WORK INSTRUCTION
1.
Conducting an Accident/Incident Investigation
Version:
03
Page:
1 of 2
Issue Date:
26 October 2000
Authorised by: Marjorie Dickenson
PURPOSE
The purpose of accident investigation is undertaken to identify causes with the aim of preventing a
recurrence. It should:

Identify other potential causes of the accident/incident.

Comply with statutory requirements e.g., OHS Act 2000, Notification of Accidents Regulation
10990.

Ensure remedial actions have been/will be taken.
An accident investigation has the following objectives:

Identify all of the factors that contributed to the accident/incident.

Ensure that responsibility for issues raised / corrective actions are allocated to appropriate
personnel.

Ensure that the issues raised / corrective actions are addressed.

Identify the OH&S Management systems that have allowed the situations/conditions to occur.
2.
SCOPE
The work instruction applies to the investigation of all accidents and incidents.
3.
REFERENCES
Occupational Health & Safety Act 2000, Notification of Accidents Regulation 10990
Form – Accident / Incident Investigation.
4.
RESPONSIBILITY
Manager/Supervisor of the injured person
Undertake accident/incident investigation
OH&S Representative
Undertake accident/incident investigation
Persons with engineering or other specialist skills, if
appropriate
Undertake accident/incident investigation
Personnel conducting the accident / incident investigation must have knowledge of the workplace
and the procedures concerned, and appropriate technical knowledge in the fields of:

causes of accidents;

equipment and processes;

personnel management; and

ability to gather evidence objectively and to determine the underlying causes of accidents.
5.
ACTION / METHOD
An effective system of investigation relies on the following strategies:
1. Prompt reporting of accidents - it is important that evidence is not disturbed prior to the
investigation.
2. Immediate control actions - to ensure that further accidents do not occur.
5.1.
Levels of Accident Investigation
There are two levels of accident investigation:
1.
Immediate Causes (situations immediately preceding the event)
a.
Unsatisfactory Conditions such as:

Buildings and Structure - stairways and paths, electrical/water supply,
warnings signs, etc.

Equipment - controls, isolating/safety devices, defective equipment, etc.
03-010
Conducting an Accident/Incident Investigation
Version:
03
Page:
2 of 2
Issue Date:
26 October 2000
Authorised by: Marjorie Dickenson
WORK INSTRUCTION


b.
2.
5.2.
Procedural - work practices, procedures, etc.
Environmental - ventilation, noise, lighting, fumes/dust, etc.
Unsatisfactory Practices such as:

Buildings and Structures - failure to remedy slippery surfaces, failure to
comply with access/egress restrictions.

Equipment - inadequate PPE, incorrect tool or equipment failure to report
obvious hazard, etc.

Procedural - incorrect lifting techniques, failure to wear PPE, variations in
safe working practices, etc.

Environmental - failure to activate emergency, ventilation, fume, dust,
noise controls.
Underlying (REAL) Causes

Failure of one or more management systems which allowed the
unsatisfactory conditions/practices to be present.

Preventative Systems: Risk identification, assessment and control,
standard work procedures, maintenance and testing procedures, hazard
reporting and investigation, etc.

Support Systems: Induction/Specific/ongoing training.

System Breakdown Management: Emergency procedures, accident
investigation, workers compensation and rehabilitation.

Evaluation Systems: OH&S inspections, system reviews, internal audits,
quality control evaluation.
How to Complete an Accident/Incident Investigation
Using the SimuLab form 05-101, Accident / Incident Investigation:
STEP 1: Get the facts

Note observations.

Eye Witnesses.

Photo/sketches.
STEP 2: Determine the sequence of events (who, what, when, where, why)

Identify all conditions at the time of the incident.

Identify all variations from standard practices.
STEP 3: Identify the Management Systems Failures for each of the above categories

Consider possible remedies.

Select the best solution in terms of effectiveness, cost, meeting acceptable
standards.
STEP 4: Determine Remedial Action This may include:

Modifications to the workplace or equipment.

Changes in work practices.

Provision of training.
STEP 5: Follow-up and Evaluate

Effectiveness.

Acceptability.
03-010