Investigating Incidents: Steps of Investigation

Basic Investigation Procedure

Step 1 : Gathering the information.

Step 2 : Analyze the information.

Step 3 : Identify risk control measures.

Step 4 : The action plan and its implementation

Step 1 - Gathering Information (Where do I start?)

How and what? (Collecting information)

First Casualty care:

First-aid treatment.
Hospitalisation:
Also consider that by-standers may be in shock (mental trauma).Then start the following steps:

1. Secure the accident scene.

2. Identify witnesses.

3. Collect factual information: (Use investigation kit – Camera, Tape recorder, Measuring Tape, Barricade Tape , scissor, scotch tape, PPEs, gloves, plastic envelopes, Accident investigation and report forms, graph paper etc.)

Photo/sketch ,
Videos, CCTV recordings, mobile recording of where the accident occured
Photo of injuries before being treated
Accident scene Measurements.
Investigator Notes.
Mark-up plans. (Blue-Print/ Site Layout)
Samples , damaged parts of Machinery

4. Interview witnesses & witness statements

Medical reports of your injury or illness from a medical professional who examined you at the time of the accident.

5. The report from the company Accident Book, showing the details of your accident and any other similar accidents that have also occurred in the workplace.

6. Examine documents.

Safety of the accident scene: (Secure the accident scene.):

Is the area safe to approach? (e.g. fire , chemical spillage, electrocution etc.)
Is immediate action needed to eliminate danger before casualties are approached?

Why should the scene of the accident have been secured?

Due to the following reasons, the accident scene is secured:

To preserve the physical evidence: After accident, the conditions to be recorded otherwise these evidences may be disappear which will help to identify the root cause, for claim and insurance purpose.
To identify the cause and sequence of events: It provides the memory of what could have happened before, during and after accident as witness can be identified immediately and by site condition, lot of relevant information is revealed.
Easy Gathering the factual information in timely manner: From accident scene, the photos, sketch, drawings, videos, measurements can be taken which will help in successful investigation.
How and what happened: By preserving the accident scene, it would help to recreate and to tell us how & what would have been happened like Safety gate was opened and safety device were not working.
Safe to approach: To ensure area is safe to approach (e.g. undesired machine movement, electrocution etc.) or any immediate action needed to eliminate danger before casualties are attended or investigation team are approached.

Due to the following reasons, the accident scene is secured:

To preserve the physical evidence
To prevent the temper of the evidences
To prevent any alterations to the scene of the accident
To prevent removal of evidences(critical evidences)
To prevent unauthorised access to accident scene (To avoid the unauthorised access at accident scene)
To allow the investigation to start
To allow external bodies to investigate
To prevent the further prevention of loss of material /life , reduce the severity of accident
To prevent the harm to others like other workers
To prevent additional hazards to others
To prevent the additional Risks to others
To ensure the safety of everyone who is involved in process/activity/work
To avoid the liability for any injury or damages
Helps to successful investigate by third parties i.e. enforcement Authorities/ Labour Inspector
Avoid losing of the evidences
Later on , it will help to identify the immediate/underlying/root cause and for claim and insurance purpose.
To identify the cause and sequence of events:
Easy Gathering the factual information in timely manner (Gather useful information about what contributed to the accident directly and indirectly)
Identify How and what happened
Help to recreate the accident scene
Safe to approach for others
Helps to identify the immediate action which are needed to eliminate danger before casualties are attended
Helps to inspection of the area

Witness Interview Technique(steps)

Quiet room, no distractions.
Establish a rapport. (positive image)
Explain the purpose of interview, not about blame.
Use open questions, e.g. Who? What? Where? When? Why? How? (5W1H)
Keep an open mind.
Take notes. (Record) (mobile/video/voice record after permission)
Ask for a written statement from witness.
Thank the witness.

Group Discussion - Question: You have to interview a witness who has just seen his friend injured at work. Suggest some golden rules that should be followed.

Document examination to be done during the investigation.

Site plans & actual Site conditions . ( e.g. exact location of accident and what should be actual site conditions)
Company H&S policy. ( As per policy , employer implement Safety CM or not etc.)
Risk assessments. ( Whether it was General / Generic / Specific done or not.)
Training records. ( What , when , whom –competent worker? )
SSW. E.g. SOP, Methods statement, JSA,PTWs ( Any effective SSW, PTW was followed?)
Maintenance records / Logs . ( Was maintenance done or not , or due for Maintenance of particular plant/ machinery or equipment)
Previous accident reports and relevant near misses. ( Similar Accidents & CAPA, sustainability)
Sickness records. , Staff Turnover Records . ( Health condition of worker before accident ?)
Enforcement notices which constitute previous advice; ( Actions were taken or not , what type of advices given by HSE inspector, their implementation and sustainability etc.)
Legal Compliances ( Legal requirement were met or not?)
Process parameters ( any changes in them)
Working Hours (beyond 8 hours i.e. 12 hours working / Overtime)
Personal details of Employee ( whether he was wilful defaulter or received any warning or censure against that worker), has he received induction and job specific training , Pre joining medical report, Any ill health condition , Health Surveillance report etc.
Weather conditions
Earlier near misses , Worker’s Complaints records
Check sheets
Shift Handover Report
PPE register
In and Out Register of worker
MOC documents , MSDS etc.

Availability of Information—Legal registers, Risk Register, previous examination and Inspection Reports, Personal File, etc.

Group Discussion :

What and WHY documents to be examined during investigation?

Step 2 – Analysing Information

(Find out the cause of adverse events/accidents)

Immediate causes (direct causes):

The immediate causes are the unsafe acts and unsafe conditions that gave rise to the event itself. These will be the things that occurred at the time and place of the accident.

