Procedures

Incident Investigation - Procedure

Printer-friendly version
Body

1.0    Purpose and Scope

The purpose of this procedure is to outline the requirements for the investigation of health and safety incidents at The University of Queensland (UQ) and applies to UQ supervisors, managers or others that are required to undertake workplace incident investigations. It is applicable to all incidents where UQ work activities are undertaken at UQ workplaces and external work environments. This procedure should be read in conjunction with the Incident Investigation Guidelines.

The purpose of an incident investigation is not to assign blame - incidents occur for a variety of reasons. The main aim is to establish what the contributing factors are and to put measures in place to prevent a recurrence.

Whenever a worker or other person is involved in a UQ related incident, it must be reported, investigated and corrective actions taken to prevent recurrence. Workers or other persons may be required to take part in the investigation.

The processes outlined in this procedure align with:

1.1    Context

UQ is legally obliged under the Work Health and Safety Act 2011 (WHS Act) and the Work Health and Safety Regulation 2011 (WHS Regulation) to comply with duties to provide, as far as reasonably practicable, a safe workplace. It is also obliged to manage risks to an acceptable level to prevent harm.

2.0    Process and Key Controls

The objective of an incident investigation is to determine the contributing factors and identify appropriate controls to prevent a recurrence. Incident investigations should result in enhanced health and safety management systems.

The process involves systematically collecting evidence, assessing data, reporting outcomes and implementing corrective actions. Key controls supporting effective incident investigation include: 

1)    Determining the objectives and the level of investigation - the extent and complexity of the investigation should be proportionate to the risk attributed to the incident event.

2)    Analysis of evidence and conclusions are based on evidence collected and facts.

3)    UQ management is responsible for ensuring effective incident investigation occurs and that investigation outcomes are implemented.

3.0    Key Requirements

3.1    Scoping an incident investigation

3.1.1    Investigation objectives

The severity of the incident or potential severity, may assist in determining the objectives of the investigation.  Consideration should be given to the legal, insurance, human resource, enterprise compliance and third-party aspects, and will also determine whether one or multiple investigations are required.

Clarity about what is included and excluded from the investigation scope will drive the objectives.

3.1.2    Determine investigation level

Incidents will be investigated proportionately in order to produce appropriate corrective actions to minimise the risk of repeat incidents. The depth of investigation and nature of tools used to complete an investigation are dependent on the incident risk rating (at the time of the incident) and level determined on UQSafe, in consultation with the local Work Health and Safety Coordinator (WHSC) or Health, Safety and Wellness (HSW) Manager. An incident marked as a “HiPO” in UQSafe may require a fuller investigation and this can be completed using the “basic” investigation within UQSafe.

A Level 1 Investigation is required for incidents with low or medium risks. These incidents are to be investigated by the supervisor of the person reporting or involved in the incident, with support from the local WHSC. Level 1 investigations are documented through the creation of an Action Plan in UQSafe. Refer to the table in section 7.2.

A Level 2 Investigation is required for an incident that is rated as having a ‘high’ risk. These incidents are to be investigated by the local WHSC or HSW Manager and findings recorded in UQSafe. Level 2 investigations can be documented using the Basic Investigation tool in UQSafe. Refer to the table in section 7.2

A Level 3 Investigation is required when an incident is notifiable to a Regulator (or had a high likelihood of being notifiable) or the risk level is determined as ‘Extreme’. In addition to reporting the incident and corrective actions in UQSafe, a formal investigation is to be conducted by the local HSW Manager with support, if required, from the HSW Division. Refer to section 7.2. A separate report is required, and may on occasions be provided to a Regulator or inspector either voluntarily or if compelled by a Regulator.

3.2    Preparation activities

3.2.1    Investigation team

While it is appropriate to have a number of people involved in investigations, Level 1  investigations only need to be completed by Supervisors. WHSC’s and HSW Managers could be included if required.

Level 2 investigations must be completed by WHSCs and /or HSW Managers.

Level 3 investigations are usually more complex and require a suitably competent and skilled investigation team.  They must be carefully selected to ensure a considered and balanced outcome. A lead investigator is to be appointed to ensure the investigation meets all the criteria and timeframes are me

If there is a Health and Safety Representative (HSR) that represents the workgroup involved, they should be offered the opportunity to be included in all investigations, with permission from injured worker, if applicable.

3.2.2    Report requirements

It is important to determine who the audience of the investigation report will be, considering confidentiality and sensitivity.  The expectations of the reporting deadlines must be considered in conjunction with the scheduling of evidence gathering.

3.3    Evidence collection and recording

3.3.1    Recording of evidence

The recording of evidence must be systematic and catalogued to ensure integrity. This is especially critical for Level 3 investigations.

3.3.2    Evidence collection

Evidence used to support an incident investigation must be based in fact. Opinions, hypotheses, hearsay and conjecture are not considered as evidence and should not be used except where further inquiries lead to actual evidence supporting them. Interpretation of data may be considered to be evidentiary, if the person conducting the interpretation is qualified to do so, such as an engineer interpreting data relating to load bearing issues.

