Incident investigations

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 due to a chain of events. The cause of an incident is usually characterized by three main categories: direct, indirect and root causes.

Direct cause

What was the direct cause of the incident? Direct causes are usually actions initiated by the root cause.

Indirect cause

What were the latent or hidden causes that led to the incident?

Root cause

What is the fundamental reason for an event? Root causes are not always immediately evident.

Example

A worker was 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) and prevent the incident from recurring.

Psychological or critical incident management guidelines

A critical incident is an event that takes place suddenly—like an injury, fatality or robbery—which can cause emotional or psychological trauma. As a result of a critical incident, workers may have difficulty concentrating, thinking clearly, being alone, being around people and other responses. Workplace morale and productivity may also suffer. Know that this is expected and usually resumes to normal overtime.

Employers in Manitoba must oversee psychological incidents like physical ones because both can cause significant harm, lead to serious health and safety claims, and negatively impact productivity and morale. Workplace incidents can trigger psychological injury through a single, sudden traumatic event like a serious injury or violence, or through the cumulative effect of ongoing psychosocial hazards such as bullying, harassment, or high stress.

As an employer, you can support workers by providing information about available services for counselling, meet with your workers regularly and answer their questions as best as you can. Clear policies as well as detailed procedures are necessary to help workers who have been affected by a critical incident or a psychological-related incident.

In the case that a worker seeks medical help, a WCB claim should be made. If a worker has made you aware that they have sought medical help, submit a claim with the WCB.

Incident investigation procedures

The investigation should start as soon as reasonably practicable after the incident. The first priority would be to care for the injured worker. Certain procedures, including lockout, may need to be followed 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 fit the workplace’s needs. The procedure should state the following:

the objective of the 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 actions
who will prepare a written investigation report including the requirements outlined in Part 2.9(3) of The Workplace Safety and Health Regulation
who keeps documents and records
what summary and statistics reports are to be developed and how often these reports will be prepared

Here is a sample incident report form.