Incident Investigation

What Does Incident Investigation Mean?

An incident investigation is a formal and systematic process for identifying the events that caused, contributed, or led to workplace incidents. The main goal of an incident investigation is to determine the root causes of near misses, property damage, injuries, or fatalities in order to implement corrective measures to prevent future occurrences.

The Occupational Safety and Health Administration (OSHA) recommends that employers conduct investigations of every incident that results in an injury or in which an injury is narrowly avoided.

Safeopedia Explains Incident Investigation

Why Conduct an Incident Investigation?

An incident investigation provides employers with a detailed picture of the events leading up to and surrounding an incident. This information can uncover new insights about hazards in the workplace, highlight gaps in the existing control measures, and identify risk factors that were previously overlooked.

The findings of an investigation can also be used to strengthen the company’s safety program. Employers can modify the working environment, update safety procedures, restructure training programs, or upgrade safety equipment to reduce the likelihood of a similar incident occurring again in the future. 

Incident investigations can also be used as a compliance tool. A thorough investigation can bring attention to compliance issues in the workplace. The incident report produced as part of the investigation can also be presented to regulatory authorities as evidence that the employer treated the incident seriously and took steps to better ensure the safety of their employees. 

Determining the Root Cause of an Incident

The aim of an incident investigation is to determine the root cause of the event. Several incident methodologies exist, and each has merit.

One of the simplest approaches is the 5 Whys Analysis, which involves asking why the incident happened, then asking why that event (the one that caused the incident) happened. This is repeated until the investigator has asked “why?” five times. The idea being that the answer to the fifth “why?” will be closer to the root cause of the incident than the answer to the first “why?”

More complex procedures can be used for a more thorough investigation. The TapRooT system, for instance, involves the creation of flowcharts to sort out the sequence of events and formulate detailed corrective action plans. 

Regardless of the method used to uncover the root cause of the incident, finding it is essential to improving workplace safety. Each incident has multiple causal factors and correcting the proximate causes of the event without also addressing its root causes might not be sufficient for preventing future incidents.

Which Types of Incidents Should Be Investigated?

Any incident which has caused harm to an individual, the environment, or company property should be investigated. This includes:

• Near Misses – Incidents which did not cause an adverse effect, but could have if conditions were slightly altered
• Damage to Property – Incidents in which equipment, infrastructure, or other property has been damaged or destroyed
• Injuries – Incidents in which an employee or member of the public is hurt
• Exposure – Exposure to harmful substances, such as breathing toxic fumes or being splashed by a corrosive liquid
• Illness – A worker beginning to exhibit symptoms of an illness while on the job
• Security Breaches – Trespasses, attempted break-ins, and threats or acts of violence
• Environmental Harm – Such as chemical spills, accidental release of air pollutants, or a pipeline leak
• Fatalities – Any incident that results in a loss of life, including suicide, fatal heart attack, or a death that happens on the job or in the workplace (even if it does not appear to have a work-related cause)

Why Near Misses Should Be Investigated

Although a near miss does not result in any adverse outcomes, it still warrants an investigation.

This is because a near miss is essentially a close call – a serious incident that was narrowly avoided due to favorable factors or sheer luck. If any of those factors were slightly modified, the same event could have caused harm.

Investigating a near miss and identifying its root causes allows employers to implement measures to prevent the conditions that gave rise to the near miss from occurring again. Since those conditions could have resulted in harmful outcomes, controlling them can prevent more serious incidents down the line.

“Near-misses are not to be dismissed lightly. In my experience, they often indicate underlying safety hazards or weaknesses in existing protocols,” said Jennifer Silver, a dentist and owner of Macleod Trail Dental in Calgary.  “Ignoring them can pave the way for more severe incidents in the future. That’s why I treat near-misses as valuable opportunities for learning and improvement. I investigate them with the same diligence as actual incidents, seeking to understand the underlying causes and implementing preventive measures to mitigate future risks.”

How to Conduct an Incident Investigation

Incident investigations should be conducted in an organized and systematic fashion, following a set procedure to ensure that every relevant detail is recorded and all potential causal factors are considered. 

Before starting, it’s important to make sure that everyone is out of harm’s way, first aid has been administered, and medical treatment has been arranged for anyone who is injured. Once everyone is safe, the investigation can proceed.

An effective incident investigation procedure will include the following steps:

1. Secure the scene where the incident occurred and make sure no one tampers with any part of it. Assessing the conditions in the area will be part of the process and any changes to it could compromise the results of the investigation.
2. Take photos or videos to document the scene of the event.
3. Brief everyone involved in the purpose of the investigation. Stress the fact that the goal is to understand what happened in order to prevent future incidents, not to find fault or place blame on anyone.
4. Interview anyone who was involved in the incident or witnessed it. Ask them pertinent questions and record their answers in detail.
5. List all the factors that contributed to the incident and identify the root causes.
6. Document the findings and draft an incident report.
7. Identify corrective measures that could have prevented the incident from taking place.
8. Make a concrete plan for implementing those measures, including planned follow-ups to ensure that the proposed actions have been taken. 