There are two main types of evidence, perishable and non-perishable.  Perishable evidence after an incident can change swiftly e.g. memory, incident site, real-time recordings. Non-perishable evidence is that which does not change over time and can include items such as documentation and training records.

Evidence can be collected from the site through a site inspection. Photographs of the site should be taken as soon as practical, and capture any items left in situ.

3.3.2.1    Interviews

Interviews form part of the key evidence in investigations and should be conducted as soon as possible after the incident as memory declines rapidly. Interviews should be scheduled with:

  • Principal witnesses – those directly involved in the incident.

  • Eyewitnesses – those that directly observed the incident, or the conditions immediately preceding or following the incident.

  • General witnesses – those with knowledge about the activities.

  • Subject matter experts (SME) – those with specific process or technical expertise.

Witnesses cannot be forced to providing an interview – it is a voluntary process.

Refer to the Incident Investigation Guideline for further details on planning for and conducting interviews.

3.3.2.2    Documentation and records

As documents and records are non-perishable, these can be collected at a later stage. Documents and records collected will depend on the incident, but can include things such as risk assessments, safe operating procedures, training records, induction processes etc. 

3.3.2.3    Chain of evidence

Managing the evidence must be controlled and it must remain secure. Evidence should be catalogued and managed by a person so the chain of evidence remains intact. All items should be catalogued with a date and time as to when the evidence was obtained or collected.

3.4    Conducting the investigation

3.4.1    Level 1

Level 1 investigations are for low and medium risk rating incidents, including near misses, and are completed in UQSafe by the Supervisor of the injured person and verified by the Work Health and Safety Coordinator (WHSC) or local Health, Safety and Wellness (HSW) Manager.

3.4.2    Level 2

Incidents having a high risk rating require Level 2 investigation, be completed in UQSafe, and involve the local WHSC or HSW Manager and Health and Safety Representative (HSR) for the workgroup if there is one. The HSW Manager or the HSW Division (as appropriate) should review details to:

  • Ensure the risk rating level is appropriate.

  • Assess the quality of the investigation.

  • Follow up with management to ensure that consultation has occurred with relevant persons, and actions and timing for implementation has been agreed.

  • Enable legal implications to be considered.

3.4.3    Level 3

Incidents requiring Level 3 investigations are notifiable to a Regulator (or had a high likelihood of being notifiable) or have an ‘extreme’ risk rating.  This type of investigation requires a formal report and a planned and methodical investigation process conducted by an investigation team. The investigation report must be uploaded to UQSafe as an attachment to the incident report at the conclusion of the investigation. The attachment should be marked as ‘confidential’, which only allows the WHSC, HSW Manager and selected people in the HSW Division to view the investigation report. A Lead Investigator will lead the team.  If there is a HSR for the workgroup, they must be offered the opportunity to be included in the investigation team.

3.5     Analysis of evidence

Analysis is the methodical and logical link between the fact-finding process (collection of evidence) and the development of conclusions. UQ uses the ICAM (Incident Cause Analysis Method) for investigations and is supported by several templates.  This method allows investigations to extend beyond intentional and unintentional actions of human error (active failures) to identify the underlying factors that contributed to those actions and the context (latent conditions). It allows for the investigation into contributing factors that may have influenced the individual to make choices that led to an incident, for example, organisational factors, task/environmental conditions, individual/team actions, absent/failed defences (e.g. supervision, guards etc).

Further information can be found in the Incident Investigation Guideline.

3.6    Conclusions and recommendations

The conclusions will be based on facts and the analysis of the facts.  These will be substantiated by the physical evidence, interviews and analysis tools.

The recommendations will flow from the causal factors and will directly tie back to the evidence collected.

3.7    Report and action plan

Where system deficiencies have been identified through the investigation process, recommendations for corrective action must be made to reduce future risk and improve health and safety performance.  Action plans must be created in UQSafe within three weeks of the incident occurring and allocated to a person responsible for actioning. These recommendations must be linked to the evidence collected.

A deadline for implementation of corrective actions must be set, and monitoring processes in place to ensure actions are addressed satisfactorily. Follow up to evaluate the effectiveness of the corrective actions is required by the supervisor, and adjustments made as needed for continual improvement.

3.8    Investigation close-out meeting

Once the report has been completed, a meeting with relevant managers and supervisors will be organised to review the report and discuss the findings. This allows for the agreement of the action plan and ensures the correct person is allocated against each corrective action along with the agreed timeframe for implementation.

4.0    Roles, Responsibilities and Accountabilities

4.1    Head of Organisational Unit

Heads of Organisational Units are responsible for:

  •  Ensuring all incidents are investigated to the appropriate level.

  •  Allocating suitable resources and time for an appropriate level of investigation.

  • Following up with HSW Manager and supervisors to ensure action plans and  recommendations are instigated and completed in the appropriate timeframe.

  • Liaising with HSW Manager, WHSC and/or HSW Division to report serious events  to relevant stakeholders.

  • Reviewing and accepting the Investigation Report including its findings and assigning responsibility for addressing the correct actions identified and within the agreed timeframes.

4.2    Supervisor

Supervisors, within their areas of responsibility, are responsible for:

  • Ensuring all relevant incidents are reported in UQSafe and reviewing the circumstances of the incident.

