The Skills Shack

This resource has been designed for anyone who needs to undertake an investigation into a workplace health &amp; safety incident. It introduces you to the skills and knowledge required to carry out a successful investigation.At the completion of this course you will have a better understanding of: Why successful investigations prevent further events and injuries occurring; 6 key steps of undertaking the investigation; Why it is important to visit the scene of the incident; The importance of the order of the interviews; An understanding of Root Cause Analysis; How to conduct the interview; The setup of the Investigation Report

When a health and safety incident occurs within a workplace, a thorough investigation assists in determining the cause of the incident and allows for corrective actions or solutions to be implemented.  This is to prevent recurrence of the incident and to minimise or eliminate any current or future risk.  Because, if you can find the cause of an incident you may prevent future incidents.

<img alt="" src="https://resources.skillsshack.com.au/files/image/SafetyConceptsFixedCourses/Incident%20Investigations/Investigations1.png" style="float:right;height:308px;margin-left:15px;margin-right:15px;width:400px;" />It is important to remember that health and safety investigations are not conducted to apportion blame or liability for what occurred.

Every incident investigation involves 6 key steps:

<ol>
	<li>Preparation</li>
	<li>Visiting the scene</li>
	<li>Conducting interviews</li>
	<li>Examining physical evidence</li>
	<li>Analysing the evidence</li>
	<li>Preparing a report</li>
</ol>

When a person is delegated the responsibility of carrying out an investigation, he or she will generally be given the scope and purpose of the investigation.  If not, the scope and purpose of an investigation can be developed by the investigator and then settled or endorsed by the safety team or the head of the organisation.

Incident Investigations

<img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/investigate.jpg" style="float:right;height:358px;margin:20px;width:300px;" />The object of an investigation is to:

<ul>
	<li>Establish the Facts</li>
	<li>Develop appropriate corrective and preventable actions</li>
	<li>Effectively implement these actions</li>
</ul>

 

Preparing and conducting the investigation is a process that requires certain steps to be followed in order.

An Investigator must:

<ul>
	<li>Clearly define the purpose of the investigation</li>
	<li>Consider any relevant policies or other guidelines to use</li>
	<li>Prepare an investigation plan</li>
	<li>Collect information</li>
	<li>Organise information</li>
	<li>Analyse information</li>
	<li>Recommend solutions</li>
	<li>Report outcomes</li>
</ul>

Objectives of an Investigation

In order to undertake a successful and competent investigation, a simple plan of what you need to do is required.  Asking the right questions will greatly assist in determining the real causes of the incident, so it is important to plan. 

<img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/investigatelocation.jpg" style="float:left;height:201px;margin:25px;width:300px;" />When preparing an Investigation Plan you need to consider the final report you will be writing and to identify the core issues or outcomes that you are likely to be addressed in this report.

One of the first steps to take in planning an investigation is to ask yourself “What are the potential sources of information that will assist me to inquire into the matter as defined by my scope and purpose".

 

 

 

Make preliminary inquiries to determine:

<ul>
	<li>The interview questions;</li>
	<li>The witnesses to interview; and</li>
	<li>The order in which to interview the witnesses</li>
</ul>

 

When investigating an incident you should visit the incident scene wherever possible.  This allows for a basic understanding of the incident and assists in gathering some basic facts relating to the incident.  It will also help in formulating appropriate questions to ask those involved.

Planning the Investigation

Conducting an Investigation

<img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/interview_1.jpg" style="float:right;height:550px;margin-left:15px;margin-right:15px;width:400px;" />

Interviewing is a critical part of the investigation process.  You should be fair and professional at all times and only gather and document the facts, being careful not to make assumptions as to what might have occurred.

When planning your interviews it is necessary to identify witnesses who saw the events leading up to the incident, those who actually saw the incident, and those who came upon the scene immediately following the incident.

Any others who may have useful information should not be overlooked.  Witnesses and others should be interviewed as soon as possible to minimise the possibility that they will subconsciously adjust their stories to fit the interviewer’s concept of what occurred or to protect someone involved.

In the case of a complaint, for example, discrimination or harassment, the order of interviews is perhaps even more important.  The investigator should interview all other relevant witnesses and be prepared to refer to this information during the interview of the accused.  This way the accused will have the opportunity to respond to an employer’s concerns.

Planning the Interview

<img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/answerssign.jpg" style="float:left;height:360px;margin-left:25px;margin-right:25px;width:450px;" />Before interviewing witnesses:

<ul>
	<li>Identify the order of the witnesses to be interviewed</li>
	<li>Prepare a framework of questions</li>
	<li>Select a location for the interview</li>
	<li>Plan to kick off the interview on a positive note to gain the trust of the person being interviewed</li>
	<li>Be prepared to answer questions about the investigative process and explain the purpose of the interview</li>
</ul>

Before interviewing witnesses

<img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/RCAred.jpg" style="float:right;height:400px;margin-left:15px;margin-right:15px;width:400px;" />

The 5 Whys is a question-asking method known as Root Cause Analysis, it is used to explore the cause/effect relationship underlying a particular problem. Ultimately, the goal of applying the 5 Whys method is to determine the root cause of a defect or problem.

The following example demonstrates the basic process:

The problem - My car will not start  
1st Why? - The battery is dead  
2nd Why? - The alternator is not functioning  
3rd Why? - The alternator belt has broken  
4th Why? - The alternator belt was well beyond its useful service life and has never been replaced  
5th Why (a root cause)? - I have not been maintaining my car according to the recommended service schedule  
6th Why (optional footnote)? - Replacement parts are not available because of the extreme age of my vehicle  
 

The Solution - I will start maintaining my car according to the recommended service schedule  
The questioning for this example could be taken further to a sixth, seventh, or even greater level.

