How to Investigate Incidents in the Workplace

Incident investigation in the workplace is a critical process for preventing future incidents and ensuring a safe work environment. A proper investigation is fact-finding, not fault-finding.

The primary objective of incident investigation is to identify the root causes (both immediate and systemic) so that corrective actions can be implemented to prevent recurrence.

Steps in Incident Investigation

Step 1: Immediate Response (Secure the Scene)

Ensure medical help for the injured.
Secure the area to prevent further injury or disturbance of evidence. Use caution tape, lock out equipment, or shut down processes if necessary.
Preserve evidence. Do not clean up, move tools, or alter the scene until evidence is collected (unless necessary for safety).

Step 2: Assemble the Investigation Team

Include people with direct knowledge of the work and area. Team may consist of:

A supervisor or manager.
A safety officer/representative.
An experienced employee from the area.
A health and safety committee member.
Technical experts (engineer, mechanic) if needed.
Ensure the team has the authority and resources to conduct a thorough investigation.

Step 3: Gather Information & Evidence

Collect facts from multiple sources as soon as possible while memories are fresh.

A. Physical Evidence:

Photograph/Videotape the scene from multiple angles, including:
Overview of the area.
Equipment, tools, and materials involved.
Environmental conditions (lighting, spillage, weather if outdoors).
Close-ups of specific components or defects.
Examine equipment/machinery. Look for defects, failures, position of guards, controls, maintenance records.
Collect samples or preserve defective parts (if safe and permissible).

B. Documentary Evidence:

Check relevant documents: Procedures (SOPs), work permits, training records, maintenance logs, previous inspection reports, past incident reports for similar events.

C. Human Evidence (Witness Interviews):

Interview witnesses individually and in a private setting.
Use open-ended questions: “What did you see/hear?” “Describe the work being done…” “What happened before, during, and after the event?”
Avoid leading questions: “Was the guard removed?” is leading. Instead ask: “Describe the condition of the machine’s safety features.”
Interview the injured worker(s) if medically able.
Reassure witnesses that the goal is prevention, not blame. Document their statements accurately.

Step 4: Analyze the Facts to Determine Causes

This is the core of the investigation. Don’t stop at the obvious.

1. Identify the Immediate Cause(s):

The direct, visible cause of the injury or damage (e.g., “Worker’s hand contacted the rotating blade,” “Slipped on an oily floor”).

2. Identify the Underlying (Root) Causes:

These are the system failures that allowed the immediate cause to exist. Use models like “The 5 Whys” to drill down.
Why did the hand contact the blade? The guard was missing.
Why was the guard missing? It was removed for cleaning.
Why was it removed for cleaning without locking out? The procedure was unclear and lockout wasn’t required by the SOP.
Why was the procedure unclear? It hadn’t been updated after a machine modification.
Why wasn’t it updated? No formal management review process for procedure updates existed. ← Root Cause

Common root cause categories include:

Unsafe Acts: (Performed by people) – bypassing safety procedures, inadequate training, rushing, fatigue.
Unsafe Conditions: (In the workplace) – defective equipment, poor housekeeping, inadequate guards, noise, hazards.
Systemic/Management Factors: (Most critical) – inadequate training programs, poor safety culture, missing or poor procedures, lack of supervision, failure to identify hazards, pressure for production over safety.

Step 5: Recommend Corrective Actions

Develop specific, actionable, and measurable recommendations for each root cause identified.
Assign a responsible person and a target completion date for each action.
Hierarchy of Controls: Prioritize solutions that are most effective:
Elimination – Physically remove the hazard.
Substitution – Replace the hazard.
Engineering Controls – Isolate people from the hazard (e.g., guards, ventilation).
Administrative Controls – Change the way people work (e.g., procedures, training, signage).
PPE – Protect the worker with personal equipment (least effective, as a last line of defense).

Step 6: Write the Investigation Report

A clear report is essential for communication and accountability. It should include:

Executive Summary: Brief overview of what, when, where, who, and immediate outcome.
Background: Details of the incident, people involved, and investigation team.
Factual Findings: Evidence collected (photos, interviews, documents).
Analysis & Root Causes: Immediate and root causes (use a logic tree or timeline if helpful).
Recommended Corrective Actions: With priorities and assignments.
Appendices: Supporting evidence (photos, interview notes, diagrams).

Step 7: Follow-Up and Implementation

Share findings with management, safety committee, and affected workers. Transparency builds trust and educates.
Monitor progress on corrective actions. Ensure they are completed effectively and on time.
Verify effectiveness. After implementation, check that the actions have actually eliminated the hazard and not created new ones.
Update records. File the report and use findings to update risk assessments, training programs, and safety manuals.

By conducting thorough incident investigations, businesses learn from incidents, create safer environments, and build a stronger safety culture, turning every event into a chance for improvement.

Primelift Safety Resources Limited provides training on incident investigation and reporting to enhance the safety of personnel in the workplace.

www.primeliftsafetyng.com