  • Determining the incident classification to ensure the appropriate level of investigation is conducted.

  • Assisting or leading the preparation and completion of the incident report and investigation.

  • Ensuring for serious incidents, any witnesses or other workers are provided with information on the Employee Assistance Program and that appropriate check-in/s are scheduled for a future time.

  • Ensuring completion of the action plan in UQSafe within the required timeframe and that corrective measures  are identified and implemented in consultation with the local WHSC.

  • Liaising with the HSW Manager, WHSC and/or head of the Organisational Unit to report serious events to the HSW Division and senior management.

4.3     Lead investigator

The lead investigator:

  • Provides guidance to ensure the appropriate and required people are involved in the investigation team.

  • Guides the investigation team to ensure the appropriate scope, and that all areas are covered, appropriate evidence is collected, stored and chain of evidence maintained.

  • Oversees all aspects of the investigation.

  • Completes the investigation paperwork and report.

  • Arranges meetings with people (including appropriate manager and supervisors) to review the report and discuss the recommendations.

4.4    HSW Manager / WHS Coordinator

The HSW Manager and WHSC are responsible for:

  • Providing assistance and advice for the investigation, review circumstances and incident classification.

  • Undertaking a role in the investigation team if requested by the lead investigator and complete assigned actions.

  • Following up to ensure that action plans are completed, and relevant corrective actions are assigned and implemented.

  • Ensuring the scene is maintained (not disturbed) for notifiable incidents.

  • Ensuring photos are taken of the scene, unless otherwised arranged by the Lead Investigator.

  • Ensuring Health and Safety Representatives (HSRs) are offered the opportunity to be involved in the incident investigation.

  • Assisting in the preparation and completion of the incident report and investigation, where required.

  • Supplementing the investigation report, where necessary, with further information in the notes section of UQSafe, by uploading documents or by adding further actions to the action plan in UQSafe.

  • Assisting with the identification and implementation of corrective actions or controls.

  • Liaising with the HSW Division to ensure it is aware of incidents leading to level 2 and 3 investigations, and work with the Division to arrange any required notification to the appropriate Regulator of any notifiable events.

  • Marking investigation reports as confidential prior to uploading to the relative UQSafe report.

  • Issuing a Safety Notice for dissemination to local staff and students, where appropriate.

4.5    Workers

Workers are responsible for:

  • Reporting all incidents directly to their supervisor and submit an incident report in UQSafe as soon as possible after the incident.

  • Assisting in post-incident investigation and assist in identifying gaps and to implement corrective actions where required.

4.6    HSW Division

The HSW Division is responsible for:

  • Providing assistance and/or advice for the investigation.

  • Assisting where required, in the preparation and completion of the investigation and report.

  • Liaising with the Supervisor, Head of Organisational Unit and HSW Manager/WHSC if required.

  • Liaising with the relevant regulatory body (and legal counsel if necessary) in the event of a notifiable incident.

  • Where a notifiable incident/event has occurred, a senior member of the HSW Division will review the investigation prior to it being finalised and sent to the Regulator.

  • Where appropriate, issuing a Safety Notice for dissemination to UQ.

  • Where applicable, assisting with Regulator site visits.

5.0    Monitoring and Review

The HSW Division will review the effectiveness of this procedure and update it to reflect contempory investigation processes as required.  Investigation process are monitored through the Division and investigation reports and outcomes reported to the Vice-Chancellor's Risk and Compliance Committee as required.

5.1    Level 1

UQSafe has automatic workflow properties that notifies various roles in UQ if action plans are not completed. HSW Managers will follow up with the supervisor responsible for the action plans.

5.2    Level 2 

The HSW Manager or the HSW Division (as appropriate) reviews the report to:

  • Ensure the risk rating level is appropriate.

  • Assess the quality of the investigation.

  • Follow up with management to ensure that consultation has occurred with relevant persons, and actions and timing for implementation has been agreed.

  • Enable legal implications to be considered.

5.3    Level 3

The HSW Manager and/or HSW Division review these reports for clarity, factual evidence and clear recommendations. The tone of the report needs to be approved by the HSW Director (or other senior member of the HSW Division) who will forward to the Regulator if required. In some circumstances, other senior members of UQ may receive the report.  This will be determined by the HSW Director. 

6.0    Recording and Reporting

All investigations are recorded and reported using UQSafe. UQSafe include automatic workflows which escalates to the next level of management when actions fall past their due date. The HSW Division reports on outstanding actions as part of monthly reporting.

For level 1 investigations, action plans are documented in UQSafe as part of the original incident report.

For level 2 investigations, in addition to the action plan, investigation findings and conclusions must be documented in UQSafe by the WHSC\HSW Manager using the note, attachements, and\or basic investigation function.

Level 3 investigations, the formal investigation report is to be attached to the original incident report in UQSafe, and all actions entered into the UQSafe action plan. The report remains open until all the actions are completed, this is monitored by the HSW Manager. These actions are expected to be discussed at local HSW Committee meetings.

All investigation reports relating to notifiable incidents must be retained as per the requirements of the General Retention and Disposal Schedule (GRDS), which may be up to 80 years.

