WorkSafe Tasmania

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How to run an effective incident investigation

Senior Advisor Brett Hislop guides you through the principles and practices of running your own workplace investigation. This article appeared in the April 2021 edition of Workplace Issues.

An incident is defined within Australian Standards as ‘any unplanned event resulting in, or having a potential for injury, ill health, damage or other loss’. It is therefore reasonable to state that incidents are not planned in workplaces. However when they do occur, there is a responsibility by the employer to identify the cause/s and take reasonable action to prevent them from reoccurring.

All too often, investigations are inadequate or poorly done. They attempt to apportion blame on the worker or workers involved in the incident and focus too much on human error.

Most incidents are the result of system failures, inadequate risk assessment, poor work practice, work culture, defective or poorly maintained equipment, inadequate training, time pressure and so on.

What to do first

If an incident does occur in your workplace, there are some initial steps you should take:

  • make the incident scene safe
  • treat injured workers (if applicable)
  • take photographs of the incident scene; too many is never enough
  • get the names of people associated with the incident (regardless of who they are)
  • take witness statements as soon as possible after the incident.

If the incident is a notifiable incident, you must notify WorkSafe Tasmania immediately. Find out how to notify WorkSafe and requirements around matters such as not disturbing the incident site.

Questions to ask

Once these have been achieved, then keep in mind the famous saying by Rudyard Kipling: ‘I keep six honest serving men (they taught me all I knew), their names are What and Why and When and How and Where and Who’.

Use these points when framing questions about the incident: what happened? When did the incident occur? How did it happen? What did you see?

Start a timeline of events that covers all elements of the activity, from the start of the shift until the incident occurred, and actions taken post-incident until you begin your investigation.

This would also include a review of all associated documents such as your risk assessments, safe operating procedures, plant pre-start checks, worker competencies, and notes from any prestart meeting.’

Following this, dig deeper and assess environmental conditions around the time of the incident, shift arrangements, hours worked, staffing levels for the task, time constraints, supervision and so on.

Essentially, your investigation should consider all elements of the work system:

  • environment
  • work methods
  • equipment
  • materials
  • people
  • organisational culture.

Training and external help

If you can, having key workers or WHS personnel trained in a form of recognised incident methodology (such as ICAM, TapRooT, 5 Whys) is a real bonus if you’re serious about finding the causal factors that lead to incidents occurring, and ensuring that your controls are implemented in the correct areas of your operations to prevent recurrence.

Or you might consider using the services of external workplace incident investigators to ensure the investigation, findings and proposed actions are undertaken in an impartial manner.

What to do next

Don’t just ask questions during your investigation: look for solutions and control measures to prevent a similar incident occurring again. Ensure the controls you identify are implemented within the operational areas where deficiencies were found.

The ‘SMART’ acronym is worth considering: make sure your controls are Specific, Measurable, Achievable, Realistic and Timely. Implementing controls that are complex, expensive, difficult to get in place, unrealistic and take long periods are not always practical in achieving a successful outcome. However, the exception is changing your workplace culture; this may require planning and time to gain a reasonable outcome.

Consultation

You should complete a report of your investigation in the shortest possible timeframe. Provide it to your managers for review, as well as to your workers. You should also consult with your workers about any proposed changes in the workplace, explaining why the changes are needed and how these will improve workplace safety.

No business owner or worker wants to see or be involved in a workplace incident. Therefore every effort should be taken to prevent incidents from occurring. But if they do, then take the time and the energy to truly find out what happened, where the system was deficient, and how similar incidents can be prevented from happening again.

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Updated: 19th January 2022