Incident Investigations

Get to the root causes with an investigation

Report and support

• Report the incident to a designated person within your organization.
• Provide first aid and medical care to the injured person(s).

The investigation team begins its work

• Manage the scene

  Secure the scene and make sure it’s safe to proceed.

• Witness management

  Support and interview witnesses. Limit interaction with other witnesses.

• Gather the facts

  See conditions as they were at the time. Document with photographs.

• Start the investigation

  Investigate, gather data, then analyze data to identify the root causes.

• Analysis and recommendations

  Be specific and constructive. Outline what went wrong and recommendations.

Make a plan, make change

• Plan and correct

  The organization will develop and implement a plan for corrective action.

• Evaluate

  Make sure plan is effective.

• Change for the better

  Make changes for continual improvement.

An incident is an occurrence, condition, or situation that arises during work that has or could have resulted in injuries, illnesses, damage to health, or fatalities.

Incidents happen

When they do, the investigation should ask:

What work procedure was being used at the time of the incident? (Task)

What equipment and materials were used? (Materials)

What was the physical work environment like when the incident occurred? (Environment)

How were the physical and mental conditions of individuals directly involved? The purpose is not to blame someone. (Personnel)

Did failures of management systems directly or indirectly cause the incident? (Management)

Who investigates

Designated employees or representative who are experienced or knowledgeable in areas like incident causation models, investigation techniques, and occupational health and safety.

Communication is key

Once the investigation is done, findings should be communicated with workers, supervisors and management.

Everyone should understand how the incident occurred and the actions being put in place to prevent it from happening again.

Wrap up with a written report

• Sequence of events
• Specific details and evidence, like photos and diagrams
• The reasoning behind conclusions
• Findings and recommendations

Most Canadian jurisdictions have specific incident investigation legislation. In some situations, employers need to involve the health and safety committee or representative, or contact their regulatory agency if applicable.