Who Is Involved in an Incident Investigation?

An incident investigation usually involves:

• Injured workers (if any)
• Their immediate supervisor(s)
• Witnesses to the event
• The individual or team tasked with investigating the incident

The investigation is generally conducted by the supervisor in charge of the employee who has been injured or is most directly involved in the incident. A member of the safety committee can also provide assistance and guide the process.

In the event of a fatality, management and the legal team may also be involved. 

Is Training Required for Investigating an Incident?

Specific training is not mandatory for conducting an incident investigation. However, having trained personnel handle investigations ensures that they: 

• Adhere to a systematic procedure
• Can explain the difference between a proximate cause and a root cause
• Use an effective root cause analysis method
• Know what type of information should be recorded and reported
• Are able to make better recommendations for corrective measures

Safety managers, supervisors, or employers can complete a stand-alone training module, like the Incident Investigation Course offered by the National Safety Council. Occupational safety certification programs will also generally cover incident investigations.

Information to Collect for an Incident Investigation

In brief, any and all information that is relevant to understanding why the incident occurred should be collected at the scene of the event. 

This includes:

• Details about injured worker(s) – job title, experience level, tenure, training records, type of contract, age, gender
  • Note that the type of incident might dictate what information is considered pertinent – you may not normally record an injured person’s height, but if they struck their head against something it might be an important detail
• Details about the outcome of the incident
  • For injuries, note the part of the body that has been affected, describe the appearance of the injury, how the injured party feels, their reported level of pain, and so on
  • For exposure or illness incidents, note the type of exposure, the substance and its concentration, any symptoms they are experiencing
  • For property damage or environmental incidents, describe the extent of the damage, the size of the spill, any other damage related to the incident (e.g. if a forklift knocks over a storage rack in the warehouse, describe anything that was damaged by the rack when it fell)
  • For near misses, describe the situation that almost happened, such as the injury that was narrowly avoided or the chemical splash that almost got into an employee’s eyes
• A complete sequence of the events leading up to the injury, including:
  • A step by step recounting of the events as told by witnesses or those affected
  • Time when the incident happened, including whether it happened during a break, on the way out of work, or while working overtime
  • Details about the location of the incident and the condition of the area, including lighting, noise levels, temperature, and weather conditions (if the incident happened outdoors)
  • Any equipment involved in the incident and how it was being used
  • Behavioral details, such as whether anyone involved was intoxicated, feeling fatigued, not wearing required PPE, using equipment improperly, or not following safe working procedures
  • Steps taken immediately after the incident, including any first aid measures that were administered
• Details about any equipment being used at the time of the incident, such as the type, whether any machine guards were installed, and the condition they were in
• Type of job being performed when the accident took place, the specific tasks that were being done, and whether the person affected was working alone
• The supervisor(s) in charge of the site or the affected employees, including where they were during the incident and what measures they took in response to it

Incident Investigation and Reporting

Once all the information has been collected, it should be used to draft an incident investigation report. This report is a documentation tool used to record the details of the events surrounding the incident and present them in an organized format.

Reviewing investigation reports is a vital step when updating safety policies, procedures, or control methods. Knowing the proximate and root causes of previous incidents allows employers to make better informed decisions about how to mitigate risks on the worksite. 

Analyzing these reports can also uncover trends across multiple incidents and highlight hazards that may have gone unnoticed.

Key Elements of an Incident Investigation Report

The general layout of an incident investigation report form consists of:

• The name of the investigator, their role, contact information, and the date and time they of the investigation
• Location where the incident took place
• Information about the person(s) involved in the incident or affected by it
• Contributing factors and root causes of the incident
• Recommended actions in response to the incident (e.g. policy updates, additional training, more frequent equipment maintenance), as well as:
  • A specific timeline or deadline for the corrective actions to be implemented
  • The person(s) responsible for ensuring the completion of those actions
• Photos of the scene can be printed and attached to the report
  • For videos or photos that are saved in a digital format, there should be a note explaining where and how to access them 

Best Practices for Drafting Incident Reports

Here are some key points to remember when drafting an incident investigation report: 

• The report must be accurate and provide clear and specific information
• The information should be presented objectively, without the investigator’s personal opinions or conjectures
• It should name the causes of the incident, not blame anyone for it
• A first draft of the report should be shared with witnesses and those involved to ensure that it reflects their experience of the event

Incident Investigation vs. Accident Investigation

Incident investigations are sometimes referred to as accident investigations. In both cases, however, they refer to the same type of procedure.

OSHA suggests referring to unplanned adverse events as incidents rather than accidents, since accidents imply that the event was random and unpreventable. OSHA holds that nearly all of these events could be prevented with greater awareness of the hazards, better control measures, and stronger safety programs.

Referring to these procedures as incident investigations encourages employers and safety professionals to identify root causes rather than chalking it up as a random occurrence or a freak accident. It also holds them accountable for mitigating risks and taking steps to prevent future incidents.

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