OCCUPATIONAL HEALTH AND SAFETY Dr.
Khizer Mehmood
INCIDENT INVESTIGATION
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INCIDENT INVESTIGATION
Accident
an event that results in injury or ill health
Incident:
– near miss: an event that, while not causing harm, has the potential to cause
injury or ill health. (In this guidance, the term near miss will be taken to include
dangerous occurrences)
– undesired circumstance: a set of conditions or circumstances that have the
potential to cause injury or ill health, eg untrained nurses handling heavy
patients.
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INCIDENT INVESTIGATION
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INCIDENT INVESTIGATION
The causes of adverse events
Adverse events have many causes. What may appear to be bad luck (being in the
wrong place at the wrong time) can, on analysis, be seen as a chain of failures and
errors that lead almost inevitably to the adverse event. (This is often known as the
Domino effect.)
These causes can be classified as:
Immediate causes: the agent of injury or ill health (the blade, the substance, the dust
etc.);
Underlying causes: unsafe acts and unsafe conditions(the guard removed, the
ventilation switched off etc.);
Root causes: the failure from which all other failings grow, often remote in time and
space from the adverse event (eg failure to identify training needs and assess
competence, low priority given to risk assessment etc.).
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INCIDENT INVESTIGATION
The causes of adverse events
Each domino represents a failing or error which can combine with other failings and errors to
cause an adverse event. Dealing with the immediate cause (B) will only prevent his sequence.
Dealing with all causes, especially root causes (A) can prevent a whole series of adverse
events.
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INCIDENT INVESTIGATION
Incident Reporting
Incident Reporting is a critical component of any workplace or business. Without a mechanism
to report when incidents have occurred, it is challenging to understand whether processes
prevent future incidents from occurring. Yet, even with a sound reporting system, incidents
may not be reported because people feel uncomfortable, or the incident is viewed as
‘insignificant’ and not worth reporting.
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INCIDENT INVESTIGATION
Incident Reporting Benefits
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INCIDENT INVESTIGATION
Incident Report Format
The layout of information in an incident report form may vary depending on a number of factors. As a general rule,
you should write incident reports in the third person since its purpose is to be objective; stating only facts and
avoiding the inclusion of opinions and biases. Below is an example incident reporting format you can use for your
operations.
Introduction: The first part of the incident report form covers the who, what, when, and where of the incident: Include
the names of all the people involved in the incident. If names are not available, you can instead cite the person’s role
in relation to the incident e.g. the customer, the guest, Summarize the incident itself in no more than three sentences
e.g. a printer caught fire causing minimal damage to a room, Include the time and date of occurrence. An estimate
works if the exact time could not be noted, Note the location of the incident and be exact if possible.
Body: This is where you lay out all of the incident’s details in a comprehensive manner. Talk about the incident from
start to finish, ensuring details are laid out in chronological order to avoid confusion. Make sure to include the who,
what, when, and where mentioned in the introduction when they are mentioned.
Conclusion: Was the incident resolved? How? If the incident was not resolved, explain why, and provide the steps
that need to be taken in order to resolve it.
Sign off: Include the full name and signature of the incident report writer for accountability and record-keeping.
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INCIDENT INVESTIGATION
Incident Reports’ Importance
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INCIDENT INVESTIGATION
Why investigate?
There are hazards in all workplaces; risk control measures are put in place to
reduce the risks to an acceptable level to prevent accidents and cases of ill
health. The fact that an adverse event has occurred suggests that the existing
risk control measures were inadequate. Learning lessons from near misses can
prevent costly accidents.
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INCIDENT INVESTIGATION
Benefits arising from an investigation
• The prevention of further similar adverse events. If there is a serious accident,
the regulatory authorities will take a firm line if you have ignored previous
warnings.
• The prevention of business losses due to disruption, stoppage, lost orders and
the costs of criminal and civil legal actions.
• An improvement in employee morale and attitude towards health and safety.
Employees will be more cooperative in implementing new safety precautions
if they were involved in the decision and they can see that problems are dealt
with.
• The development of managerial skills which can be readily applied to other
areas of the organization.
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INCIDENT INVESTIGATION
Steps to take following an adverse event
Emergency response:
Take prompt emergency action (eg first aid);
Make the area safe (in some cases this may need to be done first).
Initial report:
Preserve the scene;
Note the names of the people, equipment involved and the names of the
witnesses;
Report the adverse event to the person responsible for health and safety who
will decide what further action (if any) is needed.
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