Incident Investigation Process

Introduction

An incident is an unplanned or undesired event that adversely affects a company’s work

operations. Incidents include work-related injuries, occupational illnesses, property damage,
spills, fires or near miss events that could have resulted in any of these.

All incidents should be investigated. An incident that results in a serious employee injury,
considerable property damage, a major fire, or spill obviously warrants an extensive
investigation. A minor incident or near incident also requires a thorough investigation and may
reveal significant potential for a serious incident if the conditions are left uncorrected.

There are two major components that contribute to the cause of an incident. They are the
“work element” and the “root cause”.

• The “work element” is the condition or act that directly caused the incident. An
example of a work element might be a small spill of oil on the floor that someone
slipped on.

• The “root cause” is the system failure that allowed the work element to become
deficient or to occur. For example, a root cause may be a lack of preventive
maintenance that resulted in the fork truck leaking oil on the floor.

A thorough investigation will reveal the root cause of the incident. The purpose of an incident
investigation is to determine the work element and root causes of incident, and to assist in
providing the company with a solution to prevent recurrence.

Companies should have an incident investigation process to ensure that:

• All incidents (including near misses) are investigated

• Corrective action are determined that identify the root cause
• Corrective actions are tracked until they are completed
• Trends are reviewed, gaps are identified and improvement plans are developed to
prevent future occurrences.

Investigation Process

Proper training and a clear understanding of roles and responsibilities is essential to the
investigation process. All employees and people that will be involved in an incident
investigation should be aware of what their role is in the process and how to perform their
assigned responsibilities during an investigation process.

RM+ 1706 4/15

Employees:
• Report all work-related incidents in a timely manner
• Participate in the investigation process, as needed

Supervision/Management:
• If the incident was very recent, secure the scene of the incident to ensure the safety of
any emergency responders and other employees, and to preserve any evidence that
may contribute to the investigation
• Ensure the injured person is properly cared for
• Ensure management or other company personnel who require it are notified. OSHA or
another government agency may also be required to be notified, depending on the type
and/or severity of an incident.
• Ensure the investigation begins as soon as possible after the incident occurs
• Identify the potential sources of information, such as the injured person, witnesses
and any physical evidence
• Gather the facts about the incident
• Ensure the investigation identifies the root cause
• Make and/or implement recommendations to control or eliminate the hazard
• Ensure all regulatory and company requirements are met (OSHA recordkeeping,
notification, written reports, insurance claims, etc.)
• Perform any trend analyses of past incidents that may identify additional hazard
prevention methods (i.e. training, maintenance, procedures, etc.)

The ultimate responsibility for an incident investigation rests with management. Supervisors
must take charge of a thorough incident investigation. Depending upon the type and scope of
an incident (i.e. major spill or fire, or several employees injured in one incident), a team
approach to the investigation of the incident may identify additional corrective actions that will
help prevent similar incidents in the future.

Investigations must be constructive, credible and timely. Remember that the investigator is
trying to figure out what happened and how to prevent similar situations, not trying to place
blame on any individual or group. If the investigation is antagonistic, and takes a “what did you
do wrong?” approach, then the process becomes much more difficult, as employees do not
want to be blamed or cooperate in a blame-giving situation. A more constructive approach is
“what happened, and what can we do to prevent this from happening again?”

Timing of an incident investigation could be crucial to the outcome. If an employee reports an

incident that happened three weeks ago, all an investigator has to go on is what can be
remembered by the persons involved. People’s memories fade or evidence may be disturbed
which could hamper the investigation process. With timely reporting, an investigation can take
significantly less time to complete, and operations will be able to resume more quickly.

RM+ 1706 4/15

Gather Evidence

One of the most critical and complex parts of the investigation is the gathering of evidence.
There are some basic rules that may help the process.

Interviewing involved employees:

