Table of Contents
Incident Investigation Policy
Incident Investigation is an essential tool that is used to determine the causal factors of incidents in workplaces. A comprehensive, systematic Incident Investigation carried out with consultation can significantly assist to implement proactive prevention and intervention strategies to reduce the potential for further incidents of the same or similar nature.
Objective: The primary purposes of an incident investigation are to:
- Identify the factors that contributed to the incident so that action and control procedures can be implemented to prevent the recurrence of a similar incident
- Identify the “change” in systems or processes that lead to the error
- Establish a systematic method of recording causation of serious incidents
- Determine compliance with legislation
- Use a process, which encompasses the principle of Natural Justice to determine the causation of incidents
- Improve systems of work, policy and procedures to eliminate or at least lower the number and severity of workplace incidents.
The investigation intends to determine what happened and what it was that went wrong to allow the incident to occur. The intent is not to establish blame of any person but to identify any causal factors and their effects.
Scope: This procedure covers the formal investigation of incidents at A2Z Services. In the event of a Serious Incident or Dangerous Occurrence, an Incident Investigation is carried out “internally” by Responsible Person(s) at A2Z Services on behalf of the PCBU.
Incident Investigation Procedure
When an investigation shall take place: The requirement and the circumstances in which it is necessary to conduct an incident investigation is aligned with the Incident Reporting Policy, Incident Reporting Procedure and legislative requirements. Incident Investigations may be required to start immediately and complete within 24 hours after a notifiable incident. Note: ‘incidents’ include Near misses/near hits.
The Incident Investigation Team: The size and makeup of the Incident Investigation Team will depend upon the type and seriousness of the incident and injury. It is the responsibility of the PCBU directly involved to establish an Incident Investigation Team.
The size and makeup of the team will be influenced by, but not limited to:
- Type of incident
- Type of injury/injuries
- Seriousness of injury/injuries (severity)
- Number of person(s) injured
- Number of person(s) in that workplace
- Size of the workplace
- Types and complexities of the activities undertaken
- Hazards and risks
In the case of a notifiable incident involving a permanent injury, illness or death of a person an indicative Incident Investigation Team would be composed of the following person(s);
- The PCBU/Business owner
- The Senior Manager
- The person(s) involved (if possible)
- The person(s) supervisor
- The Field Supervisor and Workplace Supervisor
- A Health and Safety Representative
- A person with specialised knowledge of hazards involved in the incident. E.g. a person with chemical training and qualifications if the event involves chemicals, an electrician if the incident involves electricity.
How to conduct the investigation: Investigators shall avoid any emphasis on identifying any individual for the incident. The level of effort involved in the inquiry will depend mainly on the incident severity or potential severity. Regular and supportive consultation between management and the members of the Incident Investigation Team members will be an essential part of the investigation process.
Conduct the investigation with full cooperation with officers and Inspectors from relevant State Authorities (e.g. WorkSafe, police, Emergency Services etc.) and following legislative requirements and the principals of Natural Justice.
The investigators shall:
- Visit the scene of the incident before the physical evidence is disturbed
- Collect samples of any substance, which may have contributed, to the incident, noting conditions that may have affected the example. (Using Personal Protective Equipment if required)
- Make comprehensive visual records, e.g. video, photos, diagrams
- Preserve incident-related items
- Identify and interview the people who were involved in the incident including eyewitnesses
- Review all sources of potentially useful information. These may include original designs, design specifications, drawings, operation records, purchasing records, previous reports, maintenance records, SWMSs, standard operational procedures, inspection and testing records, staff training records
- Identify and analyse all of the contributing (causal) factors as evidenced by the facts. Keep an open and objective mind
- Determine and document interim and long-term control measures, aiming at preventing the recurrence of similar incidents. The determination and implementation of control measures should be based on the hierarchy of control principles and made in consultation with all members of the investigation team, and when appropriate, the Principal Contractor
- Complete the relevant sections of an Incident Investigation Checklist and Action Report Form (OF0027)
- Maintain a high level of confidentiality and professionalism before, during and after the investigation.
Evaluation: Upon completion of the investigation, the PCBU, Senior Managers and Investigating Officers will have completed an Incident Investigation Checklist and Action Report Form (OF0027). Submit this report for assessment and action to:
- The PCBU
- The Senior Manager
- The relevant Field Supervisor
- Any applicable Principal Contractor and Workplace Supervisor
- The relevant investigating Regulator, if required.
