The overall purpose of an incident investigation is to:
- ascertain the contributing factors of an incident, near miss or hazard and determine corrective actions
- as legislative requirement, to record the details surrounding an incident and the follow up actions implemented
- for insurance purposes, as part of an insurance claim, worker compensation claim or common law proceeding
The findings or outcomes of an incident investigation, when implemented will prevent a reoccurrence of the incident, near miss or hazard.
The purpose of this guideline is to outline the requirements and/or process for:
- the instigation of an incident investigation by Human Resources (HR)
- the process for conducting an incident investigation
- the required response of relevant stakeholder groups to an incident investigation
This guideline applies for any incident, hazard or near miss identified at USC or associated with the undertakings of USC and applies to all USC employees, students, contractors, visitors and volunteers, where relevant.
3. The investigation
3.1 When is an investigation performed
Upon receiving an incident, near miss or hazard report, Human Resource, Health Safety and Wellbeing (HR HSW) will determine if an investigation is required. This may be based on:
- severity, or potential severity of the incident
- the level of risk
- the number of stakeholders involved
- the complexity of contributing factors
Note: all notifiable incidents will be investigated.
An investigation can be requested by any of the health safety and wellbeing committees.
If an investigation is required it should commence as soon as is practicable.
3.2 Who conducts the investigation
The investigation is conducted by staff from HR HSW. HR HSW may assemble a team to assist with the investigation, which may include, but is not necessarily limited to:
- local supervisor or manager
- persons involved in the incident
- appropriate ‘expert’ (USC staff with relevant expertise)
The area health safety and wellbeing representative (HSWR) will always be asked if they wish to be involved in an investigation in the area they represent.
3.3 Notifiable incidents
If an incident is deemed to be a notifiable incident in accordance with the Work Health and Safety Act 2011 (refer Appendix 1), HR HSW will notify the regulator within the required time frame or as soon as is possible.
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.
4.1 Establish background
This involves the compilation of information to establish the sequence of events that lead to the incident, near miss or hazard, to assist in determining the cause or contributing factors, and involves:
- investigation of the incident/near miss or hazard site
- interview of relevant people
- review of documents:
- USC and departmental or school policies, procedures and guidelines
- risk assessments
- MSDS if there were chemicals involved
- manufacturer and/or supplier equipment information/operators guidelines/instructions etc. where applicable
- relevant codes of practice and/or standards
- determine risk rating of near miss, hazard or incident being investigated
4.2 Determine contributing factors
Contributing factors are determined in accordance with root cause analysis principals and grouped into four categories:
- People – eg: supervision, experience, training, fatigue
- Organisational/ procedural – eg: no or inadequate risk assessment, inadequate procedures, no induction process for new staff or contractors
- Equipment/materials – eg: equipment failure, appropriate tools/equipment not available
- Environmental conditions/physical environment – eg: raining or low light conditions, housekeeping
Recommendations are made to address the contributing factors and are aimed at eliminating or minimising risks associated with this or similar incidents, near misses or hazards. 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
- where possible give alternate approaches to addressing contributing factors
4.4 Developing an action plan
This incorporates a stakeholder meeting which should include, but not necessarily be limited to:
- HR Director or his/her representative
- HR HSW representative
- HSWR for the area
- managers/supervisors from area/s where incident, near miss or hazard occurred
- relevant stakeholders
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 accountable 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.
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 (firstname.lastname@example.org), prior to the proposed completion date, so that a new date can be set or alternate arrangements made.
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.
(Work Health and Safety Act 2011 s35-37)
‘A notifiable incident means:
- the death of a person
- a serious injury or illness of a person
- a dangerous incident
Serious injury or illness of a person means an injury or illness requiring the person to have:
- immediate treatment as an inpatient in hospital
- immediate treatment for:
- the amputation of any part of his or her body
- a serious head injury
- a serious eye injury
- a serious burn
- the separation of his or her skin from the underlying tissue (eg, degloving or scalping)
- a spinal injury
- the loss of a bodily function
- serious lacerations
- medical treatment within 48 hours of exposure to a substance
- a prescribed serious illness ( as per Work Health and Safety Act 2011 s699)
A dangerous incident means an incident in relation to a workplace that exposes a worker or any other person to serious risk to a person’s health or safety emanating from immediate or imminent exposure to:
- an uncontrolled escape, spillage or leakage of a substance
- an uncontrolled implosion, explosion or fire
- an uncontrolled escape of a pressurised substance
- electric shock
- a fall or release from a height of any plant, substance or thing
- the collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use under a regulation
- the collapse or partial collapse of a structure
- the collapse or failure of an excavation or any shoring supporting an excavation
- the inrush of water, mud or gas in workings, in an underground excavation or tunnel
- the interruption of the main system of ventilation in an underground excavation or tunnel
- any other event prescribed under a regulation