incident investigation procedure

incident investigation procedure must fulfil the following requirements:


The organization shall establish, implement and maintain a procedure to record, investigate and analyze incidents in order to:

a) determine underlying OH&S deficiencies and other factors that might be causing or contributing to the occurrence of incidents;
b) identify the need for corrective action;
c) identify opportunities for preventive action;
d) identify opportunities for continual improvement;
e) Communicate the results of such investigations.

The investigations shall be performed in a timely manner.
Any identified need for corrective action or opportunities for preventive action shall be dealt with in accordance with the relevant parts of 4.5.3.2.
The results of incident investigations shall be documented and maintained.

Incident investigation is an important tool for:
- Preventing reoccurrence of incidents and identifying opportunities for improvements.
- It can also be used for raising the overall OH&S awareness in the workplace.

The organization should have a procedure for reporting, investigating and analyzing incidents.
The purpose of the procedure is to provide a structured, proportionate and timely approach for determining and dealing with the underlying (root) cause(s) of the incident. All incidents should be investigated.
The organization should seek to prevent the under-reporting of incidents. In determining the nature of the investigation, the resources needed, and the priority to be
given to investigation of an incident, account should be taken of:
- the actual outcome and consequences of the incident, and
- The frequency of such incidents and their potential consequences.
In developing those procedures the organization should give consideration to the following:
- the need for a common understanding and acceptance of what constitutes an “incident” and the benefits that can be gained from its investigation,
- that reporting should capture all types of incidents, including major and minor accidents, emergencies, near-misses, instances of ill health and those that take place over a period of time (e.g. exposure),
- the need to meet any legal requirements relating to the reporting and investigation of incidents, e.g. maintenance of a register of accidents,
- defining the assignment of responsibilities and authorities for the reporting of incidents and subsequent investigations,
- the need for immediate action to deal with imminent risks,
- the need for investigation to be impartial and objective,
- the need to focus on determining causal factors,
- the benefits of involving those with knowledge of the incident,
- defining the requirements for the conduct and recording of the various phases of the investigation process, such as:

• gathering facts and collecting evidence, in a timely manner,
• analyzing the results,
• communicating the need for any identified corrective action and/or preventive action,
• Providing feedback into the processes for hazard identification, risk assessment, emergency response, OH&S performance measurement and monitoring and Management review.

Those assigned to conduct incident investigations should be competent.
The outputs from the incident investigation processes should address items:
a) determine underlying OH&S deficiencies a) and other factors that might be causing or contributing to the occurrence of incidents;
b) identify the need for corrective action;
c) identify opportunities for preventive action;
d) identify opportunities for continual improvement;
e) Communicate the results of such investigations.