• Put the individual at ease – make sure they know the primary purpose of the interview
is to prevent a recurrence of the incident and that it can only be done with their help.
Avoid finger-pointing and applying blame. Treat people with tact and respect. Make
them aware that they need to be thorough and truthful in their account of the incident
and that you are not there to get anyone into trouble, only to find out what happened
and why, so that it won’t happen again.
• Be aware that injured employees and witnesses to injuries may have some emotions
involved that affect them. Especially if the incident was severe, there may be some
trauma that occurs.
• Stress fact gathering. Let involved employees tell their story completely. Wait until
they have finished their version of events before interrupting or clarifying what was
said. Then go over what they stated with them, to assure that you have their account of
the story accurately and that you understand what they meant, not just what they said.
Do not make assumptions or state opinions during this process. If other people have
said something different from what was stated in this interview, ask leading questions
to discover more information, but do not contradict what was stated in either interview.
• Conduct the interviews at the scene, if possible. This may help people to explain and
may help the interviewer understand what happened. Make the interviews as private as
possible, so that other employees cannot take any offense or contradict what is said.
Witnesses may be interviewed at a later time, if privacy is at issue.
• Ask any necessary questions to determine what happened, what was done, and how it
was done. Try to avoid asking WHY questions that may make people defensive.
• Close the interview on a positive note. Discuss the actions taken, or that will be taken
if you know them. That will reaffirm the purpose of the interview. Make sure you thank
the interviewee for their help in the investigation process.

Use the right tools during the investigation process:

• Paper and pencil is the basic tool. Taking notes can jog a memory later on when you
are writing any investigation or incident reports. Record times, places, names, distances,
comments, conditions or anything else you may think will help.

RM+ 1706 4/15

 • Take pictures, if possible. A picture is worth a thousand words. Take an overall picture
first to keep an idea of where the incident took place. Then get any close up shots of
spilled material, machinery or equipment that may have been involved. If needed, place
a ruler or other object that is of a known size in the picture, so that you can more easily
determine size or scale within the picture.
• Draw a sketch or diagram. This is useful especially when the incident is complex. Use
the diagram to indicate where key objects or people were during the incident.

Determine the Root Cause

Many times it is easy to determine what the work element is that directly caused the incident.
It could have been a flying chip, a spill on the floor, or lifting a load that was too heavy.
However, discovering the system failure that allowed the deficient work element to occur is
sometimes more difficult. This system failure is also known as the root cause. To make it easier
to determine, root causes (in general) can be placed into six different categories.

Some examples of each of these root cause elements are as follows:

Materials Machine/Equipment
- Defective raw material(s)
- Wrong type of material for job
- Not enough raw material
- Incorrect selection of tool or equipment
- Poor equipment maintenance or design
- Poor equipment or tool placement
- Defective equipment or tool

Environment Man
- Orderly workplace
- Job design or layout of work
- Surfaces poorly maintained
- Physical demands of the task
- Other conditions (noise, lighting, etc.)
- No or poor management involvement
- Inattention to task
- Task hazards not guarded properly
- Other (horseplay, inattention, etc.)
- Stress demands

RM+ 1706 4/15

 Methods Management System
- No or poor procedures
- Practice does not mesh with written procedures
- Poor communication
- Training or education lacking
- Poor employee involvement
- Poor recognition of hazard
- Previously identified hazards were not eliminated

Document the Findings

A well conducted investigation identifies the work element(s) that caused the incident and
helps to eliminate the root cause(s). After the investigation is completed, the investigator then
begins to document the incident and their findings. The incident documentation should contain
specific elements.

• When the incident happened. Date and time may be crucial because of work load or
shift change.
• Who or what was affected or hurt by the incident. If an employee was involved, or a
piece of equipment damaged, be specific about which piece of equipment and the
extent of damage or injury.
• Where it happened. Again, specific details may be critical to the investigation analysis
or trends that may be present.
• What object, if any, caused the incident.
• What work element was deficient and most directly caused the incident. If there was a
specific condition (i.e. lifting, twisting, spills, poor maintenance, falling object, defective
equipment, lack of procedure, poor lighting, etc.).
• What system failure (or root cause), if any, was evident that needs to be corrected
that will prevent a recurrence (i.e. lack of a maintenance schedule, lack of training, lack
of procedures, etc.).

Follow Up and Analyze

Once the documentation phase is complete, corrective actions should be implemented.

Employees in the work area should be notified of any equipment, procedures or additional
training that has resulted from the investigation process. These corrective actions should be
followed up to assure they are effective, and that employees are following any new processes.

RM+ 1706 4/15

If more than one incident has occurred that may be related, management should review these
incidents and look for similarities that may need to be addressed. Individual incidents and near
misses may show one or two items that need addressing, however when taken all together,
there may be a greater issue that can address the overall problem.

Frequently the answer to individual incidents is as simple as wearing/using protective

equipment/guards or proper lifting procedures. But sometimes a manager needs to take a step
back and look at a group of incidents that may be less obviously related. A lifting/lowering
training program, or hand protection awareness program, a written procedure for locking out
all types of machinery prior to servicing, or a preventive maintenance schedule for fork lift
trucks, may address several needs at one time.

RM+ 1706 4/15