OCCUPATIONAL HEALTH AND SAFETY Dr.
Khizer Mehmood
INCIDENT INVESTIGATION
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INCIDENT INVESTIGATION
Steps to take following an adverse event
The decision to investigate
In a minimal level investigation, the relevant supervisor will look into the circumstances of the event
and try to learn any lessons which will prevent future occurrences.
A low level investigation will involve a short investigation by the relevant supervisor or line manager
into the circumstances and immediate, underlying and root causes of the adverse event, to try to
prevent a recurrence and to learn any general lessons.
A medium level investigation will involve a more detailed investigation by the relevant supervisor or
line manager, the health and safety adviser and employee representatives and will look for the
immediate, underlying and root causes.
A high level investigation will involve a team-based investigation, involving supervisors or line
managers, health and safety advisers and employee representatives. It will be carried out under the
supervision of senior management or directors and will look for the immediate, underlying, and root
causes.
2 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation
The four steps include a series of numbered questions. These set out in detail the information
that should be entered onto the adverse event investigation form. The question numbers
correspond to those on the form.
Step one Gathering the information
Find out what happened and what conditions and actions influenced the adverse event. Begin
straight away, or as soon as practicable.
3 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation: Step one Gathering the information
1 Where and when did the adverse event happen?
2 Who was injured/suffered ill health or was otherwise involved with the adverse event?
3 How did the adverse event happen? Note any equipment involved.
4 What activities were being carried out at the time?
5 Was there anything unusual or different about the working conditions?
6 Were there adequate safe working procedures and were they followed?
7 What injuries or ill health effects, if any, were caused?
8 If there was an injury, how did it occur and what caused it?
4 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation: Step one Gathering the information
9 Was the risk known? If so, why wasn’t it controlled? If not, why not?
10 Did the organization and arrangement of the work influence the adverse event?
11 Was maintenance and cleaning sufficient? If not, explain why not.
12 Were the people involved competent and suitable?
13 Did the workplace layout influence the adverse event?
14 Did the nature or shape of the materials influence the adverse event?
15 Did difficulties using the plant and equipment influence the adverse event?
16 Was the safety equipment sufficient?
17 Did other conditions influence the adverse event?
5 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation: Step two Analyzing the information
An analysis involves examining all the facts, determining what happened and why. All the
detailed information gathered should be assembled and examined to identify what
information is relevant and what information is missing. The information gathering and
analysis are actually carried out side by side. As the analysis progresses, further lines of
enquiry requiring additional information will develop.
To be thorough and free from bias, the analysis must be carried out in a systematic way, so
all the possible causes and consequences of the adverse event are fully considered. A
number of formal methods have been developed to aid this approach.
18 What were the immediate, underlying and root causes?
6 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation: Step two Analyzing the information
What Happened and Why?
The first step in understanding what happened and why is to organise the information you
have gathered. This guidance uses the simple technique of asking ‘Why’ over and over, until
the answer is no longer meaningful. The starting point is the ‘event’, eg John has broken his
leg. On the line below, set out the reasons why this happened. This first line should identify: n
the vulnerable person, eg John on a ladder; and the hazard, eg falling due to gravity; n
the circumstances that brought them together, eg John fell off the ladder.
7 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation: Step two Analyzing the information
What if ‘human failings (errors and violations)’ are identified as a contributory factor?
If your investigation concludes that errors or violations contributed to the adverse event,
consider carefully how to handle this information. Not addressing the ‘human’ factors greatly
reduces the value of the investigation. The objective of an investigation is to learn the lessons
and to act to prevent recurrences, through suitable risk control measures. You will not be able
to do that unless your workforce trusts you enough to co-operate with you.
8 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation: Step two Analyzing the information
When considering how to avoid human failings, bear in mind the fact they do not happen in isolation. If human
failings are identified as a cause of an adverse event, consider the following factors that can influence human
behavior.
Job factors:
how much attention is needed for the task (both too little and too much can lead to higher error rates)?
divided attention or distractions are present;
inadequate procedures;
time available.
Human factors:
physical ability (size and strength);
competence (knowledge, skill and experience);
fatigue, stress, morale, alcohol or drugs.
9 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation: Step two Analyzing the information
Organizational factors:
work pressure, long hours;
availability of sufficient resources;
quality of supervision;
management beliefs in health and safety (the safety culture).
Plant and equipment factors:
how clear and simple to read and understand are the controls?
is the equipment designed to detect or prevent errors? (For example different sized connectors are
used for oxygen and acetylene bottles to prevent errors in connecting the hoses);
is the workplace layout user-friendly?
10 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation: Step three Identifying suitable risk control measures
The methodical approach adopted in the analysis stage will enable failings and possible
solutions to be identified. These solutions need to be systematically evaluated and only the
optimum solution(s) should be considered for implementation. If several risk control measures
are identified, they should be carefully prioritized as a risk control action plan, which sets out
what needs to be done, when and by whom. Assign responsibility for this to ensure the
timetable for implementation is monitored.
19 What risk control measures are needed/recommended?
20 Do similar risks exist elsewhere? If so, what and where?
21 Have similar adverse events happened before? Give details.
11 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD
INCIDENT INVESTIGATION
The investigation: Step four The action plan and its implementation
22 Which risk control measures should be implemented in the short and long term?
23 Which risk assessments and safe working procedures need to be reviewed and updated?
24 Have the details of adverse event and the investigation findings been recorded and
analyzed? Are there any trends or common causes which suggest the need for further
investigation? What did the adverse event cost?
12 DECE,FET,INTERNATIONAL ISLAMIC UNIVERSITY,ISLAMABAD