Apply Specialist Incident Investigation Techniques to a Specific Incident in a Work Environment
This Health and Safety Course has been designed for persons who are required to demonstrate the ability to
conduct specialist investigations into workplace incidents.
During this workshop you will participate in the following :
Theory and Principles of Incident Investigation
What are the key principles of an incident investigation?
Initial Responses at the Incident Scene
What are the required initial responses at the scene?
Conducting the Investigation
What is the process to follow when conducting an investigation?
After completing this course you will be able to:
Explain the theory and principles of incident investigation.
Explain the initial response required at an incident scene.
Investigate the incident, gather evidence and describe the review/follow-up processes
The Theory and Principles of Incident Investigation
Losses in terms of financial, social, emotional and environmental impacts are explained with regard to incident
The term “accident” can be defined as an unplanned event that interrupts the completion of an activity, and that
may (or may not) include injury or property damage.
An incident usually refers to an unexpected event that did not cause injury or damage this time but had the
potential. “Near miss” or “dangerous occurrence” is also terms for an event that could have caused harm but did
Please note: The term incident is used in some situations and jurisdictions to cover both an “accident” and “incident”. It is argued that the word “accident” implies that the event was related to fate or chance. When the
root cause is determined, it is usually found that many events were predictable and could have been prevented if
the right actions were taken — making the event not one of fate or chance (thus, the word incident is used). For
simplicity, we will use the term accident to mean all of the above events.
The information that follows is intended to be a general guide for supervisors or joint occupational health and
safety committee members. When accidents are investigated, the emphasis should be concentrated on finding the
root cause of the accident rather than the investigation procedure itself so you can prevent it from happening
again. The purpose is to find facts that can lead to actions, not to find fault. Always look for deeper causes. Do not
simply record the steps of the event.
Reasons to investigate a workplace accident include:
Most importantly, to find out the cause of accidents and to prevent similar accidents in the future
To fulfil any legal requirements
To determine the cost of an accident
To determine compliance with applicable safety regulations
To process workers’ compensation claims
Incidents that involve no injury or property damage should still be investigated to determine the hazards that
should be corrected. The same principles apply to a quick inquiry of a minor incident and to the more formal
investigation of a serious event.
The cost of workplace injury isn’t just financial. It has a human, social and organisational and economic cost.
A workplace accident can have catastrophic effects on the quality of life of the worker and also have a devastating
effect on family and friends. When workers are incapacitated they will be given some financial compensation but
their life has been changed forever. As a parent the loss of a leg will mean that running around with your children
is gone forever. Even if the injury is only a temporary injury, the loss of confidence a worker will sustain may
permanently affect their ability to work happily and efficiently.
The mental health of a worker can be seriously affected after an accident. Depression after an accident is common,
especially where there are lasting . Relationships can be seriously affected, as living with a person
who has been permanently injured and is suffering depression is very stressful and can result in the breakup of a
marriage. In some cases Post Traumatic Stress Disorder (the term for a severe and on-going emotional reaction to
trauma) is suffered by the injured worker. It can also affect colleagues who witnessed or were involved in the
E.g. A permanently incapacitated worker has to be supported by the community and in many cases is no longer
able to contribute to the community.
A worker who has been injured needs a great deal of support. Occupational rehabilitation services are used to
rehabilitate workers to assist them in their return to work. Prior to a worker returning to work, the occupational
rehabilitation service may need to visit the workplace to ensure the worker will be able to physically cope.
Sometimes, special ergonomic furniture is required to allow the worker to be comfortable in the work environment.
Some injuries cause permanent chronic pain which means the injured worker will need pain management and
Financial compensation doesn’t really compensate for the loss of the ability to earn an income for the remainder of
your working life. Continued medical costs and home care costs soon consume the insurance pay-out and the
injured worker is forced to spend the remainder of their life on an invalid pension. This results in a further
decrease in the standard of living the worker previously sustained before the accident.
When an employee is injured, it means they cannot work. The company must then find a replacement worker and
train them in the job. This costs the company time as well as money. Lost productivity while a new worker is
trained is expensive for any company. Other workers may be affected by the accident and lose confidence due to
concerns over their own safety.
Other costs to the company include damaged equipment, increased insurance premiums, fines from Work Cover
and damage to the reputation of the company.
Key Functions of Respective Team Members during the Investigation Process
Key functions of respective team members during the investigation process are explained.