6.1    Regulator notification and inspection

Regulator notification occurs in accordance with Health and Safety Incident and Hazard Reporting Procedure.

When an inspection is conducted on UQ premises by a regulatory authority, the following will occur as a minimum:

  • The first point of contact with the regulatory authority, will advise the HSW Division of the reason/scope of the visit.

  • Where possible, an “inspection coordinator” will be appointed by the HSW Director (or other senior member of the HSW Division) for the purposes of accompanying the regulator and to act as liaison.  This will usually be the local HSW Manager, or an person within the HSW Division.

  •   The inspection coordinator will:
    • determine and facilitate the required actions before and following the inspection.
    • record and where practicable, take samples and photographs similar to those taken by the regulatory authority.
    • communicate required actions to the HSW Director and to the relevant management of the local area.
  • The HSW Director, in conjunction with the relevant HSW Manager, will be responsible for establishing and maintaining a record of the inspection.

  • The HSW Director/Division will provide advice on UQ’s obligations to assist regulatory authorities in performing their functions under the relevant legislation.  Additional assistance may also be provided by UQ Legal Services.

6.2    Contentious investigations

It is important to be cognisant that some incidents requiring investigation could potentially be contentious, of interest to media, and pose other enterprise risks to UQ e.g. reputational and potentially significant legal risks.  In these cases, timely advice should be sought firstly from the HSW Division who may engage the advice of UQ Legal Services with respect to the direction of the incident investigation. 

Information related to these investigations must not be circulated within UQ or given to a third party without permission from the HSW Director or relevant Head of Organisational Unit.

7.0    Appendix

7.1    Definitions

Action Plans - includes corrective actions which are improvements to rectify and preventative actions which are improvements to address the potential of a non-conformity or other undesirable situation which caused an incident.

High-potential incident (HiPo) - is an incident or near-miss that, could have under other circumstances, caused a serious injury and/or a notifiable incident.

Incident - any occurrence that leads to, or might have led to, injury or illness to people, danger to health and/or damage to property or the environment. For the purpose of this procedure, the term "incident" is used as an inclusive term for injuries/illnesses, accidents, near misses,non-conformance and notifiable incident.

Near miss - an unplanned event that has the potential to cause, but does not actually result in human injury, environment or equipment damage.

Non-compliance - incident or breach that may be reportable under specific legislation e.g. breaches relating to genetically modified organisms, chemical imports, boating or diving incidents.

Notifiable incident – a serious incidents (serious injury / illness or dangerous events) which, in accordance with legislative obligations, are required to be reported to a regulator. For a full definition – refer to Health and Safety Incident and Hazard Reporting Procedure section 7.1.

Organisational Units - UQ faculties, schools, institutes, directorates, administrative and management divisions.

UQ workers - for the purposes of this procedure ‘worker’ includes:

  • UQ staff, including continuing, fixed-term and casual staff;

  • contractors, subcontractors and consultants;

  • higher degree by research students;

  • visiting academics and researchers;

  • visiting research students; and

  • volunteers engaged by UQ.

7.2    Investigation level

Custodians
Director, Health, Safety and Wellness Mr Jim Carmichael

Guidelines

Incident Investigation - Guideline

Printer-friendly version
Body

1.0    Purpose and Scope

The purpose of an incident investigation is not to assign blame - incidents occur for a variety of reasons and the main aim is to establish what the contributing factors were and to put measures in place to prevent a recurrence. This guideline supports the Incident Investigation Procedure and provides practice guidance on how to conduct an effective investigation.

Whenever a worker or other person is involved in a UQ related incident, it must be reported, investigated and corrective actions taken to prevent recurrence. Investigations should commence early and be given appropriate priority and resources by UQ management.  This guideline is intended to provide those in an investigation team with guidance to be able to conduct a thorough and fair investigation.

2.0    Process and Key Controls

The objective of an incident investigation is to determine the contributing factors and identify appropriate controls to prevent a recurrence. This guideline should be read in conjunction with the Incident Investigation Procedure and Incident and Hazard Reporting Procedure.

The objectives of this guideline are to:

  • Ensure all incidents reported that resulted in or had the potential to cause injury or illness investigated in a consistent and proportionate manner.

  • Provide practical instruction on how to determine the level of investigation required – the type of investigation conducted depends on the seriousness or complexity of the incident.

  • Support an investigation process that determines the cause of incidents and identifies opportunities for improvement to health and safety systems to prevent a recurrence.

  • Ensure investigation findings and conclusions are evidence based.

3.0    Key Requirements

3.1    Immediate action following an incident

Immediate actions following the incident can mitigate further risk to persons or property and support effective incident investigation.

  • For serious incidents, suspend work in the affected area. It may also be necessary to suspend similar work if there is a risk of a similar incident occurring.

  • Restrict access to the site/area so that it is preserved and only allow authorised persons into the site/area e.g. emergency personnel, manager etc.

  • Secure the scene to preserve evidence, and if appropriate and safe to do so, collect evidence for investigation e.g. photos, statements, damaged equipment. UQ is legally obliged under the WHS Act to notify the regulator of particular incidents, and also to preserve the incident site. If the incident is notifiable to the regulator, the Director HSW Division (or a senior member of the HSW Division) will facilitate this process

  • Report the incident in accordance with Health and Safety Incident and Hazard Reporting.