For example, a worker slips on a patch of oil spilt on the floor - immediate causes: the slip hazard (unsafe condition), the worker walking through it (unsafe act).

Unsafe acts. ( Unsafe Behaviour)
Unsafe conditions.

Example-

Driving Forklift Truck at speed,
Opened wrong valve,
Using damaged equipment

Underlying cause : (Intermediate cause) -

The less obvious ‘system’ or ’organisational’ reason for an adverse event happening,

Underlying are the things that lie/hidden behind the immediate causes.

( e.g. Intermediate Reason / Technical Reason/ Technical Failures )

E.g.:

pre-start-up machinery checks are not carried out by supervisors;
the hazard has not been adequately considered via a suitable and sufficient risk assessment;
production pressures are too great etc.
guard removed,
ventilation switched off etc.

Root causes:

The Root cause is the most fundamental and indirect cause of an accident or incident. (Trace the reasons behind the immediate causes.)

Root causes are generally management, planning or organisational failings.

Example-

Failure to identify training needs, assess competence;
Failure to use the Risk assessments,
Failing to be proactive ( like no Safety Inspection etc.)
Failure to involve the workforce in health and safety etc.
Poor management Practices( No maintenance provision)

Management Failure (Root causes)

Root causes are the things that lie behind the immediate causes.

For example, with the slip we described above, the Root causes might be a poorly maintained machine that has leaked oil onto the floor, and a poorly inspected and maintained workshop with broken light-fittings and inadequate lighting levels.

Here, the worker might be blameless on the basis that, given those conditions, the accident was bound to happen eventually.

Examples of failures in the management system/ Root cause/ Basic Cause / Management Failure

Failed to provide effective supervision (No supervision) (Inadequate Supervision )- - - - -(only one-way communication)
Failed to provide the specific PPEs (No PPE provided.)
Failed to provide the induction training & Job-specific training (No training/ inadequate Training)
Failed to provide the proper maintenance schedule (No maintenance.) (Inadequate/ insufficient maintenance) (Maintenance errors)
Inadequate Safety monitoring
Failed to implement the Active monitoring
No Reactive monitoring (No provision of Active and Reactive monitoring ) (Inadequate Safety Monitoring)
No checking or inspections arrangement
Failed to develop and implement the effective risk assessment (Inadequate or no risk assessments.) Failure to carry out the risk assessment (inadequate risk assessment, or no review of RA)
Failed to develop the OH&SMS ,
H&S Policy (Lack of system, Policy )
Failed to provide the adequate resources (Lack of resources)
Failed to provide the effective Internal & External Communication (Lack of Communication) , Inadequate Communication issues e.g. between shifts, between personnel and management etc
Failure to develop effective SSW/SWP)Safe Working Procedures)
Failed to develop / implement the SOP (Inadequate procedures)
Failed to prevent the Violations
Non-compliance behaviour ( Management & young worker behaviour)
Inadequate Housekeeping ( Items stored in the FLT pathway / Aisles)
Disciplinary action not developed
Pressure to meet production targets ( busy retail store )
Failure to learn lessons from previous incidents (Lesson learn not shared) ( e.g. Previous collisions)
Modification/ updates to equipment without operator knowledge and/or revised risk assessments
Failed to act/resolve the Worker’s complaints/concerns
Inadequate SOP ( Not developed any SOP)
Failed to hire competent manpower (Lack of competency) ( e.g. Young worker)
Could not provided the right equipment/plant design (Poor workplace layout, poor design of tools and equipment, Poor workstation set-up)
Not planned & developed any H&SMS (Inadequate safety management systems)
Failed to avoid the Excess workloads, ( e.g 12 hours working, Rota system etc.)
Excessive work demands
Excess physical & mental pressure - - - - - (Excessive working hours resulting in mental fatigue)
Failure to monitor actual performance
Failure to provide feedback
Failed to implement the accident reporting procedure / system (Inadequate reporting systems)
Not implemented any accident Investigation System (ineffective accident investigation system)
Poor management practices e.g. inadequate supervision
Production focus instead of Safety Focus

Difference between Immediate Cause & Root Cause

Inadequate policies & procedures – no clear objectives
Timeliness (Lack of time to complete)
Poor development of information
Change- Management , business, people , technology
Lack of motivation to complete
Reluctance to accept responsibility (Lack of accountability)
Narrow interpretations of Safety rules /Safety causes
Erroneous emphasis on a single cause
Allowing solutions (shortcut) to determine causes
Wrong person(s) investigating- incompetent / biased , lack of investigation skills
Corporate memory loss /short memories – we forget & have to relearn

Step 3 – Identifying Suitable Control Measures

(Identifying risk control measure)

Controls measures should be appropriate to unsafe act and unsafe condition of the worker and management failure. e.g. strict monitoring , trainings to workers.

• Identify the risk control measures which were missing, inadequate or unused

• compare with standards, guidance and good practice

• identify additional measures needed to address the immediate, underlying and root causes

• provide meaningful recommendations which can be implemented.

(e.g. Elimination, substitution, Engineering Control, Administrative & PPES)

For immediate causes: Examples

Clean up the spill.
Replace the missing guard.
Relocate the trailing cable.

For underlying and root causes: (needs investigation)

More difficult.
We need to make changes in management system.

Step 4 – The action plan & its implementation

Remedial action should focus the prioritise to be given , within the timescale and action to be taken along with personal responsible to complete the action.

Need for prioritisation - Dangerous conditions must be dealt with immediately.
Interim actions may be possible.
Underlying causes and Management failure will require more complex actions- It will take time, effort, disruption, money etc.