INCIDENT INVESTIGATION AND
REPORTING
Objectives:
General:
Offer basic skills which are
necessary in conducting an effective
accident investigation.
Specific:
To define the reasons for
investigating accident and incidents.
To outline the process for
effectively investigating accidents
and incidents.
To facilitate an effective
investigation.
ACCIDENT VS. INCIDENT
Accident - can be defined as an
unplanned event that interrupts the
completion of an activity, and that
may (or may not) include injury or
property damage.
Incident - usually refers to an
unexpected event that did not cause
injury or damage this time but had
the potential. "Near miss" or
"dangerous occurrence" are also
terms for an event that could have
caused harm but did not.
REPORTABLE ACCIDENTS
• A worker falling a vertical
distance of three metres or more.
• A worker falling and having the
fall arrested by a fall arrest system
other than a fall restricting system.
• A worker becoming
unconscious for any reason.
• Accidental contact by a worker
or by a worker's tool or equipment
with energized electrical equipment,
installations or conductors.
• Accidental contact by a crane,
similar hoisting device, backhoe,
power shovel or other vehicle or
equipment or its load with an
energized electrical conductor rated
at more than 750 volts. Structural
failure of all or part of false work
designed by, or required by this
Regulation to be designed by, a
professional engineer.
• Structural failure of a principal
supporting member, including a
column, beam, wall or truss, of a
structure.
• Failure of all or part of the
structural supports of a scaffold.
 • Structural failure of all or part
of an earth- or water-retaining
structure, including a failure of the
temporary or permanent supports for
a shaft, tunnel, caisson, cofferdam or
trench.
• Failure of a wall of an
excavation or of similar earthwork
with respect to which a professional
engineer has given a written opinion
that the stability of the wall is such
that no worker will be endangered by
it.
• Overturning or the structural
failure of all or part of a crane or
similar hoisting device.
TYPES OF ACCIDENTS
Accident at work claims
Road accident claims
Medical negligence claims
Slip or trip accident claims
CAUSES OF ACCIDENTS
Shortcuts
Humans are notoriously lazy, so
taking shortcuts is a rather common
practice in all walks of life, not
necessarily work alone. However,
when workers take shortcuts at work,
especially when they are working
around dangerous machinery or
lethal chemicals, they are only
exposing themselves to a potential
catastrophe. Simply put, shortcuts
that are taken on the job are not
actually shortcuts. They are simply
increasing your risk of injury, or
worse, death.
Overconfidence
Confidence is always a great thing
to have, but there is also such a thing
as too much confidence. When
workers walk into work everyday
with the attitude that, “It will never
happen to me”, they are setting an
attitude that leads to incorrect
procedures, methods, and tools while
working. Be confident, but remember
that you are not invincible.
Poor or Lack of Housekeeping
Whenever someone walks
through your workplace, they can get
a pretty good idea of your attitude
towards workplace safety by just
looking at how well you’ve kept up
your area. Housekeeping is one of the
most accurate indicators of the
company’s attitude towards
production, quality, and worker
safety. A poorly kept up area leads to
hazards and threats everywhere. Not
only does good housekeeping lead to
heightened safety, but it also set a
good standard for everyone else in
the workplace to follow.
INVESTIGATION
The action of investigating
something or someone; formal or
systematic examination or research.
Investigation Type:
Type A Investigation (Extreme Risk
Category) :
-fatality, serious injury, equipment
damage and each greater than
100,000 $
Type B Investigation (High Risk
Category) :
- Lost-time injury requiring
medical aid treatment and
damage to equipment greater
than 10,000$ but less than
100,000 $
Type C Investigation (Medium Risk
Category):
-Medical treatment injuries not
resulting in lost time, damage to
equipment, materials greater than
1,000 $ but less than 10, 000 $
Type D Investigation (Low Risk
Category):
- NO detailed investigation is
required but a documentation is
needed.
WHO SHOULD DO THE ACCIDENT
INVESTIGATION?
An investigation would be
conducted by someone experienced
in accident causation, experienced in
investigative techniques, fully
knowledgeable of the work
processes, procedures, persons, and
industrial relations environment of a
particular situation.
Some jurisdictions provide
guidance such as requiring that it
must be conducted jointly, with both
management and labour
represented, or that the investigators
must be knowledgeable about the
work processes involved.
In most cases, the supervisor
should help investigate the event.
Other members of the team can
include:
  Employees with knowledge
of the work
 Safety officer
 Health and safety committee
 Union representative, if
applicable
 Employees with experience
in investigations
 "Outside" expert
 Representative from local
government
HUMAN ERROR
Human Error is commonly defined
as “a failure of a planned action to
achieve a desired outcome”. Error-
inducing factors exist at individual,
job, and organizational levels, and
when poorly managed can increase
the likelihood of an error occurring in
the workplace. When errors occur in
hazardous environments, there is a
greater potential for things to go
wrong.
Human error typology
Skill-based Errors
Skill-based errors tend to occur
during highly routine activities, when
attention is diverted from a task,
either by thoughts or external
factors.
Mistakes
Mistakes are failures of planning,
where a plan is expected to achieve
the desired outcome, however due
to inexperience or poor
information the plan is not
appropriate. People with less
knowledge and experience may be
more likely to experience mistakes.
However, as mistakes are not
committed ‘on purpose’, disciplinary
action is an inappropriate
response to these types of error.
 WHAT SHOULD BE DONE IF THE
INVESTIGATION REVEALS HUMAN
ERROR
A difficulty that has bothered
many investigators is the idea that
one does not want to lay blame.
However, when a thorough worksite
accident investigation reveals that
some person or persons among
management, supervisor, and the
workers were apparently at fault,
then this fact should be pointed out.
The intention here is to remedy the
situation, not to discipline an
individual.
Failing to point out human failings
that contributed to an accident will
not only downgrade the quality of the
investigation. Furthermore, it will
also allow future accidents to happen
