
the workplace is designated as the worker health and safety representative
to monitor the health, safety and welfare of workers employed at the
workplace.

28

Accident/Incident Investigations

42.1 Workplace designate

(1) Notwithstanding section 41, where less than six persons are engaged at a
workplace and the designation of a worker health and safety representative is
impracticable, the employer may designate a workplace health and safety
designate to monitor the health, safety and welfare of workers employed at the
workplace.
54. Reporting accidents
(1) Where an accident takes place at a workplace
(a) that results in serious injury to a person or results in the death of a
person; or
(b) that had, or continues to have, the reasonable potential of
causing serious injury to or the death of a person
the employer, or principal contractor shall immediately notify the
assistant deputy minister of the accident.
(2) Where an accident is reported under subsection (1), notification shall
immediately be given to the committee, the worker health and safety
representative or the workplace health and safety designate.
(3) In this section and section 55 "serious injury" means
(a) a fracture of the skull, spine, pelvis, femur, humerus, fibula or tibia, or
radius or ulna;
(b) an amputation of a major part of a hand or foot;

Appendix B - References to Legislation

(c) the loss of sight of an eye;

(d) a serious internal hemorrhage;
(e) a burn that requires medical attention;
(f) an injury caused directly or indirectly by explosives;
(g) an asphyxiation or poisoning by gas resulting in a partial or total loss
of physical control; or
(h) another injury likely to endanger life or cause permanent injury,
but does not include injuries to a worker of a nature that may be treated through
first aid or medical treatment and the worker is able to return to his or her work
either immediately after the treatment or at his or her next scheduled shift.

29

Accident/Incident Investigations

OH&S Regulations
4. Occupational health and safety program
(1) An occupational health and safety program required under section
36.1 of the Act shall be signed by the employer and by the person or persons
responsible for the management of the employers operations in the province
and shall include
(f) a system for the recognition, evaluation and control of hazards that
includes:
(iv) procedures for the prompt investigation of hazardous
occurrences to determine the cause of the occurrence and the
actions necessary to prevent a recurrence,
(j) maintenance of records and statistics, including occupational
health and safety committee minutes, reports of occupational
health and safety inspections and investigations, with procedures
to allow access to them by persons entitled to receive them under
the Act.

Canada Labour Code, Part II

134.1

Policy Health and Safety Committees

(1) Establishment mandatory

Appendix B - References to Legislation

For the purposes of addressing health and safety matters that apply to
the work, undertaking or business of an employer, every employer who
normally employs directly three hundred or more employees shall establish a
policy health and safety committee and, subject to section 135.1, select and
appoint its members.
(4) Duties of policy committee
A policy committee
(d) shall participate to the extent that it considers necessary in
inquiries, investigations, studies and inspections pertaining to
occupational health and safety;
135.

Work Place Health and Safety Committees

(1) Establishment mandatory

For the purposes of addressing health and safety matters that

apply to individual work places, and subject to this section, every employer
shall, for each work place controlled by the employer at which twenty or more
employees are normally employed, establish a work place health and safety
committee and, subject to section 135.1, select and appoint its members.

30

Accident/Incident Investigations

(7)

Duties of committee

A work place committee, in respect of the work place for which it is

established
(e) shall participate in all of the inquiries, investigations, studies and
inspections pertaining to the health and safety of employees,
including any consultations that may be necessary with persons who
are professionally or technically qualified to advise the committee on
those matters
136.

Health and Safety Representatives

(1) Appointment of health and safety representative

Every employer shall, for each work place controlled by the employer at
which fewer than twenty employees are normally employed or for which an
employer is not required to establish a work place committee, appoint the
person selected in accordance with subsection (2) as the health and safety
representative for that work place
(2) Selection of person to be appointed
The health and safety representative for a work place shall be selected as
follows:
(a) the employees at the work place who do not exercise managerial
functions shall select from among those employees the person to be
appointed; or

Appendix B - References to Legislation

(b) if those employees are represented by a trade union, the trade union
shall select the person to be appointed, in consultation with any
employees who are not so represented, and subject to any
regulations made under subsection (11).
The employees or the trade union shall advise the employer in writing of the
name of the person so selected

Canada Occupational Health and Safety Regulations

Reports by Employee
15.3
Where an employee becomes aware of an accident or other
occurrence arising in the course of or in connection with the employees work
that has caused or is likely to cause injury to that employee or to any other
person, the employee shall, without delay, report the accident or other
occurrence to his employer, orally or in writing. SOR/89-479, s. 1.

