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 causes 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.

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 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 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