(1) 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. (2) 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. (3) 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 Health and Safety Incident and Hazard Reporting Procedure. (4) The objectives of this Guideline are to: (5) Immediate actions following the incident can mitigate further risk to persons or property and support effective incident investigation: (6) 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. (7) 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. (8) In addition, UQ policies and procedures and local standard operating procedures that outline required practices and processes should be considered. (9) 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). (10) 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. (11) 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 Incident Investigation tool in UQSafe. (12) 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. (13) While it is appropriate to have a number of people involved in investigations, Level 1 investigations only need to be completed by Supervisors. WHSCs and HSW Managers could be included if required. (14) Level 2 investigations must be completed by WHSCs and /or HSW Managers. (15) 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: (16) 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. (17) 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. (18) Data collection can be divided into five main areas (PEEPO): (19) Mapping out PEEPO assists the investigation team in keeping on track and focussed on the evidence collection. (20) 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. (21) Evidence used to support an incident investigation must be based in fact as factual evidence is crucial to the outcome of the investigation. If assumptions 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. (22) 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. (23) 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. (24) 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. (25) 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: (26) 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: (27) 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. (28) 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. (29) Interview questioning tips: (30) 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. (31) 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: (32) The evidence collected must be catalogued with a date and time when collected or obtained. This includes the following: (33) 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. (34) 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: (35) For guidance on conducting a basic investigation in UQSafe refer to the Systems Training Hub. (36) 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 conclusGion 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 the Appendix – ‘Conducting the Interview – Areas to Explore’. (37) 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. (38) 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). (39) 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. (40) 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. (41) 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 the Appendix to keep the investigators open to other considerations. (42) 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. (43) 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 linked image: (44) An example of an event and conditioning chart is linked below of a car and train incident at a level crossing: (45) Consider the following at the organisational level the following: (46) Consider the following at the workplace level: (47) Based on the analysis of the evidence and the event and conditions charting – determine the most likely reasons of the incident. (48) 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: (49) 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. The Appendix has some questions to consider when thinking about recommendations. (50) The recommendations will: (51) 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. (52) 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. (53) The following considerations should be taken into account when developing action plans: (54) If a formal investigation is undertaken – the formal investigation template can be used. ‘Determining Recommendations and Conclusions’ in the Appendix may be used to assist investigators when determining recommendations. (55) 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. (56) 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. (57) 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: (58) If a report is required, the ‘Report Template’ in the Appendix has an outline of what should be included in the final report. (59) 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. (60) 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. (61) 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: (62) Examine the scene of the incident for information and to help understand the nature of the task being conducted and the local environmental conditions. (63) 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: (64) 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: (65) 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: (66) The role of supervisors and management must always be considered in an incident/event investigation. Explore: (67) The linked checklist may help the investigators when determining the recommendations. (68) If conducting an investigation, the following format may be used. If conducting a formal incident investigation, use the formal investigation template.Incident Investigation Guideline
Section 1 - Purpose and Scope
Section 2 - Process and Key Controls
Top of PageSection 3 - Key Requirements
Part A - Immediate Action Following an Incident
Part B - Scoping the Investigation
The Level of Investigation
Part C - Preparing For the Investigation
Establishing the Investigation Team
Report Requirements
Part D - Data Collection
Data Category
Collection Method
P
People:
- Witnesses
- Other associated with the incidentInterviews
Written statements
Observations
E
Environment:
- Weather
- Workplace
- Incident sceneObservation / Review
Inspection / Photography
Event reconstruction
E
Equipment:
- Vehicles, plants, tools, infrastructure, etc.Inspection
Testing
Operation
P
Procedures:
- Existing maps, charts, documents, reports, photographs, etc.Review / Comparison
O
Organisation:
- Culture to safety
- Previous incidentsReview / Comparison
Part E - Evidence Collection and Recording
Recording of Evidence
Principals of Evidence Collection
Site Inspection
Photographs and Video
Interviews
Interview Questions
Support Person
Documentation and Records
Chain of Evidence
Part F - Conducting an Investigation
Level 1
Level 2
Level 3
Part G - Analysis of Evidence - ICAM
Incident Timeline
Event and Conditions Charting
Indirect or Contributing Factors to Consider
Organisational Factors
Task/Environmental Conditions
Individual/Team Actions
Absent/Failed Defences
Determination of Causes
Part H - Key Findings and Conclusions
Part I - Recommendations
Part J - Action Plan
Part K - Close-out Meeting
Section 4 - Monitoring, Review and Assurance
Level 1
Level 2
Level 3
Section 5 - Appendix
Conducting the Interview – Areas to Explore
People
Environment
Equipment
Procedures
Organisation
Determining Recommendations
Report Template
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