Pages in this chapter (4 of 5)
The level of investigation
All incidents are reported, but not all need the same level of investigation. Serious ones need more. But also think about how likely the event is to happen again and the worst it could cause. A tool dropped from a scaffold may have injured no one, but it could have caused a major injury.
| Level | Who and how |
|---|---|
| Minimal | A supervisor looks at the circumstances and works out how to prevent similar events. |
| Low | A supervisor or line manager makes a short investigation of the immediate, underlying and root causes. |
| Medium | A more detailed investigation involving a safety practitioner and worker representatives. |
| High | A team investigation that may include line managers, supervisors, safety practitioners and worker representatives, led by a senior manager. |
A structured approach
- Information gathering. Find out where and when it happened, who was involved, and what and how it happened. Collect evidence such as broken parts and debris, photographs and witness statements, and look at documents, including electronic records and risk assessments. You need good interpersonal skills to interview witnesses.
- Analysis. Look at everything you have gathered to work out what happened and why, carefully and systematically. If human error or a deliberate violation was part of the cause, find out whether the person forgot, did not know or knowingly ignored a rule. That helps you decide how to prevent it happening again.
- Review the risk controls. Decide where the controls must change so that the incident does not recur, evaluate the options carefully, and ask whether similar changes are needed elsewhere in the organisation.
- Action planning. Decide what will change, by when and by whom. Someone in authority must be responsible for delivering the plan.
- Share and communicate. Announcing the improvements shows the workforce that the organisation cares, and can improve engagement.
External relations
Have a plan for dealing with outside bodies such as enforcement authorities, the media and local residents and businesses. Only designated people should release information, and only when it is clear what has happened and what will happen.
Enforcement authorities have the right to enter any workplace under their jurisdiction. It is an offence to refuse an inspector entry. Inspectors can copy documents, take samples and photographs and ask questions. Treat them with respect. If they find that an offence has been committed, they may issue a caution to a designated representative of the organisation. Larger organisations usually have a procedure for visits. If yours does not, name one person as the main contact.
6.4 Getting It Right
- Investigation is about finding out what went wrong and why, so that it does not happen again. It is not about finding someone to blame.
- It may never happen to you, but having plans and procedures in place before an incident helps an investigation work as well as it can.
- Sharing the findings matters as much as the quality of the investigation. Different people need different information. Workers who use similar processes need detail on how to avoid the conditions that led to the accident, while a senior manager needs a summary.
A study aid, not published or endorsed by IOSH or OSHA. Laws and limits differ between countries.