from similar causes because they
have not been addressed.
However never make
recommendations about disciplining
anyone who may be at fault. Any
disciplinary steps should be done
within the normal personnel
procedures.
WHAT TO INCLUDE IN THE
DOCUMENTED INVESTIGATION
PROCESS
Who is involved - Normally, the
investigation is conducted by the
injured worker’s immediate
supervisor. However, assistance can
also be provided by the safety
practitioner or team members from
an investigative or review committee
or safety committee if such teams
exist. In cases involving a fatality,
senior management personnel,
engineering staff or legal counsel may
also be involved. Those participating
in the investigation would include the
injured worker, witnesses to the
incident or events preceding it, and
the injured worker’s immediate
supervisor if some other person is
conducting the investigation.
What gets investigated - Any incident
resulting in a fatality or serious injury
should be thoroughly investigated. To
obtain the best possible data to aid in
predicting and preventing future
incidents, it is also recommended
that all recordable, first aid and near
miss/close call incidents be
investigated.
Information to collect - The type of
information that should be collected
during the investigation process
includes:
• Worker characteristics (age,
gender, department, job title,
experience level, tenure in company
and job, training records, and
whether they are full-time, part-time,
seasonal, temporary or contract)
• Injury characteristics (describe
the injury or illness, part(s) of body
affected and degree of severity)
• Narrative description and
sequencing of events (location of
incident; complete sequence of
events leading up to the injury or
near miss; objects or substances
involved in event; conditions such as
temperature, light, noise, weather;
how injury occurred; whether
preventive measure had been in
place; what happened after injury or
near miss occurred).
• Characteristics of equipment
associated with incident (type, brand,
size, distinguishing features,
condition, specific part involved)
• Characteristics of the task being
performed when incident occurred
(general task, specific activity,
posture and location of injured
worker, working alone or with others)
• Time factors (time of day, hour
in injured worker’s shift, type of shift,
phase of worker’s day such as
performing work, break time,
mealtime, overtime, or
entering/leaving facility)
• Supervision information (at time
of incident whether injured worker
was being supervised directly,
indirectly, or not at all and whether
supervision was feasible)
• Causal factors (specific events
and conditions contributing to the
incident)
• Corrective actions (immediate
measures taken, interim or long-term
actions necessary)
What to have on hand - To be
prepared to complete an
investigation promptly following an
incident, it is best to have prepared a
kit ahead of time that includes:
• Investigation forms
• Interview forms
• Large Envelopes
 • Barricade markers/tape
• Warning tags or padlocks
• Camera or video recorder
• Voice recorder
• Measuring tape
• Scissors
• Flashlight
• Sample containers with labels
• Personal protective equipment
• Graph Paper
• First aid kit
• Gloves
Interviewing people - Interviewing
injured workers and witnesses
necessitates reducing their possible
fear and anxiety, and developing a
good rapport.
Interviews should follow these steps:
1. State the purpose of the
investigation and interview is to do
fact-finding, not fault-finding.
2. Ask the individual to recount
their version of what happened
without interrupting. Take notes or
record their response.
3. Ask clarifying questions to fill in
missing information.
4. Reflect back to the interviewee
the factual information obtained.
Correct any inconsistencies.
5. Ask the individual what they
think could have prevented the
incident, focusing on the conditions
and events preceding the injury.
Determining causal factors – The
purpose of all this fact-finding is to
determine all the contributing factors
to why the incident occurred.
Statements such as “worker was
careless” or “employee did not follow
safety procedures” don’t get at the
root cause of the incident. To avoid
these incomplete and misleading
conclusions in your investigative
process, continue to ask “Why?” as in
“Why did the employee not follow
safety procedures?”
Contributing factors may involve
equipment, environment, people and
management.
Questions that help reveal these
may include:
1. Was a hazardous condition a
contributing factor? (defects in
equipment/tools/materials, condition
recognized, equipment inspections, or worker adequately trained, failure
correct equipment used or available, to initiate corrective action)
substitute equipment used, design or
Completing report and documenting
quality of equipment)
corrective actions - At this point,
2. Was the location of once you’ve gathered information
equipment/materials/worker(s) a and interviewed the involved worker
contributing factor? (employee and any witnesses, you can prepare
supposed to be there, sufficient the investigation report itself and
workspace, environmental formulate corrective actions. Your
conditions) company should have determined
who the report is sent to, within what
3. Was the job procedure a
time frame and what information
contributing factor? (written or
gets communicated to workers,
known procedures, ability to perform
management, or gets filed or posted.
the job, difficult tasks within the job,
Each corrective action listed should
anything encouraging deviation from
have a person assigned ultimate
job procedures such as incentives or
responsibility for the action, a
speed of completion)
completion date set and a place to
4. Was lack of personal protective mark completion of the item.
equipment or emergency equipment
a contributing factor? (PPE specified
for job/task, adequacy of PPE,
whether PPE used at all or correctly,
emergency equipment specified,
available, properly used, function as
intended)

5. Was a management system

defect a contributing factor? (failure
of supervisor to detect or report
hazardous condition or deviation
from job procedure, supervisor
accountability understood, supervisor
 -Clear description of UNSAFE ACT or
CONDITION.

-Recommended immediate corrective

action.

- Recommended long-term corrective

action.

- Recommended follow up to assure

fix is in place.

- Recommended review to assure

correction is effective.

REPORTING

All accidents and Incidents must be

reported properly. It is under the
responsibility of the supervisor to
report the casualties that happened
within his knowledge.

The reports should include:

-An accurate narrative of what

happened.