Effective Incident Investigation & Reporting

Effective Incident
Training Contents Investigation & Reporting

1. Introduction (15mins)
 Key terminology
 Types of injury
 Near Misses
 Why do we investigate incidents?
 Management system requirements (ISO 45001)
 Investigating Near Misses
2. The process of investigating incidents (20mins)
 What should be investigated?
 What should a good investigation look like?
 The four-stage process
 Types of evidence
3. Interview strategies (10mins)
 The PEACE model
 Bias
 Barriers to a good interview
4. Root cause analysis (20mins)
5. Incident investigation report (15mins)
6. Question & Answers (30mins)
7. Assessment (10min)
Introduction
Effective Incident
Key terminology Investigation & Reporting

Accident is an adverse event

that results in injury or ill health.

Incident is the occurrence arising Near miss is an event not

out of, or in the course of work that
causing harm, but has the potential
could or does result in injury or ill
to cause injury or ill health
health
Introduction
Effective Incident
Types of injury Investigation & Reporting
Introduction
Effective Incident
Near Misses Investigation & Reporting
Introduction
Effective Incident
Why do we investigate incidents? Investigation & Reporting
Introduction
Effective Incident
Management system requirements (ISO 45001) Investigation & Reporting
Introduction
Effective Incident
Investigating near misses Investigation & Reporting
The process of Investigating incidents
Effective Incident
What should be investigated? Investigation & Reporting
The process of Investigating incidents
Effective Incident
What should a good investigation look like? Investigation & Reporting
The process of Investigating incidents
Effective Incident
Level of Investigation Investigation & Reporting
The process of Investigating incidents
Effective Incident
Level of Investigation Investigation & Reporting
The process of Investigating incidents
Effective Incident
The four-stage process Investigation & Reporting
The process of Investigating incidents
Effective Incident
The four-stage process Investigation & Reporting
The process of Investigating incidents
Effective Incident
The four-stage process Investigation & Reporting
The process of Investigating incidents
Effective Incident
The four-stage process Investigation & Reporting
The process of Investigating incidents
Effective Incident
The four-stage process Investigation & Reporting
The process of Investigating incidents
Effective Incident
The four-stage process Investigation & Reporting
Interview strategies
Effective Incident
The PEACE model Investigation & Reporting
 Interview strategies
Effective Incident
Bias Investigation & Reporting

Inclination or Prejudice for or against one person or group.

Interview strategies
Effective Incident
Barrier to a good interview Investigation & Reporting
Root cause analysis
Effective Incident
Introduction Investigation & Reporting

• The problems are not solved properly unless

you understand why they are occurring
• The reason for a problem is called the
problem’s root cause
• The root cause can be found by utilizing a
technique called the 5 whys.
 Root cause analysis
Effective Incident
5 whys technique Investigation & Reporting

The method is remarkably simple:

When a problem occurs, you drill down to its root cause by asking "Why?"
five times. Then, when a counter-measure becomes apparent, you follow
it through to prevent the issue from recurring.
Sakichi Toyoda
Inventor, and founder of Toyota Industries

Developed 5 Whys
technique in 1930
Root cause analysis
Effective Incident
5 whys technique Investigation & Reporting
Incident Investigation
Effective Incident
Report Writing Investigation & Reporting

• Executive Summary
• Details of the investigation
• Basic Details
• Incident description
• Witness statements
• Investigation team
• Timeline of Event
• Technical Analysis
• Root Cause Analysis
• Immediate Cause
• Underlying cause
• Root Cause
• Conclusion
• Corrective & Preventive Actions
• Annex
QnA
Effective Incident
Investigation & Reporting

Question & Answers

Assessment
Effective Incident
Investigation & Reporting

Assessment
https://forms.office.com/r/05Z4AK14Yj