  • Consult with your Work Health and Safety Coordinator (WHSC), Health, Safety and Wellness (HSW) Manager and/or the HSW Division to verify investigation and notification requirements.

3.2    Scoping the investigation

The severity or potential severity of the incident may drive the objectives of the investigation. Consideration should be given to the legal, insurance, human resource, enterprise compliance and third-party aspects and will also determine whether one or multiple investigation as are required.

Once the objectives of the investigation have been determined, establish the legislation that may apply including, codes of practices and understanding other requirements that may apply for example Australian /New Zealand Standards, International Standards (ISO), and Building Codes.

In addition, UQ policy and procedures and local standard operating procedures that outline required practices and processes should be considered.

Clarity about what is included and exclude from the investigation scope will drive the objectives and provide clarity to the investigation team.  The content of a formal report must be considered as these may be provide to external parties (e.g. Regulators).

3.2.1    The level of investigation

A Level 1 Investigation is required for ‘low’ or medium risk incidents. These incidents are to be investigated by the supervisor of the person reporting or involved in the incident, with support from the local WHSC. Level 1 investigations are documented through the creation of an Action Plan in UQSafe.

A Level 2 Investigation is required for an incident that is rated as having a  ‘high’ risk. These incidents are to be investigated by the local WHSC or HSW Manager and findings recorded in UQSafe. Level 2 investigations can be documented using the Basic Investigation tool in UQSafe.

A Level 3 Investigation is required when an incident is notifiable to a Regulator (or had a high likelihood of being notifiable) or the risk level is determined as ‘Extreme’. In addition to reporting the incident and corrective actions in UQSafe, a formal investigation is to be conducted by the local HSW Manager with support, if required, from the HSW Division. A separate report is required, and may on occasions be provided to a Regulator or inspector either voluntarily or if compelled by a Regulator..

3.3    Preparing for the investigation

3.3.1    Establishing the investigation team

While it is appropriate to have a number of people involved in investigations, Level 1 investigations only need to be completed by Supervisors. WHSC’s and HSW Managers could be included if required.

Level 2 investigations must be completed by WHSCs and /or HSW Managers.

Level 3 investigations are more complex and require a suitably competent and skilled investigation team. The investigation team must be carefully selected to ensure the following principles:

  • Diverse team with appropriate expertise e.g. lead investigator, subject matter experts, worker experienced in the task, etc.

  • Team members are to declare conflicts of interest, these should be considered, documented and addressed as required.

If there is a Health and Safety Representative (HSR) that represents the workgroup involved, they should be offered the opportunity to be included in all investigations, with permission from injured if applicable.

3.3.2    Report requirements

Determine who the audience of the investigation report will be, considering confidentiality and sensitivity.  The expectations of the reporting deadlines must be considered in conjunction with the scheduling of evidence gathering.

Level 1 – UQSafe action plan.

Level 2 – UQSafe action plan and UQSafe Basic investigation.

Level 3 – UQSafe action plan and a formal investigation report.

3.4    Data collection

Data collection can be divided into five main areas (PEEPO):

  • People

  • Environment

  • Equipment

  • Procedures

  • Organisation.

Mapping out PEEPO assists the investigation team in keeping on track and focussed on the evidence collection.

3.5    Evidence collection and recording

3.5.1    Recording of evidence

One person should be nominated to handle the evidence which includes storage of documentation and data, and storage of physical evidence. Catalogue what the evidence is, the date obtained, where the evidence was obtained and from who.  Most of the items in this section are applicable for Level 3 investigations and in most cases do not apply to Levels 1 or 2.

3.5.2    Principals of evidence collection

Evidence used to support an incident investigation must be based in fact as factual evidence is crucial to the outcome of the investigation. If assumption are made, it is important to explain what they are based on, if there is any supporting evidence for the assumption and whether there are any alternatives that should be considered. Opinions, hypotheses, hearsay and conjecture are not considered as evidence and should not be used except where further inquiries lead to actual evidence supporting them. Interpretation of data may be considered to be evidentiary, if the person conducting the interpretation is qualified to do so, such as an engineer interpreting data relating to load bearing issues.

When scheduling evidence collection, consideration must be given to the two main types of evidence, perishable and non-perishable.  Perishable evidence is that which post incident can change swiftly e.g. memory, incident site, real-time recordings and should be collected first. Non-perishable evidence such as documentation and training records can be collected after perishable evidence has been secured.

3.5.3    Site inspection

The site should have, in some instances, been preserved immediately after the incident.  As soon as the site has been released by the authorities, a walk through the site and surroundings will be possible to take photographs (all items in situ) and measurements . Ensure any items that can be recovered are, and those that cannot be removed (due to size etc) are protected from the elements.

3.5.4    Photographs and video

Any photographic or video footage taken must be date and time stamped. If there is Closed Circuit TV (CCTV) footage, obtain this through the appropriate channels.

3.5.5    Interviews

Interviews form part of the key evidence in investigations and should be conducted as soon as possible after the incident as memory declines rapidly. Interviews should be scheduled with:

  • Principal witnesses – those directly involved in the incident.

