Incident Investigation Procedure Document Number 001001 Date Approved 27 November 2012 1 Introduction When a serious incident occurs there shall be a review of the system which is in place to manage the related hazard(s), and whether the system is suitable. This process helps to identify the contributing factors so that similar occurrences can be prevented. Incident investigations should focus on corrective actions and not on the allocation of blame. The incident management process will include supervisors and workplace representatives who have direct knowledge of the work areas and work processes. Once completed, the incident investigation report should identify the root causes which led to the incident, answering the key questions how and why. This will enable corrective actions to be implemented to prevent reoccurrence. 2 Purpose The purpose of investigating incidents is to: - 3 determine the causes and to prevent similar incidents recurring in the future, identify any new hazards, identify and choose suitable controls, fulfil legal and insurance requirements, and model industry best practice. Scope This document sets out the procedures to be followed in the investigation of hazards, incidents, injuries, dangerous occurrences and systems failures which occur on university premises or involving university staff and other workers, students, visitors, or contractors involved in university activities. 4 Definitions In the context of this document: Hazard A source or a situation with a potential for harm in terms of human injury or illhealth, damage to property, damage to the environment, or a combination of these. Incident Any event resulting in, or having a potential for injury, ill health, damage or other loss. Injury Any physical or psychological damage caused by exposure to a hazard. Dangerous Occurrence Where there is an immediate and significant risk to any person in, on, or near the relevant place, or who could have been in, on, or near the relevant place (whether or not a work-related injury occurs). System Failure Failure in a set of interrelated or interacting elements. May be that an implementation failure occurs when the system process(es) is adequate or fit for the purpose but the operator of the system fails, for whatever reason, to correctly implement the system as required. Systemic failure occurs when the operator undertakes the correct system process but is ‘let down’ by an inherent inadequacy of the system or the requirements placed on the business system have changed over time without the system having evolved. Factor One of the elements contributing to a particular result or situation. Contributing Factor A condition that may have affected an event. Causal Factor Any problem associated with the incident that, if corrected, could have prevented the incident from occurring or would have significantly mitigated the consequences. Root Cause An identified reason for the presence of a defect or problem. The most basic reason, which if eliminated, would prevent recurrence. A root cause of a consequence is any basic underlying cause that was not in turn caused by more important underlying causes. (If the cause being considered was caused by more important underlying causes, those are candidates for being root causes.) H&S Management System That part of the overall management system which includes organisational structure, planning activities, responsibilities, practices, procedures, processes and resources for developing, implementing, achieving, reviewing and maintaining the H&S policy, and so managing the risks associated with the business of the organisation. Flowchart (PDF) 5 Incident Investigation Procedure 5.1 Investigation Types The nature of the incident will determine the level of investigation required. Incidents are classified into 3 levels to determine the appropriate level of investigation response: Level 1 Incidents - those which are lower level risks and are not categorised as being immediately notifiable to WorkCover; Level 2 Incidents - those which constitute notification to WorkCover but not immediately; Level 3 Incidents - require prompt notification and investigation by WorkCover or other external agencies. In all cases, the following details are required to be obtained and considered. 5.1.1 Description of Incident The details of the incident should be factual and relevant. Describe the details of the incident as clearly as possible. This should include the exact time and place of the incident, the circumstances which led up to it, the sequence of events in the incident itself, the number, names and contact details of people involved, and the names and contact information of any witnesses present. 5.1.2 Contributing factors When trying to determine corrective actions to prevent reoccurrence, it is helpful to analyse the contributing factors that led to the incident occurring. A list of possible contributing factors is divided into four categories listed below: (i) Design Design factors include faults with the design of plant, equipment or work practices. (ii) Behavioural Behavioural factors relate to human aspects which can sometimes lead to an incident. (iii) Environmental Environmental factors relate to the surroundings of a workplace and whether they led to the incident occurring. (iv) System System factors include procedures etc which need to be changed to prevent reoccurrence. 5.1.3 Cause Determine the cause of the incident e.g. What led to the incident occurring? If this cause was removed or was not present, would this incident still happen? 5.1.4 Risk level Identify the level of risk of the incident taking into account likelihood and consequence with current controls in place. The risk score determines the priorities for corrective actions to be implemented. 