• Section 1 - Purpose and Scope
• Context
• Section 2 - Process and Key Controls
• Section 3 - Key Requirements
• Scoping an Incident Investigation
• Preparation Activities
• Evidence Collection and Recording
• Conducting the Investigation
• Analysis of Evidence
• Conclusions and Recommendations
• Report and Action Plan
• Review and Approval
• Investigation Close-out Meeting
• Section 4 - Roles, Responsibilities and Accountabilities
• Head of Organisational Unit
• Supervisor
• Lead Investigator
• Health, Safety and Wellness Manager (HSW Manager) / Work Health and Safety Coordinator (WHSC)
• Workers
• Health, Safety and Wellness Division (HSW Division)
• Section 5 - Monitoring, Review and Assurance
• Level 1
• Level 2
• Level 3
• Section 6 - Recording and Reporting
• Regulator Notification and Inspection
• Regulator notified incidents and contentious investigations
• Section 7 - Appendix
• Definitions
• Investigation Level

Section 1 - Purpose and Scope

(1) 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 Health and Safety Incident Investigation Guideline.

(2) 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 were the contributing factors and to put measures in place to prevent a recurrence.

(3) The investigation into psychosocial incidents, due to the possible sensitivity of circumstances, will be conducted in line with the Psychosocial Hazard and Risk Management Procedure.

(4) 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.

(5) The processes outlined in this Procedure align with:

1. Enterprise Risk Management Framework Policy.
2. Health and Safety Risk Management Procedure.
3. Health and Safety Incident and Hazard Reporting Procedure.

Context

(6) UQ is legally obliged under the Work Health and Safety Act 2011 and the Work Health and Safety Regulation 2011 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.

Section 2 - Process and Key Controls

(7) 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.

(8) 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.

Section 3 - Key Requirements

Scoping an Incident Investigation

Investigation objectives

(9) 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. This will also determine whether one or multiple investigations are required and whether the dominant purpose of the investigation is to obtain legal advice, such that the investigation is to be conducted on a legally privileged basis.

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

Determine investigation level

(11) All incidents will be investigated to minimise the risk of repeat incidents. A risk proportionate approach is taken to determine the level of investigation required (refer to Appendix, Investigation Level).

1. A Level 1 Investigation is required for all incidents. These incidents are to be investigated by the Supervisor of the person reporting or involved in the incident, with support from the local Safety Team. Level 1 investigations are documented by the Supervisor through the creation of a Management Action Plan in UQSafe.
2. A Level 2 Investigation is required for an incident marked as ‘significant or High Potential (HiPo)’. These incidents are to be investigated by the local Safety Team using the Basic HSW Incident Investigation process in UQSafe.
3. A Level 3 Investigation is required when an incident is notifiable to a Regulator. These incidents are to be investigated by the local Safety Team using the ICAM HSW Incident Investigation process in UQSafe with oversight from the Health, Safety and Wellness Division.

Preparation Activities

Investigation team

(12) While it is appropriate to have several people involved in investigations:

1. Level 1 investigations only need to be completed by Supervisors. The local Safety Team could be included if required.
2. Level 2 investigations must be completed by the local Safety Team.
3. 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 met. The HSW Division must have oversight of any documents or contact with the regulator.

(13) 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.

Report Requirements

(14) It is important to determine who the audience of the investigation report will be, considering confidentiality and sensitivity and whether the investigation is conducted on a legally privileged basis. The expectations of the reporting deadlines must be considered in conjunction with the scheduling of evidence gathering.

Evidence Collection and Recording

Recording of Evidence

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

Evidence Collection

(16) 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.

(17) 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.

(18) 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 on site.

Interviews

(19) 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:

1. Principal witnesses – those directly involved in the incident.
2. Eyewitnesses – those that directly observed the incident, or the conditions immediately preceding or following the incident.
3. General witnesses – those with knowledge about the activities.
4. Subject matter experts (SME) – those with specific process or technical expertise.

(20) Witnesses cannot be forced to participate in an interview – it is a voluntary process.

(21) Refer to the Health and Safety Incident Investigation Guideline for further details on planning for and conducting interviews.

Documentation and Records

(22) 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.

Chain of Evidence

(23) Managing the evidence must be controlled and it must remain secure. Evidence should be catalogued and managed by one 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.