  • Eyewitnesses – those that directly observed the incident, or the conditions immediately preceding or following the incident.

  • General witnesses – those with knowledge about the activities.

  • Subject matter experts (SME) – those with specific process or technical expertise.

It is vital to create the right environment for the interview. Keep the tone conversational and allow rapport to develop across the interview. Inviting questions around how the interview will work, describing procedural aspects like recording and note taking can assist in reducing anxiety. It is important to explain that the process is not about blame and the expected outcome of the investigation is to improve safety and prevent reoccurrences of the incident. Key principles for conducting effective interviews:

  • Prepare for the interview developing a list of questions, keeping an open mind, approach the interview without bias.

  • Establish trust through setting the expectations and providing clarity on the interviewee’s role in the investigation and how their interview statement will be used. 

  • Agree on recording method with interviewee e.g. hand written notes, typed, or audio recording. If using audio recording obtain permission.

  • Advise the interviewee to clearly articulate if the information experienced was firsthand or otherwise.

  • Allow the interviewee to elaborate, as the interviewer do not ask leading questions or provide the answer.

  • Listen actively and allow the interviewee to do the majority of the talking.

  • Group interviews may be appropriate in some circumstances; however, it is important to be mindful that ‘group think’ may occur, some people may dominate the conversation and there is no independence of witness statements.

  • Exchange contact details so that the witness statement can be forwarded to the interviewee for verification.

If a witness refuses to provide an interview, reiterate that the purpose is not to find fault but to find the weakness in the process or system.  Ask if the witness is willing to explain their reason for not wanting to participate, offer contact details if they decide to change their mind. There is an interview plan template that can assist with this process.

3.5.5.1    Interview questions

Interview questions should be developed ahead of the interview and primarily be open ended, e.g. “can you provide as much information about what happened leading up to and during the incident?”. Ask questions that explore what has already been stated by others in addition to probing for missing information. Actively listen and give the witness feedback.

Interview questioning tips:

  • Refrain from interrupting.

  • Ask the same question of several witnesses to corroborate the facts.

  • Aid the interviewee with reference points e.g. “how did the lighting compare to the lighting in this room?”.

  • Keep an open mind.

  • Don’t assume, if unclear, ask further questions to clarify your understanding, paraphrase e.g. “what I heard you say was…, did I understand that correctly?”.

3.5.5.2    Support person

When conducting interviews, the interviewee may want to have a support person with them. The role of the support person is to be present but not take part in any of the interview e.g. no answering or asking of questions, no interpretation of questions. The support person is present to provide moral support, not as an advocate, and are expected to remain silent throughout the interview.

3.5.6    Documentation and records

Documents and records are non-perishable and can be collected after the non-perishable evidence.  Documents that may be considered, depending on the incident could include:

  • Maintenance logs

  • Training records

  • Timesheets

  • Risk assessments

  • Safe operating procedures

  • Local operating procedures

  • Policies/procedures/guidelines

  • Induction records and processes

  • Audit reports

  • Maps and diagrams

  • Communication emails

  • Change papers/communication

  • Engineering/plant/equipment reports.

3.5.7    Chain of evidence

The evidence collected must be catalogued with a date and time when collected or obtained. This includes the following:

  • Label all evidence including the description and identification details.

  • Date, time and location the evidence was found.

  • How it was obtained and from who (if applicable).

  • Name of the person who handed the evidence over.

3.6     Conducting an investigation

3.6.1    Level 1

The supervisor develops the action plan in UQSafe which outlines the actions using the hierarchy of control, this is verified by the WHSC or HSW Manager.

3.6.2    Level 2

Level 2 incidents require a basic investigation and information can be collected in UQSafe. This is reviewed by the HSW Manager or the HSW Division (as appropriate), to:

  • Ensure the risk rating level is appropriate

  • Assess the quality of the investigation.

  • Follow up with management to ensure that consultation has occurred with relevant persons, and actions and timing for implementation has been agreed.

  • Enable legal implications to be considered.

For guidance on conducting a basic investigation in UQSafe refer to the Systems Training Hub.

3.6.3    Level 3

Incidents requiring Level 3 investigations are notifiable to a Regulator (or had a high likelihood of being notifiable) or,have an ‘extreme’ risk.  These investigations require a formal report and a planned and methodical investigation process conducted by an investigation team.  The report must be uploaded to UQSafe at the conclusion of the investigation and marked ‘confidential’.  Marking the report confidential only allows the WHSC, HSW Manager and selected people in the HSW Division to view the report. Refer to Appendix 5.1 – areas to explore.

3.7    Analysis of evidence - ICAM

Analysis is a methodical and logical link between the fact-finding process and the development of conclusions therefore the basis for corrective actions and preventative measures. There is usually never one single ‘cause’ of an incident – usually there are several event or conditions that together increase the likelihood of an incident – these are called indirect or contributing factors.

When analysing the evidence, there usually is several techniques that can be used depending on the severity and complexity of the incident. UQ uses ICAM (Incident Cause Analysis Method) which is based on the work conducted by Professor James Reason (also developed the Swiss Cheese Model of system accidents). 

