Incident Investigation and Root Cause Analysis Procedure

This document outlines the initial steps for conducting a thorough incident investigation and root cause analysis following a safety event or near-miss. The goal is to identify the underlying causes of the incident to prevent recurrence and improve overall safety performance.

Initial Response and Immediate Actions

The immediate response to a safety event or near-miss is critical for preserving evidence, preventing further harm, and initiating the investigation process.

Provide Medical Assistance

Provide immediate medical assistance to any injured parties. Ensure that all injured individuals receive prompt and appropriate medical attention.

Secure the Scene

Secure the incident scene to prevent further injury or damage. This may involve cordoning off the area, shutting down equipment, and preventing unauthorized access. Preservation of the scene is crucial for the subsequent investigation.

Report the Incident

Report the incident to the appropriate personnel and regulatory agencies as required by company policy and legal requirements. Ensure that all reporting is accurate and timely.

Investigation Team Formation and Planning

Assembling a qualified investigation team and developing a comprehensive investigation plan are essential for a successful root cause analysis.

Form an Investigation Team

Select a team of individuals with the appropriate knowledge, skills, and experience to investigate the incident. The team should include representatives from safety, operations, and other relevant departments.

Develop an Investigation Plan

Develop a detailed investigation plan that outlines the scope, objectives, timeline, and resources required for the investigation. The plan should include specific tasks, responsibilities, and deadlines.

Data Collection and Evidence Gathering

Gathering comprehensive data and evidence related to the incident is crucial for identifying the root causes.

Conduct Interviews

Conduct interviews with all individuals involved in or witness to the incident. Obtain detailed accounts of what happened before, during, and after the event.

Collect Documentation

Collect all relevant documents and records, including safety procedures, training records, maintenance logs, and equipment manuals. Review these documents to identify any deviations from established procedures or potential contributing factors.

Document the Scene

Take photographs and videos of the incident scene, equipment, and any other relevant evidence. Visual documentation can provide valuable insights into the sequence of events and contributing factors.

Gather Physical Evidence

Collect any physical evidence from the incident scene, such as damaged equipment, materials, or environmental samples. Ensure that all evidence is properly labeled, preserved, and stored for further analysis.

Analysis and Root Cause Identification

Analyzing the collected data and evidence to identify the root causes of the incident is the core of the investigation process.

Perform Root Cause Analysis

Use appropriate root cause analysis techniques, such as the 5 Whys, fishbone diagrams, or fault tree analysis, to identify the underlying causes of the incident. Focus on identifying systemic issues rather than individual errors.

Identify Contributing Factors

Identify all contributing factors that led to the incident, including both direct and indirect causes. Consider factors related to equipment, procedures, training, communication, and the work environment.

Corrective and Preventive Actions

Developing and implementing corrective and preventive actions to address the identified root causes and prevent recurrence is the final step in the investigation process.

Develop Action Plan

Develop specific, measurable, achievable, relevant, and time-bound (SMART) corrective and preventive actions to address the identified root causes and contributing factors.

Implement Actions

Implement the corrective and preventive actions in a timely manner. Ensure that all responsible parties are aware of their responsibilities and deadlines.

Monitor Effectiveness

Monitor the effectiveness of the corrective and preventive actions to ensure that they are achieving the desired results. Make adjustments as necessary to improve their effectiveness.

Compliance with health and safety rules should be considered a condition of employment. Rules must be explained to new workers when they start work or if they are transferred or retrained. After a suitable interval, these workers should be briefed to ensure they understand the rules applicable to their work. [1]

The employer must establish procedures for dealing with repeat rule violators. Supervisors are responsible for correcting unsafe acts, such as a breach of rules, and they must be supported in this duty. [1]

Safe work procedures are the safest way of doing a job, job instruction, monitoring performance, and incident investigation. [1]