An incident is any unplanned event that causes injury or a near miss, or a dangerous occurrence. An incident investigation is the account and analysis of an incident based on information gathered by a thorough examination of all contributing factors and causes involved.
It is widely accepted that incidents occur as a result of a chain of events. Causes of incidents are usually characterized in three main categories: direct, indirect and root causes.
What was the direct cause of the incident? Direct causes are usually actions initiated by the root cause.
What were the latent or hidden causes that led to the incident?
What is the fundamental reason for an event? Root causes are not always immediately evident.
A worker is injured when they tripped and fell over an electrical cord lying across the plant floor.
Direct Cause: electrical cord running across the floor
Indirect Cause: housekeeping, not following safe work procedures, rushing
Root Cause: design of workspace; specifically, not enough electrical outlets
The objective of incident investigation is to determine the root cause or causes of the incident so that corrective measures can be implemented to correct unsafe acts and conditions (hazards), as well as to prevent the incident from recurring.
Incident Investigation Procedures
The investigation would start as soon as reasonably practicable after it occurs. The first priority would be to care for the injured worker. Certain procedures may need to be followed, including lockout, to allow the investigation team to carry out the investigation safely.
A procedure for investigating workplace incidents, accidents and/or dangerous occurrences must be developed and must fit your needs. The procedure should state the following:
- the objective of your investigations (find and correct root causes)
- who investigates what incidents
- what training investigators and incident responders will receive
- who receives the written investigation reports
- who will correct defects found during an investigation
- who follows up on corrective action
- who will prepare a written investigation report including the requirements outlined in Part 2.9(3) of the Manitoba Workplace Safety and Health Regulation
- who keeps what documents and records
- what summary and statistics reports are to be developed and how often these reports will be prepared.