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Incident Investigation Instructions

Why investigate?

Your job as a supervisor is to promote a safe, smooth flow of work, free from interruptions. To perform this work, each department or work group operates a system made up of people, equipment, tools, scheduling, methods and procedures. An incident investigation is a tool to find and solve problems in your department's system. When one of the elements is not functioning properly, an incident can occur. We investigate incidents to:

  • discover what caused the incident (what part of the system broke down and why) and
  • eliminate the causes to ensure that employees are not harmed during their work and that work continues as planned

If your incident investigation accomplishes these two objectives you have conducted a productive incident investigation (or analysis).

When to conduct an investigation?

  • All injuries (even the very minor ones)
  • All accidents with a potential for injury
  • Events involving unsafe conditions or property damage
  • All Near Misses where there was a potential for serious injury

Who should investigate?

You. The incident occurred in your department and it was your employee who was injured (or almost injured). You want to know what happened and why. Investigating an incident is a responsibility you should not delegate to anyone else, although you should definitely call on available resources with the expertise you need. This can include a safety manager, industrial hygienist, electrician or other tradesperson with knowledge of the systems you are investigating.

The Goal or Objective of the Investigation

The goal is to find out what happened and determine the immediate and underlying or root causes. The goal is NOT to lay blame. An investigation allows you to rethink a safety hazard and discover ways to prevent a reoccurrence. An Incident has occurred, what do you do?

  • Gather information
  • Interview Witnesses (preferably separately)
  • Interview other interested persons.
  • Review records (Training records, maintenance records, previous investigations, drawings, etc.)
  • Develop a sequence of events using events and causal/contributing factors diagram;

Someone unfamiliar with the incident should be able to clearly determine the facts of the incident by reading your investigation.

Investigate or analyze incident

  • Analyze the accident and collected data
  • Focus on causal and contributing factors

Ask why or how this could have happened? Very often, the answer to the first "why" will prompt another "why" and the answer to the second "why" will prompt another and so on; This is known as the "Five whys" technique to drill down to the reason the event occurred. The Five Whys method helps you to quickly determine causal factors of an event; it's simple, and easy to learn and apply.

Consider hazardous conditions

  1. Materials
  2. Machinery
  3. Equipment
  4. Tools
  5. Chemicals
  6. Facilities
  7. Environment
  8. People
  9. Workload

Consider unsafe behavior of employee/supervisor

  1. Failing to comply with rules
  2. Safety & departmental policies/procedures/rules not enforced
  3. Using unsafe methods
  4. Taking shortcuts
  5. Failing to report injuries
  6. Failing to report hazards
  7. Allowing unsafe behaviors
  8. Failing to train or attend training
  9. Safety and craft/technical training not conducted
  10. Failing to supervise or follow procedure
  11. Failing to correct others
  12. Scheduling too much work pushing production
  13. Ignoring worker stress

Consider root causes

  1. Equipment design
  2. Inadequate or missing safety procedures and rules
  3. Training program not in place or less than adequate
  4. Inadequate work process or procedure; facilities layout
  5. Non-existent preventative maintenance or less than adequate

Determine corrective actions to prevent recurrence.

Corrective actions must be assigned formally to a responsible party if they cannot be immediately corrected by the supervisor. Share the incident investigation with the Safety Committee, ESSR or senior management for support in correcting system-wide deficiencies.