This method allows investigators to extend beyond the intentional (human violation - deliberate deviation from a rule or procedure) or unintentional (human error) acts of the person (active failures) and identify the underlying factors that contributed to those actions and context (latent conditions) – indirect or contributing factors.

The system approach has the basic premise that humans are fallible, and error are to be expected. Errors are seen as consequences rather than causes, having their origins in systemic failures. The assumption being that we cannot change the human condition, but we can change the conditions under which humans work. ICAM focuses not on who to blame, but how and why the defences in place failed.

A further assumption, and the purpose of an ICAM investigation, is that consideration of sound organisational factors produces safe workplaces which reduces errors and violations.  A range of questions that could be used is found in Appendix 5.1 to keep the investigators open to other considerations.

3.7.1    Incident timeline

The benefits of establishing an incident timeline forms the basis for further analysis, it is systematic, graphically can display a flowchart plotted on a timeline, it shows actions, decisions and context of decisions and it establishes the chain of events.  It can illustrate and validate the sequence of events leading to the incident and the conditions affecting these events. It helps to link facts and causal factors to organisational issues and management systems. The following visual can be used to represent a validated event:

 

 

3.7.2    Event and conditions charting

Using the timeline as a starting point, build outward from the validated sequence of events, add in the conditions affecting the events. Set out the conditions in visual form, include, assumed conditions and conditions, visually represented by the following:

3.7.3    Indirect or contributing factors to consider

3.7.3.1    Organisataional Factors

Consider the following at the organisational level the following:

  • Leadership

  • Safety culture

  • Safe systems of work

  • Staff selection for the role

  • Training

  • Operation vs safety goals

  • Risk management processes

  • Contractor management processes

  • Management of change 

  • Communication and consultation.

3.7.3.2    Task / Environmental conditions

Consider the following at the workplace level:

  • Working conditions

  • Time pressures applied

  • Resources available to complete the task

  • Support

  • Task complexity

  • Fitness for work

  • Workload

  • Task planning

  • Environment (outdoor/indoor/weather etc).

3.7.3.3    Individual / Team Actions

  • Errors and violations.

3.7.3.4    Absent / Failed defences

  • Interlocks

  • Isolation

  • Guarding

  • Barriers

  • Risk assessment

  • Safe operating procedures

  • Job safety analysis

  • Awareness

  • Supervision

  • Emergency response

  • Personal protective equipment (PPE).

3.7.4    Determination of causes

Based on the analysis of the evidence and the event and conditions charting – determine the most likely reasons of the incident.

3.8    Key findings and conclusions

The conclusions will be based on facts and the analysis of the facts, and these will be substantiated by the physical evidence, interviews, ICAM and event and conditions charting analysis. The conclusions will state:

  • Actual, validated, causes and contributing factors that led to the incident.

  • Highlighted weaknesses and any areas that are still unsubstantiated.

  • Highlight strengths.

3.9    Recommendations

Where system deficiencies have been identified through the investigation process, recommendations for corrective action must be made to reduce future risk and improve health and safety performance. Appendix 5.2 has some questions to consider when thinking about recommendations.

The recommendations will:

  • Flow from the causal factors and will directly tie back to the evidence collected.

  • Be such that a corrective action plan can be developed with the rectification of the cause in mind to minimise or prevent a similar event in the future.

  • Be able to be achieved, realistic and effective.

3.10    Action Plan

Action plans must be created as soon as practicable following an incident. Level 1 and 2 investigations require an action plan to be created in UQSafe within three (3) weeks of the incident occurring in and allocated to a person responsible for actioning. Level 3 investigations should also aim to have action plans in place within three (3) weeks, however due to the complexity of the investigation this timeframe may be extended.

Each corrective action must have a deadline for implementation, and a monitoring processes established to ensure actions are addressed satisfactorily. Follow up to evaluate the effectiveness of the corrective actions is required, and adjustments made as needed to continue to improve. These can be discussed at HSW Committee meetings.

The following considerations should be taken into account when developing action plans:

  • Corrective actions are specific, constructive and address the contributing factors – they must tie back to the evidence gathered.

  • The hierarchy of controls and risk management procedure has been considered when developing the risk treatment.

  • Existing knowledge and impact on the business.

  • The person responsible for the action agrees with the action being allocated to them and the target completion date for implementation.

If a formal investigation is undertaken – the formal investigation template can be used.  Appendix 5.2 – Determining recommendations and conclusions may be used to assist investigators when determining recommendations.

3.11    Close-out meeting

Once the report has been completed, a meeting with senior management should be organised to review the report and discuss the findings. This meeting should be run by the Lead Investigator.  The outcomes of this meeting should be agreement of the action plan, ensuring there is the correct person allocated against each corrective action along with an agreed timeframe for implementation.

4.0    Monitoring, Review and Assurance

4.1    Level 1

The supervisor develops the action plan in UQSafe which outlines the actions using the hierarchy of control, which is verified by the WHSC or HSW Manager.

4.2    Level 2

Level 2 incidents require a basic investigation and information can be collected in UQSafe. This level of investigation can also be conducted for HiPo incidents. This is reviewed by the HSW Manager or the HSW Division (as appropriate), to:

  • Ensure the risk rating level is appropriate

  • Assess the quality of the investigation.

