Health and Safety Committees – Refresher Course
Topic 11 – Incident investigation
When it comes to incident investigation, you need to agree with management to which extent the committee is going to get involved. Incident investigation is not for everybody, particularly if you are dealing with a serious one.
When a serious incident occurs, known under the law as a “notifiable incident”, the law requires certain steps to be followed, including reporting the incident immediately to the regulator and then they will tell you how to proceed.
But of course, a safety committee ought to be involved in incident investigation but its role should be clearly defined in consultation with management. The investigation of safety complaints, near misses and of course the review and follow up of any incident should be part of the committees functions. This way the Safety Committee can make an important contribution to prevent a recurrence of the incident.
In your course manuals there is a short and an extended version of an incident investigation process. A breakdown of the short version is as follows:
1) Establish the facts of the incident.
This can be done by by interviewing people, visiting the site, if safe to do so, taking pictures, videos, making sketches etc.
This includes information on for instance equipment, tools, substances, instructions, procedures but also people behaviours.
Consider what happened before, during and after the incident.
2) Establish what should have happened
Establish what should have happened by confirming, for instance, what equipment, substances, tools, procedures and information should have been used and who should have been involved including their behaviours.
3) Analyze and compare both sets of data
This analysis may show discrepancies between both sets of data. Based on these findings, the Safety Committee should make recommendations to improve the management system.
The Committee should focus on improvements to policies, procedures and processes and not blame individuals. If analysis by management shows that individuals have done the wrong thing, then disciplinary procedures may be commenced but this is the responsibility of management.
The full responsibility for an effective incident investigation lies with management. The Committee can play an assisting role.
Incident investigation is not easy and particularly interviewing people can be quite stressful for both the person being interviewed and the interviewer. An investigation will look to identify immediate and underlying causes of an incident. Underlying causes are often related to the safety culture of an organization.
For example, an immediate incident cause could be speeding or an unguarded machine.
Underlying causes are those that have allowed those unsafe conditions and or behaviours to occur in the first place. So a typical example of an underlying cause is, for instance, a lack of management commitment to safety. Often this is related to the safety culture of an organization.
Now, when you’re interviewing people, this can be quite difficult and stressful. In your course manual you will find an incident investigation tool and the first page of that tool sets out six areas where failures can occur and that you can ask questions about.
On the second page of the incident investigation tool, each area is worked out with a set of prompts and each prompt can be used as a question.
As in any other template, it needs to be modified to suit the organization.
Incident reporting
Incident investigations can be carried out at different levels of detail and formality. Some incidents may be classified to be minor and may be dealt with in an informal manner.
Other incidents, regardless whether an injury occurred or not, may be classified to be of significant importance and will be dealt with in a much more formal and detailed process.
It is important to realize that this incident classification must only be made by management. Management will also determine the level of investigation required and who should be involved. This may mean that the safety regulator needs to be notified.
From a general incident reporting perspective, regardless how minor an incident appears to be, it must be reported to management so that they can determine what level of investigation needs to take place.