Accident/Incident Investigation

Terms

An accident is an event which causes an injury to a person, and/or damage to property and/or equipment.

An incident is an event which has the potential to cause injury, and/or damage to property and/or equipment.

All accidents or incidents should be investigated and corrective action taken.

Investigating an Accident or Incident

All incidents should be investigated. The amount of information that needs to be gathered will vary with the seriousness of the accident/incident. There is rarely one single cause for an incident. .

Who Conducts the Investigation

The supervisor or manager of the person injured (or the area in which the incident occurred, if there was no injury) is responsible for conducting the investigation. The supervisor can seek advice and assistance from the Occupational Health and Safety Unit and/or the area health and safety representative.

The health and safety representative from the area is entitled to be involved in the investigation, and should be invited to participate.

The Accident/Incident Investigation Procedure

When an accident or incident occurs you must make sure it is reported to the OH&S Unit as described in Reporting Accidents and Incidents.

The Accident/Incident Report form asks you a series of questions which lead you through the investigation. For example:

• When did the accident occur?
• Description of the accident?
• Work area conditions?
• What factors contributed to the accident?
• What action has been taken or is planned to prevent re-occurance?

You should keep a copy of the form and send the form itself to the OH&S Unit, Registry Annexe.

If it is a construction or maintenance issue the supervisor must contact the Buildings and Property Division Maintenance department.

Principles of Accident Investigation

The purpose of accident investigation is not to attribute blame but to identify what went wrong and what can be done to prevent it from recurring. Investigators need to look beyond causes such as 'human error' or 'worker carelessness'. They need to identify underlying problems in the workplace, the plant, equipment and materials used, the system of work and management practices which may have contributed to the error.

There are three phases to incident investigation:

• gathering information
• analysing the information and drawing conclusions
• making recommendations

1. Gathering Information

The investigation should begin as soon as possible after the incident occurs. This means that the investigator is most likely to see the conditions as they were at the time of the incident and to identify witnesses. For serious accidents the area may need to be isolated/barricaded and security informed. Some accidents must be reported immediately to SafeWork SA via the Occupational Health and Safety Unit. THIS IS A LEGAL REQUIREMENT. Evidence must be retained - for example broken glass, spilt chemicals, any unknown substance that is involved.

In gathering information the investigator should consider:

• events leading up to the accident
• the system of work being done
• the instruction given for the work
• variations from instructions or safe work practices
• workplace conditions
• the exact location of the accident
• the materials in use or being handled
• the type of equipment in use
• the facts of the incident itself
• the state of the system and the actions that occurred at that moment
• the persons directly involved and those indirectly involved
• the tools, equipment and materials directly involved
• the time
• what happened after the accident
• the injuries or damage resulting
• the events leading to consequential injury or damage
• the persons involved

2. Analysing the information and drawing conclusions

Once you know what happened and how it happened, the next step is to consider why it happened. This is where you have to look past blaming people involved in the incident, and keep asking 'what circumstances allowed an error to occur?'.

3. Making recommendations

It is essential that the incident investigation should identify what action will be taken to prevent the problem from occurring again.

Corrective Action

The whole investigation process should be documented and in most circumstances recommendations for corrective action will be required when the investigation is complete. This may be noted on the Investigation Form or may require a separate report and formal risk assessment.

If corrective action has been taken immediately (eg. wiped up spilt drink in tea room to prevent others from slipping/falling) then that should be noted on the Accident/Incident Report From and a formal risk assessment and separate report will not be required.

If corrective action will be more complex then the responsible supervisor must complete a Risk Assessment and Action Plan, including nominating a time frame for completion of the action. The supervisor must 'sign-off' the Action Plan when the remedial work is completed, and send a copy to the OHS Unit.

Updated:5 September 2007