31

Accident/Incident Investigations

Investigations
15.4 (1) Where an employer becomes aware of an accident, occupational
disease or other hazardous occurrence affecting any of his employees in the
course of employment, the employer shall, without delay,
(a) appoint a qualified person to carry out an investigation of the
hazardous occurrence;
(b) notify the work place committee or the health and safety
representative of the hazardous occurrence and of the name of
the person appointed to investigate it; and
(c) take necessary measures to prevent a recurrence of the
hazardous occurrence.
(2) Where the hazardous occurrence referred to in subsection (1) is an
accident involving a motor vehicle on a public road that is investigated by a
police authority, the investigation referred to in paragraph (1)(a) shall be
carried out by obtaining from the appropriate police authority a copy of its
report respecting the accident.
(3) As soon as possible after receipt of the report referred to in
subsection (2), the employer shall provide a copy thereof to the work place
committee or the health and safety representative. SOR/89-479, s. 1; SOR/94263, s. 56; SOR/2002-208, s. 31.
Telephone or Telex Reports

Appendix B - References to Legislation

15.5 The employer shall report to a health and safety officer, by telephone
or telex, the date, time, location and nature of any accident, occupational
disease or other hazardous occurrence referred to in section 15.4 that had one
of the following results, as soon as possible but not later than 24 hours after
becoming aware of that result, namely,
(a) the death of an employee;
(b) a disabling injury to two or more employees;
(c) the loss by an employee of a body member or a part thereof or the
complete loss of the usefulness of a body member or a part thereof;
(d) the permanent impairment of a body function of an employee;
(e) an explosion;
(f) damage to a boiler or pressure vessel that results in fire or the
rupture of the boiler or pressure vessel; or
(g) any damage to an elevating device that renders it unserviceable, or
a free fall of an elevating device. SOR/89-479, s. 1; SOR/94-263, s.
57; SOR/2002-208, s. 38.

32

Accident/Incident Investigations
Records
15.6 (1) The employer shall, within 72 hours after a hazardous occurrence
referred to in paragraph 15.5(f) or (g), record in writing
(a) a description of the hazardous occurrence and the date, time and
location of the occurrence;
(b) the causes of the occurrence; and
(c) the corrective measures taken or the reason for not taking
corrective measures.
(2) The employer shall, without delay, submit a copy of the record
referred to in subsection (1) to the work place committee or the health and safety
representative. SOR/89-479, s. 1; SOR/94-263, s. 58; SOR/2002-208, s. 32.
Minor Injury Records
15.7 (1) Every employer shall keep a record of each minor injury of which the
employer is aware that affects any employee in the course of employment.
(2) A record kept pursuant to subsection (1) shall contain
(a) the date, time and location of the occurrence that resulted in the
minor injury;
(b) the name of the employee affected;
(c) a brief description of the minor injury; and
(d) the causes of the minor injury. SOR/89-479, s. 1.
Written Reports

Appendix B - References to Legislation

15.8 (1) The employer shall make a report in writing, without delay, in the
form set out in Schedule I to this Part setting out the information required by
that form, including the results of the investigation referred to in paragraph
15.4(1)(a), where that investigation discloses that the hazardous occurrence
resulted in any one of the following circumstances:
(a) a disabling injury to an employee;
(b) an electric shock, toxic atmosphere or oxygen deficient
atmosphere that caused an employee to lose consciousness;
(c) the implementation of rescue, revival or other similar emergency
procedures; or
(d) a fire or an explosion

33

Accident/Incident Investigations

(2) The employer shall submit a copy of the report referred to in

subsection (1)
(a) without delay, to the work place committee or the health and
safety representative; and
(b) within 14 days after the hazardous occurrence, to a health and
safety officer at the regional office or district office. SOR/89479, s. 1; SOR/94-263, s. 59; SOR/2002-208, s. 33.
15.9 Where an accident referred to in subsection 15.4(2) results in a
circumstance referred to in subsection 15.8(1), the employer shall, within 14
days after the receipt of the police report of the accident, submit a copy of
that report to a health and safety officer at the regional office or district office.
SOR/89-479, s. 1; SOR/2002-208, s. 38.