  • Follow up with management to ensure that consultation has occurred with relevant persons, and actions and timing for implementation has been agreed.

  • Enable legal implications to be considered.

If a report is required, Appendix 5.3 has an outline of what should be included in the final report. 

4.3    Level 3

Incidents requiring level 3 investigations are notifiable to a Regulator (or had a high likelihood of being notifiable) or have an ‘extreme’ risk.  These investigations require a formal report and a planned and methodical investigation process conducted by an investigation team, using ICAM.

A formal report should be produced for the senior management that summarises all the elements of the investigation. The report should be reviewed by the HSW Director (or senior member of the HSW Division) prior to it being released. Using the formal investigation template can be used as the final report.

5.0    Appendix

5.1    Conducting the interview – areas to explore

5.1.1    People

Review personnel records (work history, training, time sheets, induction, etc) as required. Identify all the people who might have information about the incident/event and obtain statements from parties as soon as possible. Explore the following:

  • Experience of those involved in task/activity

  • Training requirements and evidence

  • Appropriate and adequate supervision.

  • Fatigue

  • Work stress or time pressures

  • Safety procedures

  • Appropriate emergency response.

5.1.2    Environment

Examine the scene of the incident for information and to help understand the nature of the task being conducted and the local environmental conditions.

The physical environment, especially sudden changes to that environment, are factors that need to be identified. The situation at the time of the incident/event is important, not what the “usual” conditions were. Explore:

  • Weather conditions

  • Appropriate housekeeping

  • Thermal comfort

  • Noise

  • Lighting

  • Visibility

  • Toxic or hazardous gases, dusts, or fumes.

5.1.3    Equipment

Examine any equipment involved in the incident/event looking at the condition of equipment. Identify any design flaws, mismatched components or confusing labelling or marking. Explore:

  • Equipment used in the way it was designed to be used

  • Equipment fit for purpose

  • Equipment failure

  • Equipment modifications post purchase

  • Equipment design

  • Safety devices fitted to plant and equipment

  • Maintenance

  • Hazardous substances.

5.1.4    Procedures

Review the task/activity that was being conducted. Examine the work procedures and the scheduling of the work to ascertain whether they contributed to the incident/event.  Examine the availability, suitability, and supervisory requirements. Explore:

  • Work schedules

  • Equipment instruction manuals

  • Local safe operating procedures for the task

  • Communication of procedures to workers

  • Risk Assessment for the task/activity

  • Risk Assessments approved

  • Workers aware of risk assessments  

  • Changed conditions / processes

  • Appropriate tools and materials available

  • Tag-out lockout procedures used.

5.1.5    Organisation

The role of supervisors and management must always be considered in an incident/event investigation. Explore:

  • Workers understood safety requirements

  • Safety requirements enforced

  • Adequate supervision for the skill level of the workers

  • Training provided to workers

  • Regular safety inspections

  • System for reporting hazards

  • Corrective action plans in place  

  • Unsafe conditions corrected

  • Changes to equipment, environment, people or procedures

  • Worker consultation.

5.2    Determining recommendations

This checklist may help the investigators when determining the recommendations.

5.3    Report Template

If conducting an investigation, the following format may be used. If conducting a formal incident investigation, use the formal investigation template.

  • Title of the report

  • Date of the report

  • Table of contents

  • Executive Summary (one page)

    • Brief summary of the event (one paragraph)

    • List of causes

    • Conclusion

    • Recommendations

  • Introduction

    • Background of the incident

    • Full description of where and when the event took place

    • Scope and purpose of the investigation

    • Description of how the investigation was undertaken

  • Factual information (known)

    • Facts collected and type e.g. reports, photographs, interviews etc

    • Sequence of events

    • Photographs

    • Including any missing evidence (unable to obtain)

  • Analysis

    • Description and analysis of the facts

    • ICAM tools

    • Indirect or contributing factors

    • Incident timeline

    • Analysis of the facts impact on the incident and its causes

  • Conclusions

  • Recommendations and action plans

    • Include which area the recommendation applies, who may be responsible for the implementation and a realistic timeframe

  • Appendices

    • Definitions and abbreviations or specific terminology

    • Photos

    • Site Map

    • Maintenance reports

    • Procedures, policies etc

    • Risk assessments and safe operating procedures

Custodians
Director, Health, Safety and Wellness Mr Jim Carmichael

Forms

Printer-friendly version

HSW Interview Plan

HSW Interview Plan

Printer-friendly version
Body
Description: 

Use this templated plan when conducting a Health and Safety Incident Investigation Interview 

Custodians
Director, Health, Safety and Wellness Mr Jim Carmichael
Incident Investigation Template

Incident Investigation Template

Printer-friendly version
Body
Description: 

Use this template with the guidance provided in the Incident Investgation Guideline to complete an incident investigation report.

Custodians
Director, Health, Safety and Wellness Mr Jim Carmichael
Custodians
Director, Health, Safety and Wellness Mr Jim Carmichael
Custodians
Director, Health, Safety and Wellness Mr Jim Carmichael