1 The objective of an investigation is to prevent
related incidents from recurring. An investigation should identify
the circumstances of the injury, illness or incident and reveal the
proximate causes, contributing factors, and root causes by gathering
and analysing information and drawing conclusions. Identification
and correction of causes may prevent similar incidents from recurring.
Furthermore, identifying and correcting a true root cause may prevent
other, apparently unrelated incidents, giving even more return on
the effort expended to identify root causes. For example, if a problem
with the company's training system was identified as the root cause
for a confined space incident, then correcting the entire training
system may prevent an injury that would have been caused by an untrained
person improperly operating a piece of machinery.
2 Start the investigation as soon as possible
after the incident occurs. Interview workers involved in the incident
and all witnesses. Discover situations leading up to the incident
including several days before. These situations may include contributing
factors. (Human factors including fatigue often are found as root
or contributing factors and may accumulate over a period of time.)
Examine the location of the incident and identify factors associated
with the incident. Interview other company personnel as needed to
determine root causes. Document the investigation and recommendations.
3 The final report should include:
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.1 a summary outlining the basic facts of the
incident;
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.2 a narrative detailing the circumstances of
the casualty or near incident;
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.3 analysis and comment that lead to logical conclusions
or findings, establishing all the factors, including root cause(s)
that contributed to the incident; and
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.4 immediate and long-term recommendations aimed
at preventing similar accidents and correcting root causes.
4 It may be helpful to categorize investigation
data. An example of a one-page form divided into information categories
is provided. Additional pages might be used to record the summary,
narrative, analysis and recommendations.