TOPIC

How to Conduct
Incident Investigation?

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Terms & Definitions
Hazard
Anything which
has potential to
cause harm

Safety
Accident Process of Risk
An event that eliminating or The likelihood
results in reducing risk that a hazard
Injury or Ill- to an can cause
health harm
acceptable
level

Incident
An event that does
not result in
personal injury but
may result in
property damage
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Injuries – Matter of Probabilities

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Why Accidents Occur??

UN-
SAFE
NATURAL CALAMITIES, 2%
CON-
DI-
TIONS,
10%

UNSAFE ACTIONS; 88%

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Incident Investigation – ISO 45001
Requirements
 The organization shall establish, implement and maintain a process(es), including reporting,
investigating and taking action, to determine and manage incidents and nonconformities.
 When an incident or a nonconformity occurs, the organization shall:
 a) react in a timely manner to the incident or nonconformity and, as applicable:

 1) take action to control and correct it;

 2) deal with the consequences;
 b) evaluate, with the participation of workers (Cl. 5.4) and the involvement of other

relevant interested parties, the need for corrective action to eliminate the root cause(s) of
the incident or nonconformity, in order that it does not recur or occur elsewhere, by:
 1) investigating the incident or reviewing the nonconformity;
 2) determining the cause(s) of the incident or nonconformity;
 3) determining if similar incidents have occurred, if nonconformities exist, or if
they could potentially occur;
 c) review existing assessments of OH&S risks and other risks, as appropriate (Cl. 6.1);

 d) determine & implement any action needed, including corrective action, in accordance

with the hierarchy of controls (Cl. 8.1.2) and the management of change (Cl. 8.1.3);
 e) assess OH&S risks that relate to new or changed hazards, prior to taking action;

 f) review the effectiveness of any action taken, including corrective action (Cl.10.2);

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Incident Investigation
 There are 2 major components that contribute to the cause of an incident.
 Work Element
The condition or act that directly caused the incident.

Example - Oil on the floor leading to slip and fall injury

 Root Cause
The system failure that allowed the work element to become deficient or

to occur.
Example - The Preventive Maintenance clean up not done well.

 Incident investigation process to ensure that

All incidents (including near misses) are investigated

Corrective action are determined that identify the root cause

Corrective actions are tracked until they are completed

Trends are reviewed, gaps are identified and improvement plans are

developed to prevent future occurrences.

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Investigation Process
 Evidence of Consultation & Participation – Cl.5.4
 Employees
Report all work-related incidents in a timely manner

Participate in the investigation process, as needed

 Supervisor/Manager/Management
If the incident was very recent, secure the scene of the incident to ensure the

safety of any emergency responders and other employees, and to preserve any
evidence that may contribute to the investigation
Ensure the injured person is properly cared for

Ensure management or other company personnel who require it are notified.

 Ensure the investigation begins as soon as possible after the incident occurs

Identify the potential sources of information, such as the injured person,

witnesses and any physical evidence

Gather the facts about the incident

Ensure the investigation identifies the root cause

Make and/or implement recommendations to control or eliminate the hazard

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Investigation of Incident - Steps
1. Gather Evidence
Interviewing involved employees:

Put the individual at ease. Avoid finger-pointing and applying blame.

 Be aware of the emotions

Stress fact gathering. Let involved employees tell their story completely.

Conduct the interviews at the scene, if possible.

Ask any necessary questions to determine what happened, what was done

and how it was done. Try to avoid asking WHY questions that may make
people defensive.
Close the interview on a positive note. Thank the person interviewed.

2. Use the right tools during the investigation process:

Paper and pencil is the basic tool.

Record times, places, names, distances, comments, conditions

Take pictures, if possible. A picture is worth a thousand words.

Draw a sketch or diagram. Use the diagram to indicate where key objects or

people were during the incident.

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Investigation of Incident – Contd..
3. Determine the Root Cause
 Work Element is easy to identify
flying chip, a spill on the floor, or lifting a load that was too heavy.

 System Failure/Root Cause is difficult to identify

To make it easier to determine, root causes (in general) can be placed

into six different categories.

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Investigation – Root Cause
Materials
• Defective raw material(s)
• Wrong type of material for job
• Not enough raw material
Environment
• Orderly workplace
• Job design or layout of work
• Surfaces poorly maintained
• Physical demands of the task
• Other conditions (Noise, lighting etc)
Methods
• No or inadequate procedures
• Practices do not match with written
procedures
• Poor communication
Machine / Equipment
• Incorrect selection of tool/equipment
• Poor equipment maintenance/design
• Poor equipment or tool placement
• Defective equipment or tool
Man
• No or poor “management”involvement
• Lack of concentration to task
• Task hazards not guarded properly
• Stress/Psychological factors
• Other ( horseplay, inattention, etc.)
Management System
• Lack of training or education
• Poor employee involvement
• Poor recognition of Hazard
• Previous hazards not eliminated
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Investigation of Incident - Contd..
4. Document the Findings
When the incident happened. Date and time

Who or what was affected or hurt by the incident.

Where it happened.

What object, if any, caused the incident.

What work element was deficient and most directly caused the incident.

What system failure (or root cause) caused the incident

5. Follow up & Analyse

Once the documentation phase is complete, corrective actions should be

implemented.
Employees in the work area should be notified of changes/training etc.

Verify the effectiveness of corrective actions

Frequently, the answer to individual incidents is as simple as wearing/using

PPEs/Guards /Proper lifting procedures.

Blanket training programs may address several needs at one time.

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Hierarchy of Controls
 While implementing Corrective Action, consider the hierarchy of
controls
 

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