Key actions in effective accident/incident investigation
Leaders
Verify that plans are in place to deal with immediate risks following unforeseen events
Make sure there is a reporting process so that leaders are informed of accidents, incidents or cases of occupational ill health
Consider lessons from the accident/incident history of others in similar industries or organisations - could the same mistakes be avoided?
Ensure that people are held to account if failings reoccur
Managers
Formulate plans:
What must workers report?
How will reporting procedures be communicated to workers?
How will work-related ill health, accidents or near misses be notified?
Who will assist in the investigation?
What action will be taken as a result?
How will you identify trends?
Ensure reporting procedures are suitable and workable
Examine all incident/accident/near-miss reports and identify trends
Be proportionate in any investigation, according to the level of risk identified. Establish what happened, when, where and why. Collect evidence:
consider what the evidence shows
compare what you have found against industry standards/HSE guidance etc
Investigate accidents with a high priority - before people’s memories fade and while evidence is still available
Look at root or underlying issues not just immediate causes:
immediate causes - premises, plant and substances, procedures, or people
underlying causes - management arrangements and organisational factors such as design, selection of materials, maintenance, management of change, adequacy of risk controls, communication, competence etc
Record and keep findings:
They may be required later in a formal investigation or legal proceedings
Engage specialist help to support complex investigations, eg an operation involving major accident hazards
Worker consultation and involvement
Involve workers or their representatives in the planning process and in the target-setting process
Carry out joint investigation with workers’ representatives
Involve workers or their representatives in monitoring performance
Competence
Consider how competency is achieved, tested and maintained
Do investigators have the necessary training, knowledge and experience to carry out their duties?
Consider whether training issues contributed to causes of accidents/incidents/near misses