A number of specific roles must be filled subsequent to an incident; the main responsibilities of these roles are as
Incident Responsible Person (IRP)
Have ultimate responsibility for ensuring that incidents are appropriately assessed, classified, investigated and
When necessary, appoint an Investigation Team Leader (ITL) to lead the incident investigation;
Ensure that all actions arising from the incident are appropriate and auctioned, and that the incident is closed
out in a timely manner.
Investigation Team Leader (ITL)
The ITL must:
Where appropriate, be the person who is responsible for the task/group of personnel involved with the incident
as this person will ultimately be responsible for correcting most of the identified in the investigation.
Alternatively, an independent person could act as ITL to ensure impartiality with respect to the investigation;
Not have been personally involved in the incident;
Be competent to lead an investigation and familiar with investigation principles;
Together with the IRP, appoint relevant personnel to the Investigation Team;
Lead the team to effectively investigate the incident;
Determine underlying causes and establish follow-up actions;
Investigation Team Leader (ITL)
Members of the Investigation Team must be experienced, but must not have been directly involved in the incident.
The Team shall comprise as a minimum:
ITL (not necessarily the most senior person in the team);
Relevant Supervisor/Manager (shall be included in the investigation team even if not appropriate to be the ITL);
OHS Representative and/or OHS Committee members.
The Investigation Team may also include:
Representatives of disciplines involved in the incident;
Relevant technical engineers/experts;
Third parties and/or contractor representatives involved in the incident;
What should be included in incident investigation procedures?
Investigation procedures for incidents must fit your needs. Ideally, they should state:
The objective of your investigations (find and correct )
Who investigates what incidents
What training investigators and incident responders will receive
Who receives the written investigation reports
Who must fix defects found during an investigation
Who follows-up on corrective action
What investigation reports and follow-up records will be kept
Who keeps what documents and records
What summary and statistics reports are to be developed and how often these reports will be prepared
Depending on the circumstances, persons with expertise may be called upon to be involved or actually conduct the
investigation. The determining factor for involving an expert relates to the severity and complexity of the incident.
For example, in the case of a fire, outside experts in fire investigation will be utilized.
If the investigator is not familiar with machinery involved in an incident, he or she should consult someone who
has experience and skill in a particular situation. Sometimes a subject matter expert (SME) on the process/activity
in question can play an important role during the investigation.
Specialist Incident Investigation Techniques
Specialist incident investigation techniques required at a specific incident are identified and explained.
The process of investigating an incident involves gathering evidence, analyzing it then making recommendations in
a written report.
Basic Incident Investigation Methodology
All information and evidence relating to the incident, as well as to the events and conditions leading up to the
incident, should be gathered. Evidence is considered to be anything which records or shows clearly a course of
events or actions taken before and at the time of the incident. In order to determine what happened to cause the
incident and how it happened, the Incident Investigation Team needs answers to the following: WHO, WHAT,
WHEN, WHERE and WHY. Effective evidence preservation is the key building block to answering these questions
and achieving a successful investigation. The 4 types of evidence, known as the Four P’s, are Position, People,
Parts and Paper.
Determine the Scope of The Investigation
As discussed previously, under who should conduct an incident investigation, it is recommended that a plan be
developed which identifies who will conduct investigations and under which circumstances investigations are
performed. A plan of this nature will aid greatly in determining the scope. Every incident is unique and requires an
investigation tailored to the particular situation. Take the time up front to determine the techniques that will be
employed, sequence of events, data to be analyzed, individuals involved and expected outcomes. Factors to
1. What resources are needed to perform the investigation? (staff, equipment, budget and time)
2. Investigation Kit:
Investigation checklist, investigation form,
High visibility tape, pencils, pens,
Measuring tape, clipboard, camera/video camera with film/tape, graph paper, plastic bags & envelopes,
notepaper, flashlight, ruler
3. Safety Equipment:
Hard hat, eye protection,
Hearing protection, protective clothing,
4. What will be the deliverable (output)?
Internal report to management,
Communication to the media, workers, union, associations,
5. What is your attitude regarding the investigation?
The investigator(s) must be seen as sincere, impartial and knowledgeable (in terms of the techniques of
conducting an incident investigation). It is important that the investigator exhibit behaviour of non-judgment
and diplomacy. Much of the success of the investigation depends on the investigator’s attitude, approach and
communication style. Some tips to consider:
Biases (Individual, Team, Others?)
Your experience and skills (how it affects your perception)
Avoid jumping to conclusions
Use appropriate voice tone
Minimize stress wherever possible
Be aware of your non-verbal communication (e.g. facial expressions, gestures)
Behave professionally (be a representative of your company’s and health culture, courteous, open,
honest, candid, non-threatening)