Corrective Measures (Control Actions): Any hazardous situation and causal factor identified during the investigation must not be allowed to remain, without attention, while the proposed control actions are pending.
It is the responsibility of the relevant Senior Manager to ensure that any interim and long-term corrective measures identified by the Incident Investigation are carried out are useful, and are communicated to all related person(s). Temporary and long-term remedial actions and any preventative measures must be signed off by the relevant Senior Manager on an Incident Investigation Checklist and Action Report Form (OF0027) once completed.
Records: The Investigation Report form will be filed and kept in the PCBU’s Head Office in a secure, confidential and appropriate environment, in alignment with the Document Control Policy and Procedure. Review of the Incident Investigation file shall be conducted on a regular basis to address all corrective and preventative measures. A2Z Services will maintain the records for a minimum of thirty (30) years.
Guidance Notes for Incident Investigation
| Incident Causation Factors | |
| Events leading up to the incident (at least to think about): | The system of work adopted The instructions, if any, given to the worker for the work to be done Any alternative method or variation from instructions given Workplace conditions such as lighting, floor surfaces, warning signs, temperature, etc. |
| Facts of the incident – it is important to determine: | What happened at that exact moment? The person(s) directly involved The tools, plant, equipment, substances and materials that were used at the time The time it happened. |
| What occurred immediately after the incident: | The injuries or damage incurred What did the person(s) involved do when the incident happened? Any problems, damage or faulty equipment identified during the incident scenario. |
Interviewing person(s)
Ask witnesses questions that vary with each incident and determined on a case-by-case basis. Indicative witness questions:
- Where were you at the time of the incident?
- What were you doing at the time?
- What did you see or hear?
- What were the environmental conditions at the time?
(e.g. weather, light, noise, restricted access etc.)
- What was the injured person doing at the time of the incident?
- Was the injured person using any plant, equipment, tools or chemicals at the time of the incident?
- In your opinion, what may have caused or contributed to the incident?
- Was anyone else present at the time of the incident?
- Did you notice anything unusual that you feel is significant to mention?
During the interview process ensure:
- To use a quiet, non-threatening location
- To conduct the investigation discussion in private at the workplace
- The interviewee knows the purpose of the interview is to gather the facts and that the investigation is not to seek blame but rather a basis for the development of preventative action
- The interviewee tells his or her own story revealing the worker(s)’ version
- The interviewer repeats what is said to ensure that it was understood
- The person being interviewed reads through any written statements they make and they sign them
- The interview is not interrupted
- Do not prompt the interviewee
- The interviewer takes into account any ‘special needs’ presented by the interviewee, which may require interview procedures to be modified. For example:
- A reader/writer for person(s) with low literacy skills
- A writer for person(s) who are unable to write due to injury or illness
- An accompanying adult (parent/guardian) for person(s) under the age of 18 years.
General suggestions:
- Do not take sides or offer personal opinions
- Be friendly; speak in calm, low tones. Be aware of your body language
- Do not rush the interview
- Use language, which is familiar to the interviewee. Avoid using complex vocabulary.
- Allow the person being interviewed to have their say, listen to what they have to say, but discourage inappropriate or irrelevant discussion
- Always ensure the interview closes on a positive note.
Forms and Registers
| Document Number | Document Name |
| OF0027 | Incident investigation and Actions Form |
| OF0023 | Incident and Near Miss Report Form |
| OM00026 | Incident Reporting Policy |
| OF0077 | Hazard report Form |
| OF0029 | Discomfort Survey |
Amendment Record
Issue#: 1 Issue Date: 13/7/2022
| Rev# | Date | Section# | Para.# | Description of Change | Prepared By | Approved By |
| 1 | ||||||
| 2 | ||||||
| 3 |
Click here to download OM00027 – Incident Investigation Policy in PDF Format
Disclaimer: This documentcontains material to assist in meeting environmental management, Work Health and Safety and Quality obligations under the International Standard ISO AS/NZS ISO 9001:2016,14001:2016 and other legislative bodies. This document contains material sourced from Safe Work Australia. Any such material remains subject to copyright © Commonwealth of Australia. https://www.safeworkaustralia.gov.au/copyright. Although every effort has been made to ensure the accuracy of this information at the time of publication, it is provided as guidance only and does not provide legal advice on meeting your obligations. This document and its contents are © A2Z services 2018 and or the originating source authors and no permission is given for its duplication or copying, in part or in its entirety, for use outside its original purposes as stated within the company.