5.2 Level 1 Investigation Level 1 Incidents are those which are a lower level of risk and are not categorised as being notifiable to WorkCover. Examples of Level 1 incidents may include: • • • • • first aid injuries injuries which may require minor medical treatment identified hazards which do not present a serious risk of injury minor property damage minor environmental damage. Level 1 incidents require the operational line e.g. line managers, supervisors, employees, to review the details of the incident, identify possible contributing factors, provide a cause of the incident, assess the risk of the hazard and implement appropriate corrective actions. The outcome of Level 1 incident investigation shall be recorded on the Online Incident Reporting form. The following outlines the required information for the relevant fields. 5.2.1 Corrective Action Plan Identify those controls to be implemented which will control the incident causes. Further information on the process of Level 1 reporting can be found in the Incident Management and Reporting web page. 5.3 Level 2 Investigation Level 2 incidents are those which present a risk to health and safety but are not immediately threatening to life. These incidents are typically reported to WorkCover although not via immediate notification. Examples of Level 2 incidents may include: • an injury or illness (supported by a medical certificate) that results in the person being unfit to perform their usual duties for a continuous period of at least 7 days • damage to any plant, equipment, building or structure or other item that impedes safe operation The H&S team may deem any Level 1 incident to require a level 2 investigation if there is reason to believe that a detailed investigation is required. 5.3.1 Process Steps There are seven key steps in the incident investigation process: (i) (ii) (iii) (iv) (v) (vi) (vii) Determination of investigation team. Collection of facts. Determination of root causes. Determination of corrective and preventative actions. Record of findings. Communication of findings. Review of implemented corrective actions. The process is integrated into the incident investigation report form. The following outlines the key steps in more detail. 5.3.2 Determination of Investigation Team The investigation team will be led by either the Associate Director - Health and Safety, or a designated Health and Safety Officer, or another nominated party determined to be able to lead the required multi cause investigative process (could be University Staff or an external consultant). The composition of the investigation team will be determined by the Associate Director – Health and Safety in consultation with other stakeholders in the investigation. The investigation team may also include involvement or representation from: • • • • Supervisor, Manager or Head of School/ Unit; Faculty or Division Health and Safety Committee member or University Health and Safety Committee member; Relevant Technical Specialists as required. Investigations are to be initiated within 24 hours from the notification of the injury to the OHS unit. 5.3.3 Collection of Facts University staff, students and visitors are to assist the investigation team to collect the relevant facts to permit a full investigation and are not to hinder or be an obstruction in the team undertaking the investigation task. The resources required and the depth of the collection will be determined by the investigation team leader. The collection of information required in order to establish facts relating to the investigation may also occur using, but not limited to the following methods: • • • • • • • photos, interviews with staff, witness statements, video footage, re-enactments, diagrams, engagement of a primary technical specialist to report on evidence and establish the relationship of facts and falsehoods against a hypothesis. The primary source of information will involve interviews with appropriate persons that may have knowledge of the incident or expertise in the work process concerned. Examples of key persons to interview may include: • • • • the injured person or person reporting the hazard, witnesses to the incident, manager or supervisor of the area or work process and local Workgroup Health and Safety representative. Specialist expertise may be required when conducting an investigation. For example, this may include the Electrical Maintenance Supervisor when investigating an incident relating to an electrical hazard. 5.3.4 Determination of Root Causes The University commits to a systematic process of piecing together the information in a logical sequence which outlines the cause-effect relationship. The process is to identify the factor(s) that led to the injury, illness, incident or other system failure. To do this, the investigation needs to review the situation from first principles e.g. recheck that all hazards were initially identified, and whether the risks were correctly assessed before the control measures were selected. A pictorial approach, such as a chart or map, may be used to provide a visual explanation of why and how the incident occurred. This helps connect the individual cause-and-effect relationships to reveal the system of causes. An example is contained in 9 Appendix 1 Root Cause Chart Example.. When using the root cause chart, the incident should be positioned to the left and causes placed on the right. Asking questions such as was caused by? or why did this effect happen? for each box will provide cause(s) for the next occurrence and then the process continues until no further causes can be identified e.g. the event is a back injury, caused by falling down the stairs caused by the person slipping etc. The final process is then allocating the root causes identified to one of the following categories with a minimum of one root cause being allocated: (i) Lack of or inadequate plant/equipment. (ii) Lack of or inadequate procedures/instructions. (iii) Lack of or inadequate training. (iv) Lack of or inadequate management/supervision. (v) Inappropriate or inadequate work environment. (vi) Inappropriate actions and/or behaviour. (vii) Lack of or inadequate management system. (viii) Other contributory issues. 