(24) If the investigation is undertaken on a legally privileged basis, then any action plans, reports and other information must not be uploaded to UQSafe until directed to do so by the Director, HSW (or a senior member of the HSW Division).

Conducting the Investigation

Level 1

(25) All incidents require a Level 1 Investigation, and are completed in UQSafe by the Supervisor of the injured person and verified by the local Safety Team.

Level 2

(26) A Level 2 Investigation is required for an incident marked as ‘significant or High Potential (HiPo)’. These incidents are to be investigated by the local Safety Team using the Basic HSW Incident Investigation process in UQSafe and include the Health and Safety Representative (HSR) for the workgroup if there is one. The Safety Team with oversight by the local HSW Manager should review details to:

1. ensure the risk rating level is appropriate;
2. assess the quality of the investigation;
3. follow up with management to ensure that consultation has occurred with relevant persons, and actions and timing for implementation has been agreed; and
4. enable legal implications to be considered.

Level 3

(27) A Level 3 Investigation is required when an incident is notifiable to a Regulator. These incidents are to be investigated by the local Safety Team using the ICAM HSW Incident Investigation process in UQSafe with oversight from the Health, Safety and Wellness Division. This type of investigation requires a formal report and a planned and methodical investigation process conducted by an investigation team led by a Lead Investigator. The investigation report must be uploaded to UQSafe as an attachment to the incident report at the conclusion of the investigation, or as otherwise directed by the Director, HSW (or a senior member of the HSW Division) if the investigation was undertaken on a legally privileged basis. 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. If there is a HSR for the workgroup, they should be offered the opportunity to be included in the investigation team.

Analysis of Evidence

(28) 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.).

(29) Further information can be found in the Health and Safety Incident Investigation Guideline.

Conclusions and Recommendations

(30) 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.

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

Report and Action Plan

(32) 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, or as otherwise directed by the Director, HSW (or a senior member of the HSW Division) if the investigation was undertaken on a legally privileged basis, and allocated to a person responsible for actioning. These recommendations must be linked to the evidence collected.

(33) 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.

Review and Approval

(34) The lead investigator should review the report for accuracy of data based on evidence and facts gathered. The action plan should be achievable, in the action owners’ control and set in a timely manner.

(35) The investigation is then provided to the Investigation Reviewer (Safety Manager/Lead of the Faculty, Institute or Division) to ensure the investigation and actions are easily understood and are within the boundaries of what occurred, it does not contain bias, interpretation or emotive language.

(36) The Investigation Lead and Investigation Reviewer should brief the Investigation Approver.

Investigation Close-out Meeting

(37) 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.

Section 4 - Roles, Responsibilities and Accountabilities

Head of Organisational Unit

(38) Heads of Organisational Units are responsible for:

1. ensuring all incidents are investigated to the appropriate level;
2. allocating suitable resources and time for an appropriate level of investigation;
3. following up with HSW Manager and Supervisors to ensure action plans and recommendations are instigated and completed in the appropriate timeframe;
4. liaising with HSW Manager, WHSC and/or HSW Division to report serious events to relevant stakeholders; and
5. reviewing and accepting the Investigation Report including its findings and assigning responsibility for addressing the correct actions identified and within the agreed timeframes.

Supervisor

(39) Supervisors, within their areas of responsibility, are responsible for:

1. ensuring all relevant incidents are reported in UQSafe and reviewing the circumstances of the incident;
2. determining the incident classification to ensure the appropriate level of investigation is conducted;
3. assisting or leading the preparation and completion of the incident report and investigation;
4. 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;
5. 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; and
6. liaising with the HSW Manager, WHSC and/or head of the Organisational Unit to report serious events to the HSW Division and Senior Management.

Lead Investigator

(40) The Lead Investigator:

1. provides guidance to ensure the appropriate and required people are involved in the investigation team;
2. 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;
3. oversees all aspects of the investigation;
4. completes the investigation paperwork and report; and
5. arranges meetings with people (including appropriate Manager and Supervisors) to review the report and discuss the recommendations.