Workplace Health, Safety and Compensation Act

56. Duties of employer
(1) An employer shall, within 3 days after the occurrence of an injury to a
worker in his or her employment as a result of which the worker is disabled
from earning full wages or the worker is entitled to medical aid, notify the
commission in writing of
(a) the occurrence of the injury and nature of it;
(b) the time when the injury occurred;
(c) the name and address of the worker;
(d) the place where the injury occurred;

Appendix B - References to Legislation

(e) the name and address of the doctor who looks after the injury; and
(f) other particulars required by the commission.
(2) An employer shall make further and other reports respecting the
injury and workers that may be required by the commission.
(3) Where an employer fails to notify the commission of the occurrence of
an injury the commission may in relation to compensation paid in respect of
that injury charge the cost of the claim against the experience record of that
employer.

34

Accident/Incident Investigations

Appendix C Hazardous Occurrence Investigation Report

Human Resources

Dveloppement des

Development Canada

ressources humaines Canada

2. Department file no.
N de dossier du ministre

1. TYPE OF OCCURRENCE / GENRE DE SITUATION

SCHEDULE 1 / ANNEXE 1
(section 15.8 / article 15.8)

Loss of Consciousness
vanouissement
Regional or District Office
Emergency Procedure Bureau rgional ou de district
Mesures d'urgence

Explosion

HAZARDOUS OCCURRENCE
INVESTIGATION REPORT
RAPPORT D'ENQUTE DE
SITUATION COMPORTANT DES RISQUES

Disabling Injury
Blessure invalidante
Other
Autre

Employer ID No.
Numro d'identification de l'employeur

Specify / Prciser

3. Employer's name and mailing address / Nom et adresse postale de l'employeur

Postal code / Code postal

Telephone number / Numro de tlphone

() Site of hazardous occurrence

Lieu de la situation comportant des risques

Date and time of hazardous occurrence

Date et heure de la situation comportant des risques:
Weather / Conditions mtorologiques

Supervisor's name / Nom du surveillant

Appendix C Hazardous Occurrence Investigation Report

pl

4. Description of what happened / Description des circonstances

Witnesses / Tmoins

Brief description and estimated cost of property damage / Description sommaire et cot estimatif des dommages matriels

5. Injured employee's name (if applicable) / Nom de l'employ bless (s'il y a lieu)

Age / ge Occupation / Profession

Description of Injury / Description de la blessure

Sex
Sexe

Years of experience in occupation /

Nombre d'annes d'exprience dans la profession

sa

Direct cause of injury / Cause directe de la blessure

Was training in accident prevention given to injured employee in relation to duties performed at the time of the hazardous occurrence?
L'employ bless a-t-il reu une formation en prvention des accidents relativement aux fonctions qu'il exerait au moment de al situation comportant des risques?
Yes / Oui

No / Non

Specify /
Prciser

6. Direct causes of hazardous occurrence / Causes directes de la situation comportant des risques

7. Corrective measures and date employer will implement / Mesures correctives qui seront appliques par l'employeur et date de leur mise en oeuvre

Reasons for not taking corrective measures / Raisons pour lesquelles aucune mesure corrective n'a t prise

Supplementary preventive measures / Autres mesures de prvention

8. Name of person investigating / Nom de la personne faisant l'enqute

Signature

Date

Title / Titre

Telephone Number / Numro de tlphone

9. Work place committee's or health and safety representative's comments / Observations du comit local ou du reprsentant

Work place committee member's or health and safety representative's name

Nom du membre du comit local ou du reprsentant

Signature

Date

Title / Titre

Telephone Number / Numro de tlphone

() 10. COPIES 1 and 2 to Health and Safety Officer, COPY 3 to the Work Place Committee or Health and Safety Representative 4 to the Employer
COPIES 1 et 2 pour l'agent de sant et de scurit 3 pour le comit local ou pour le reprsentant, COPIE 4 pour l'employeur
LAB 1070 (02-01) B

See reverse for INSTRUCTIONS au verso

35

Accident/Incident Investigations

Appendix D Sample Accident/Incident Report Form

Category/Status (Internal Use Only)

Who and When?

This report must be completed for all workrelated incidents/accidents. Please immediately
notify your manager/supervisor. Complete the
employee section and distribute as noted below.
Accurate information is required so appropriate
follow-up can occur to prevent future incidents.
PLEASE NOTE, all serious injuries must also be
immediately reported to the Dept. of Government
Services (OH&S Branch).

