Incident Investigation Guidelines - University of the Sunshine Coast, Queensland, Australia

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Incident Investigation Guidelines

1. Purpose

The overall purpose of an incident investigation is to:

  • ascertain the causal and contributing factors of an incident, near miss or hazard 
  • determine and implement corrective actions to prevent re-occurrence
  • enable USC to continually improve health, safety and wellbeing
  • fulfil legislative requirements

The purpose of this guideline is to outline the requirements and/or process for:

  • the instigation of an incident investigation
  • the process for conducting an incident investigation, including:
    • determining casual factors
    • determining and implementing corrective actions
    • monitoring the effectiveness of corrective actions
    • consultation with relevant stakeholders throughout the incident investigation

2. Scope

This guideline applies to all USC Community members and all activities conducted at, by or for USC.

3. The investigation

3.1 When is an investigation performed

All near misses, hazards and incidents must be investigated by the manager/supervisor responsible for the impacted person and/or area where the near miss, hazard or incident occurred. An investigation must commence:

  • upon receiving notification of an incident, near miss or hazard from the impacted person
  • upon receiving notification from Human Resource, Health Safety and Wellbeing (HSW) that an investigation is required
3.2 Who conducts the investigation

The immediate supervisor or manager responsible for the impacted person (staff, student, volunteer, contractor or visitor) and/or the area where the near miss, hazard or incident occurred, is responsible for conducting the initial investigation. This investigation should be undertaken in consultation with the impacted person/s (where appropriate), any additional stakeholders (including those that may be from other organisations or areas/cost centres within USC) and HSW where required.

HSW is to be included in the investigation of any incident that results in worker injury or the potential for worker injury and any incident that is deemed ‘notifiable’.

HSW reserve the right to be included in an incident investigation or to conduct their own investigation, in consultation with stakeholders.

3.3 Notifiable incidents

If an incident is deemed to be a notifiable incident in accordance with the Work Health and Safety Act 2011, HSW must be informed immediately. HR HSW will  notify the regulator within the required time frame or as soon as is possible and commence the incident investigation in consultation with relevant stakeholders

As far as is reasonably practicable, the person in control of the work area must ensure that the site where the incident occurred is not disturbed until an inspector arrives at the site or any earlier time as directed by an inspector.

4. Procedure

4.1 Establish the background

This involves the compilation of information to establish the sequence of events that lead to the incident, to assist in determining the cause or contributing factors, and may involve:

  • investigation of the incident/near miss or hazard site, including photos and/or videos
  • Consideration of exact location and environmental conditions, including; lighting, weather, ground/floor surface etc.
  • Review of (where relevant):
    • USC and departmental or school policies, procedures and guidelines
    • risk assessments
    • SDS if there were chemicals involved
    • manufacturer and/or supplier equipment information/operator’s guidelines/instructions etc. where applicable
    • relevant legislation, codes of practice and/or standards
    • past near miss hazard or incident reports
    • training content and records
  • interviews of relevant people and/or witnesses
  • consideration of the effectiveness of current controls in place
4.2 Determine contributing factors

By collating the above information the investigation team should determine the contributing factors , which are grouped into four categories:

  • Asset – eg: equipment failure, design issues, insufficient safety devices, inadequate storage etc.
  • Environmental – eg: weather, temperature, surfaces, light, hazardous substances, housekeeping etc.
  • Person – eg: fatigue, unsafe practice, working alone etc.
  • Systems of work – eg: policies and procedures, work process or design, risk assessment, training, supervision etc.
4.3 Recommendations

Once contributing factors have been determined recommendations are made to address the contributing factors and are aimed at eliminating or minimising risks associated with this or similar incidents. Recommendations should:

  • be based on best practice where possible (using Regulations, Codes and Practice, Industry Standards and appropriate benchmarking)
  • be feasible and within the management’s control to fix
  • give both short and long term actions if required, so the risk is mitigated whilst longer term actions are being implemented
4.4 Developing an action plan

This incorporates a stakeholder meeting which may include, but not necessarily be limited to:

  • managers/supervisors from area/s where incident, near miss or hazard occurred
  • relevant stakeholders
  • HR HSW

The purpose of this meeting is to review the recommendations made in the investigation report and develop an action plan for the

implementation of recommendations. This action plan MUST include:

  • details of which recommendations are to be implemented and how they are to be implemented/actioned
  • details of any additional actions arising from the discussions by the stakeholder group
  • individuals who will be responsible for the implementation and monitoring of each recommendation
  • completion dates for the implementation of each recommendation
  • dates for follow up and/or review of actions

Note: Responsibility for actioning an item cannot be delegated to a person from another department without the liaison and consent of that

person.

A complex incident involving more than one stakeholder group, department and/or school, may have more than one action plan directed at

different work areas and/or managers.

Completed incident investigations and action plans must be sent to hsw@usc.edu.au.

4.5 Implementing action plan

The manager/supervisor must ensure the implementation and monitoring of recommendations on the action plan by the dates stipulated on

the plan.

If any of the actions are not able to be implemented by the proposed date the manager/supervisor must provide details in writing/via email to

HR HSW (hsw@usc.edu.au), prior to the proposed completion date, so that a new date can be set or alternate arrangements made.

4.6 Review

The recommendations/actions must be reviewed post implementation to:

  • ensure that they are effective in reducing risks
  • ensure that the implementation has not created additional hazards

The manager/supervisor must ensure that this review takes place and that the date of the review is documented on the action plan.