Health, Safety and Wellness Manager (HSW Manager) / Work Health and Safety Coordinator (WHSC)

(41) The HSW Manager and WHSC are responsible for:

1. being aware of when Legal Professional Privilege may apply;
2. providing assistance and advice for the investigation, review circumstances and incident classification;
3. undertaking a role in the investigation team if requested by the lead investigator and complete assigned actions;
4. following up to ensure that action plans are completed, and relevant corrective actions are assigned and implemented;
5. ensuring the scene is maintained (not disturbed) for notifiable incidents;
6. ensuring photos are taken of the scene, unless otherwise arranged by the Lead Investigator;
7. ensuring Health and Safety Representatives (HSRs) are offered the opportunity to be involved in the incident investigation;
8. assisting in the preparation and completion of the incident report and investigation, where required;
9. 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;
10. assisting with the identification and implementation of corrective actions or controls;
11. acts as the Investigation Reviewer engaging with the senior executive of their area to review the investigation and action plan and obtain their approval;
12. 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;
13. marking investigation reports as confidential prior to uploading to the relative UQSafe report; and
14. issuing a Safety Notice for dissemination to local staff and students, where appropriate.

Workers

(42) Workers are responsible for:

1. reporting all incidents directly to their Supervisor and submit an incident report in UQSafe as soon as possible after the incident; and
2. assisting in post-incident investigation and assist in identifying gaps and to implement corrective actions where required.

Health, Safety and Wellness Division (HSW Division)

(43) The HSW Division is responsible for:

1. providing assistance and/or advice for the investigation;
2. assisting where required, in the preparation and completion of the investigation and report;
3. liaising with the Supervisor, Head of Organisational Unit and HSW Manager/WHSC if required;
4. liaising with the relevant regulatory body (and legal counsel if necessary) in the event of a notifiable incident;
5. 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;
6. where appropriate, issuing a Safety Notice for dissemination to UQ; and
7. where applicable, assisting with Regulator site visits.

Section 5 - Monitoring, Review and Assurance

(44) The HSW Division will review the effectiveness of this Procedure and update it to reflect contemporary investigation processes as required. Investigation processes are monitored through the Division and investigation reports and outcomes reported to the University Senior Executive Team (USET) as required.

Level 1

(45) UQSafe has automatic workflow properties that notifies various roles in UQ if Management Action Plans are not completed. The local Safety Team will follow up with the Supervisor responsible for the Management Action Plans.

Level 2

(46) The local HSW Manager reviews the report to:

1. ensure the risk rating level is appropriate;
2. assess the quality of the investigation;
3. follow up with management to ensure that consultation has occurred with relevant persons, and actions and timing for implementation has been agreed; and
4. enable legal implications to be considered.

Level 3

(47) 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 Director, HSW (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 Director, HSW who will assess whether a legally privileged investigation is required.

Section 6 - Recording and Reporting

(48) All investigations are recorded and reported using UQSafe that includes automatic workflows which escalate 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.

1. For level 1 investigations, action plans are documented in UQSafe as part of the original incident report.
2. For level 2 investigations, in addition to the Management Action Plan, investigation findings and conclusions must be documented in UQSafe by the local Safety Team using the ‘note’, ‘attachments’, and/or ‘HSW Incident Investigation’ function.
3. For Level 3 investigations, the ICAM report is to be attached to the original incident report in UQSafe, and all actions entered into the UQSafe Management Action Plan. The report remains open until all the actions are completed, this is monitored by the local HSW Manager. These actions are expected to be discussed at local HSW Committee meetings.

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

Regulator Notification and Inspection

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

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

1. The first point of contact with the regulatory authority, will advise the HSW Division of the reason/scope of the visit.
2. Where possible, an “inspection coordinator” will be appointed by the Director, HSW (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 a person within the HSW Division.
3. The Inspection Coordinator will:
   1. determine and facilitate the required actions before and following the inspection;
   2. record and where practicable, take samples and photographs similar to those taken by the regulatory authority; and
   3. communicate required actions to the Director, HSW and to the relevant management of the local area.
4. The Director, HSW, in conjunction with the relevant HSW Manager, will be responsible for establishing and maintaining a record of the inspection.
5. The Director, HSW / HSW 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. The Director, HSW will inform the Chief Operating Officer (COO) and other members of USET as required.

Regulator notified incidents and contentious investigations

(52) 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 and whether the investigation is to be conducted on a legally privileged basis.

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

Section 7 - Appendix

Definitions

Investigation Level