Recurrence

Confidentiality: The information contained in this

report is considered confidential & will only be used
for analyzing trends, injury prevention initiatives and
WHSCC claims management.

Medical Care

Lost Time

Original Injury Date

Permanent
Temp

Part Time
Full Time
Casual/On call

Your last name:

Your first name:

Your employee number:

The date and time of incident/accident

The date/time
stopped work:(if
applicable)

What was your job

classification at
time of accident/incident?

D______ M______ Y ______

_______ am/pm

The incident/accident was reported to:

Title:

Which site did the incident/accident occur? (kitchen, office, etc)

Where?

Near Miss (No injury)

Where did it actually occur?(Be as specific as possible: room, corridor, workstation, facility)

pl

Describe what happened (mention events leading up to how it occurred and if machinery/equipment/tool were
involved)

36

Special
Instructions

HR use only

What were you doing at the time?

Damage to equipment/
property

Damage to environment

sa

What Happened?

Near miss

If you have been injured, please check which most

accurately describe the type of injury.
Abrasion(s)
Burn(s)
Loss of materials
B/BF Exposure
Contusion
Injury requiring
Fracture(s)
medical aid only
Infectious Contact
Irritation (respiratory)
Injury leading
Needle Puncture
to lost time
Laceration(s)
No Injury
Strains(s) & Sprain(s)
Other ____________

Appendix D Sample Accident/Incident Report Form

This incident/accident resulted in (more than

one may need to be checked):

If you were injured, was there any immediate

treatment required?
If so, please describe briefly.
Mark with (?) if item is
applicable
Allergic Reaction
Assisting Patient for X-ray
Assisting Patient from floor/chair
Bathing Pt. (bed/tub)
B/BF Exposure
Bed Making
Catching Falling Object
Catching Patient
Changing Patient
Walking Patient
Chemical Exposure Type _____
Crushed/Pinched b/w Objects

Part of Body Injured (if applicable):

Left

Dressing Patient
Ft/Bk slide with transfer board
Hot Object/Surface
Infectious Disease Exposure
Lifting Equipment/Supplies
Lifting/Lowering Bedrails
Moving/Pushing/Pulling
Equipment/Supplies
No Specific Task
Needle Stick Puncture
Patient Aggression/
Non Cooperation
Repositioning Patient in Bed
Repositioning Patient in Chair

Right
Respond to an Emergency
Code (specific)
Sharpe Object Type:__________________
Struck by Object
Slipped/Fell on ______________________
Transferring Patient Bed Stretcher
Transferring Patient Other
Transporting Patient
______ Wheelchair
______ Bed
______ Stretcher
Working at computer workstation
Other:____________________________
Recurrence of previous injury

Employee Signature:_____________________________ Home Phone:_______________ Date:

Date first lost shift: D____ M ______ Y _____ Anticipated RTW Date: D ____ M _____ Y _____
RTW Date D____ M______ Y_____
Name of Attending Physician:_______________________________ Date Seen: D ____ M _____ Y _____
Address of Physician:
Manager (or designate) is responsible for completing the Incident/Accident Investigation portion of the form.
Please complete the section located on the lower portion of the yellow and pink copies. (Reference: Staff
Accident/Incident Investigation Policy X05).
Employee is responsible for completing the Incident/Accident Report portion and forwarding the white copy to
the appropriate Human Resources.
Report must be completed and forwarded to Human Resources within 24 hours of the incident/accident.

Accident/Incident Investigations

Appendix E Sample Accident/Incident Investigation Form

Attach all supporting documentation and evidence, ie. summaries of interviews, pictures, and
analysis of evidence.
Instruction: This form must be completed by the store manager and a member of OH&S committee
whenever an accident/incident occurs. The assistant manager or authorized designate for the store will
be responsible for completing this form in the absence of the store manager. The store manager must
ensure a copy of the completed report is forwarded to the Human Resources Manager, and the OH&S
committee.
Accident/incident resulted in: ___ injury ___ illness ___ property damage ____ near miss
____ first aid

___ medical aid

___ recurrence ____ other (check all that apply)

Store Location

Department

Location of Incident
(Be specific eg. aisle 10)

Date of incident
Time_________

Date reported accident/incident

am
pm

ACCIDENT/INCIDENT INFORMATION
Supervisor:_____________________________ Date of first missed shift:__________________

No. of days lost__________

Appendix E Sample Accidence/Incident Investigation Form

Approximate date of onset, if no specific date of

injury:______________________________________________________

pl

Object/equipment/substance inflicting damage/injury:________________________________________

Nature of injury:_______________________________ Body part(s) affected:_____________________

sa
m

EMPLOYEE INFORMATION

Name (last name first please print)

___________________________________________

Home phone number:___________________

Home Address:_______________________________

Age: ____________

Sex: M / F

________________________________

________________________________

Date of employment:___________________________

Occupation/Position: __________________________________

Experience (time) in job:________________________

Evaluation of loss
Potential if not corrected

Loss severity potential

Major
Minor
Serious

Probability of occurrence
High
Moderate
Low

Describe how the event occurred.