This would be okay, as the "five" in 5 Whys is not set in stone but it is hoped that by asking why five times it is generally sufficient to get to a root cause. The real key is to encourage the trouble-shooter to avoid assumptions and logic traps in reaching a conclusion.

Note: In this example, the fifth why suggests a broken process or an alterable behaviour, which is typical of reaching the root-cause level.

The 5 Whys

A person being interviewed (either the accused, a complainant or another witness) has the right to be represented and/or accompanied by a support person.​

 
<img alt="conducting interview" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/conductinterview.jpg" style="float:right;height:283px;margin-left:15px;margin-right:15px;width:400px;" />Place yourself in the other person's shoes and think about how you would like the interview to run if you were them.

The questions should be logical, directed to relevant issues and invite a response (that is, questions that require an explanation).

Demonstrate patience and stay focused on the purpose of the interview.

Be honest and avoid including your opinions.

If you think the interview feels a little uncomfortable – then the person you're interviewing probably feels the same.

Where an investigator wishes to record an interview, the person being interviewed should be informed of this - recording should never be carried out covertly.

Recap on all facts at the end of the interview asking the interviewee to confirm that all relevant information recorded is correct.

Thank the interviewee and finish the interview on a positive note.

Conducting Interviews

Usually, an investigation will be finalised in a report that sets out findings of the facts and any recommendations.  This report should be based on the evidence, sticking to the facts and keeping it short and to the point.

The report should start with a Summary of Investigation with one or two paragraphs on the findings of the investigation.<img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/report.jpg" style="float:right;height:323px;margin-left:15px;margin-right:15px;width:400px;" />

When writing a report:

<ul>
	<li>Refer back to your original investigation plan to confirm the structure of the report</li>
	<li>Describe the Incident being investigated and what happened</li>
	<li>Describe the methods of investigation used</li>
	<li>Document who was included in the investigation</li>
	<li>Use bullet points if required, to structure the report</li>
	<li>Use everyday language so all readers can understand it</li>
	<li>Use short sentences rather than long sentences</li>
	<li>Use an automatic spell and grammar check</li>
	<li>Include copies of evidence and statements to support your Investigation Report</li>
	<li>Include any photos and attachments if necessary</li>
</ul>

The Report

The report should end with the conclusions reached in your investigation and any recommendations, such as corrective actions, to prevent this sort of thing happening again. <img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/findings.jpg" style="float:right;height:297px;margin-left:15px;margin-right:15px;width:350px;" /> Recommendations should be based on the evidence generated by the investigation and your analysis of this evidence.

For example, recommendations may include:

<ul>
	<li>Referral to another agency – such as law enforcement agency</li>
	<li>Disciplinary actions – dealt with in accordance with policies and procedures</li>
	<li>Administrative actions – such as further training or a change to policies and procedures.</li>
</ul>

Conclusions

The Work Health and Safety (WHS) Act sets out certain types of workplace incidents that need to be notified to regulators.

Notifiable incidents relate to any person—whether an employee, contractor or member of the public.

To find further information in regard to workplace incident reporting in your state, please click on the logos below.

<a href="https://worksafe.nt.gov.au/laws-and-compliance/investigations-and-enforcement"><img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/NTworksafe.jpg" style="float:left;height:49px;width:200px;" /></a>

 

 NT Worksafe

 

<a href="http://www.safework.sa.gov.au/"><img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/safeworksa.jpeg" style="float:left;height:80px;width:200px;" /></a>

 

SafeWork SA

 

 

<a href="http://www.workcover.nsw.gov.au/"><img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/workcover_nsw.jpeg" style="float:left;height:62px;width:200px;" /></a>

 

WorkCover NSW

 

<a href="https://www.worksafe.qld.gov.au/"><img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/workcoverqld.jpeg" style="float:left;height:72px;width:200px;" /></a>

 

WorkCover Qld

 

 

<a href="http://www.worksafe.act.gov.au/health_safety"><img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/worksafe_ACT.jpg" style="float:left;height:42px;width:200px;" /></a>

WorkSafe ACT

 

<a href="https://www.commerce.wa.gov.au/worksafe"><img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/worksafe_wa.jpeg" style="float:left;height:59px;width:200px;" /></a>

 

WorkSafe WA

 

<a href="http://worksafe.tas.gov.au/"><img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/worksafe_tas.jpg" style="float:left;height:95px;width:200px;" /></a>

 

WorkSafe TAS

 

 
<a href="http://www.worksafe.vic.gov.au/"><img alt="" src="https://resources.skillsshack.com.au/files/image/Incident%20Investigations/worksafe_vic.jpg" style="float:left;height:63px;width:350px;" /></a>

  Victorian WorkCover Authority

Additional Information and Support

The information in this course is intended to be used as resource material on the subject matter covered and we are not engaged in providing or rendering legal, safety or compliance advice. If expert assistance is required, the services of a competent professional should be sought to update the content.

The author and publisher shall have neither liability nor responsibility to any person or entity with respect to any loss or damage caused, or alleged to be caused, directly or indirectly by the information contained in the various pages within this course. While every effort has been taken to ensure that all details of this resource are correct, the authors or publishers cannot accept any responsibility for the accuracy of the information contained within this site, nor for the consequences of any actions taken or not taken as a result of this information.

Incident Investigation

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