5.3.5 Determination of Corrective and Preventative Actions This is the process of reviewing the identified hazards, assessed risks and the effectiveness of the current control measures to determine and recommend corrective actions. Corrective actions can only be assigned once the investigation is complete, however interim measures may be required in order to prevent exposure of people to hazards. Corrective actions should be developed for each cause that has been identified to prevent reoccurrence. For example, a root cause identified as lack of, or inadequate procedures/instructions would require a corrective action such as conduct a risk assessment to determine appropriate controls including safe work procedures and provide instruction and information to relevant personnel. Corrective actions should: • be appropriate for the root cause, • control the hazard to an acceptable level, • not introduce a new hazard or risk. • Consider the "hierarchy of control” in structuring appropriate risk reduction activities: Order Control Example Firstly Eliminate Taking a hazardous piece of equipment out of service Secondly Substitute Replacing a hazardous substance/process with a less hazardous one Thirdly Isolation Isolating the hazard from the person at risk with a guard or barrier Fourthly Engineering Redesign a process or piece of equipment to make it less hazardous Fifthly Administrative Adopting safe work practices or providing appropriate training PPE Providing Personal Protective Equipment (PPE) including gloves, glasses, earmuffs, aprons, safety footwear, dust masks. NOTE: This is a last resort control and should be for interim periods only, while higher level control is developed or implemented Sixthly Corrective actions may not only involve process control measures but also address system deficiencies in the H&S management system. 5.3.6 Record of Findings Findings from the investigation including factual information, cause determination and corrective actions are to be documented using the incident investigation form. Corrective actions to be implemented are to be recorded with the associated Online Incident report. Incident investigation documentation should be generated and filed in accordance with document control and records handling rules. 5.3.7 Communication of Findings Once completed, the investigation report is to be distributed to the Head of School or Director of portfolio or unit manager, relevant Faculty / Divisional Health and Safety Committee, and the University Health and Safety Committee. The report should include clear recommendations and assigned accountabilities for completion of corrective actions. 5.3.8 Review of Implemented Corrective Actions Corrective actions as a result of an incident investigation shall be documented and monitored against an assigned timeline relevant to the corrective actions required and the actions recorded with the Online Incident report. The investigation team leader will appoint a person to undertake regular reviews of the corrective actions and report on the status to the investigation team leader and the relevant Health and Safety Committees on a regular basis. Corrective actions which have not been implemented within the assigned time for completion will be raised with the manager of the unit concerned. 5.4 Level 3 Investigation Level 3 incidents involve occurrences where a person has been killed or which pose an immediate threat to life. These incidents are required to be reported to WorkCover immediately and include: • • • • • • • • • • • • • • a workplace fatality, an injury which results in the amputation of a limb, the placing of a person on a life-support system, the loss of consciousness to a person caused by impact of physical force, exposure to hazardous substance, electric shock or lack of oxygen, major damage to any plant, equipment, building or structure, an uncontrolled explosion or fire, an uncontrolled escape of gas, dangerous goods or steam, imminent risk of explosion or fire, imminent risk of an escape of gas, dangerous goods or steam, a spill or incident resulting in exposure or potential exposure of a person to a notifiable or prohibited carcinogenic substance, entrapment of a person in a confined space, collapse of an excavation, entrapment of a person in machinery, serious burns to a person. Level 3 Incidents may require investigation by WorkCover and thus the scene of the incident must not be disturbed for a period of 36 hours unless actions are required to help or removed trapped or injured persons, are needed to make the site safe, or the actions are directed or permitted by a WorkCover inspector. The Associate Director - Health and Safety will liaise with WorkCover and undertake an investigation of the incident as per Level 2 incident investigation, and in accordance with any directions provided by WorkCover. 6 Roles and Responsibilities 6.1 Employees Employees are responsible for reporting hazards, incidents, injuries, dangerous occurrences and systems failures which occur or have the potential to occur. Employees are responsible to ensure unsafe conditions are immediately reported and do what they can to ensure the safety of others. 6.2 Supervisors and Managers Supervisors and managers are responsible for ensuring hazards, incidents, injuries, dangerous occurrences and systems failures are reported to the Health and Safety team, and for ensuring that any assigned corrective actions are implemented within the required timeframe. 6.3 Associate Director - Health and Safety The Associate Director Health and Safety is responsible to ensure that incident investigations are undertaken in accordance with this procedure and supporting guidelines and documentation. 7 Essential Supporting Documents Work Health and Safety Policy 000972 Health and Safety – Incident Investigation Report Critical Incident Management Policy 000828 Critical Incident Management Procedure 000829 Potential Critical Incident – Preventative Action Guideline 000853 8 Related Documents Work Health and Safety Act 2011 Work Health and Safety Regulation 2011 9 Appendix 1 Root Cause Chart Example (PDF) Approval Authority Director, Human Resource Services Date Approved 27 November 2012 Date for Review 27 November 2015 Policy Sponsor Director, Human Resource Services Policy Owner Associate Director, Health and Safety Policy Contact Senior Safety Officer, Health and Safety Amendment History New procedure prepared in response to new legislation (Work Health and Safety Act 2011), approved by Acting Director Human Resource Services, 27 November 2012.