Immediate causes: What substandard acts/practices and conditions cause d or could cause the event?
See end of form.

Basic causes: What specific personal or job/system factors led to the immediate causes?

Basic causes: What specific personal or job/system factors caused or could cause this event? See
end of form.

Remedial actions: What has and/or should be done to control the causes listed?

37

Accident/Incident Investigations

Prevention of Accident/Incident Recurrence

Describe what action is planned or has been taken to prevent a recurrence of the accident, based on the
key contributing factors
(immediate)
(long term)

Signed by Supervisor________________________ Supervisors Name

Signed by Person Involved:___________________ Signed by HR:
Signed by Store Manager: _

______________________________
_________________________

Date: ______________________ __________

REPORT FORM DEFINITIONS

INJURY physical harm or damage to a person.

ILLNESS unhealthy condition in mind or body.

FIRST AID INJURY a minor injury requiring only first aid treatment.

pl

Appendix E Sample Accidence/Incident Investigation Form

MEDICAL AID INJURY an injury requiring treatment by a health care professional.

LOST TIME INJURY a disabling injury where the injured person is unable to report for the next regular shift.
RECURRENCE an accident or incident which has occurred mor e than once.

PROPERTY DAMAGE ACCIDENT accidental loss to equipment, material, and/or the environment.
INCIDENT (NEAR-MISS) an undesired event that could have resulted in personal injury, property damage or loss.

IMMEDIATE CAUSES check all as appropriate

Actions

Conditions

sa

Operating equipment without authority

Inadequate guards or barriers
Failure to warn
Inadequate or improper protective equipment
Failure to secure
Defective tools, equipment or materials
Operating at improper speed
Congestion or restricted action
Making safety devices inoperable
Inadequate warning system
Removing safety devices
Fire and explosion hazard
Using defective equipment
Poor housekeeping, disorder
Failure to use PPE
Hazardous environmental conditions, gases, smok e,
dusts, fumes
Improper loading

Noise exposure
Improper placement

Radiation exposure
Improper lifting

High or low temperature exposure

Improper position for task
Inadequate or excess illumination
Servicing equipment in operation
Inadequate ventilation
Horseplay
Under influence of alcohol and/or other substances

BASIC CAUSES check all as appropriate

38

Personal Factors

Job Factors

Inadequate capability
Lack of knowledge/training
Lack of skill
Stress
Improper motivation

Inadequate leadership/supervision
Inadequate engineering
Inadequate purchasing
Inadequate maintenance
Inadequate tools/equipment
Inadequate work standards
Wear and Tear
Abuse and/or misuse

HOW TO REACH US
St. John's
146-148 Forest Road
P.O. Box 9000
St. John's, NL A1A 3B8
Prevention Services Inquiries (709) 778-1552
Prevention Services Fax (709) 778-1564
Toll Free 1 800 563-9000

Grand Falls-Windsor
26 High Street
P.O. Box 850
Grand Falls Windsor, NL A2A 2P7
Telephone: (709) 489-1600
Fax (709) 489-1616
Toll Free 1 800 563-3448

Corner Brook
Suite 201, Fortis Towers
4 Herald Avenue
P.O. Box 474
Corner Brook, NL A2H 6E6
Telephone: (709) 637-2700
Fax (709) 639-1018
Toll Free 1 800 563-2772

www.whscc.nl.ca
Department of Government Services
OH&S Branch
(709) 729-2706
Toll Free: 1-800-563-5471

Human Resources and Social Development

Labour Program, Newfoundland and Labrador Office
Phone: (709) 772-5022 (call collect outside St. Johns)

Newfoundland & Labrador Employers Council

(709) 368-6532
Toll Free: 1-888-738-5900

Newfoundland and Labrador Federation of Labour

(709) 754-1660