Key actions in effective accident/incident investigation
- 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
- 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
- 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
- Seek specialist advice if needed