Purpose and Objectives
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 a 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 the Safety Advisor (SA)
- the process for conducting an incident investigation
- the required response of relevant stakeholder groups to an incident investigation
Scope/Coverage
This guideline applies to any incident, hazard or near miss identified at Company or associated with the undertakings of Company and applies to all Company employees, Contractors, Customers/Clients, volunteers and visitors, where relevant.
Policy Statement
Company takes a ‘zero harm’ approach to all safety matters. This philosophy towards safety is not to be unduly risk averse but to enable risks to be identified, discussed, mitigated and monitored in a balanced manner. Understanding that whilst Company takes a proactive approach to Risk Management, it also needs the same vigilance in its monitoring and incident investigation processes. To this end Company requires that all incidents shall be reported. All incidents of a minor nature will have sufficient detail recorded to enable Management to decide if action is required viz. name of the victim, the cause of the accident, details of what happened, injuries sustained, medical attention required, recommendations by Supervisor about the adequacy of procedures and training.
Any incident that is a dangerous event or causes serious bodily injury (includes lost time injury of 4 days or more) shall be reported. For all such incidents, an incident investigation shall be undertaken. This process will include witness interviews. The report shall detail all circumstances relating to the incident. Photographs should be taken where possible. The investigation shall consider compliance with company procedures, relevant Codes of Practice, WHS Act and Regulations and where applicable Australian Standards.
The report must identify a brief description of the incident in plain English, what happened including time of day/night and weather conditions:
- Those involved in the incident
- Injuries and property damage sustained
- Details of lost time
- Cause of incident
- Contributory factors
- Non-conformance with procedures
- Direct and indirect costs incurred
Recommendations:
- For training required
- Changes to operating procedures
- Disciplinary action
- How to ensure compliance with procedures
- Modifications to plant
- Guarding issues
- Any other findings
Definitions
Hazard – a source of potential harm or a situation with the potential to cause injury or loss.
Risk – the chance of something happening that will have an impact on the workplace objectives and may result in personal injury or loss to Company. A risk is measured in terms of consequence and likelihood.
Supervisor – a person involved in the management or control of a workplace (e.g. foreman, supervisor, the person in charge or leading hand).
SA – Safety Advisor
HSR’s – Health and Safety Representatives
Incident Investigation – Process involving several stakeholders at varying tiers within the Company charged with the investigation and rectification of WHS issues of related incidents
Incident Investigation Process
1. Establish Context
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:
- Company and departmental or faculty policies, procedures and guidelines
- risk assessments
- SDS 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 the risk rating of near miss, hazard or incident being investigated
2. Identify the 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: rain or low light conditions, housekeeping
3. Make initial recommendations
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. Action Planning
This incorporates a stakeholder meeting which should include, but not necessarily be limited to:
- HR Director or his/her representative
- HR WHS representative
- HSR 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 faculty, may have more than one action plan directed at different work areas and/or managers.
Implementation
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 WHS, prior to the proposed completion date, so that a new date can be set or alternate arrangements made.
Monitor and 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.
Prevention strategies
Inspection and Auditing
Inspections are intended to identify those tasks, processes or persons, in the workplace that does not meet minimum safety standards. Non-compliances shall require that an action plan is developed, implemented and monitored for efficacy. The action to be taken is governed by the potential of the issue to result in serious bodily injury, the authority of the person performing the inspection and company policy (Site Monitoring and Review Sheet ).
Inspections
Inspections shall be carried out as required in Inspection management module. The persons responsible for carrying out inspections are nominated under Roles and Responsibilities. To ensure inspections do not become an arbitrary activity, it is required that a comment is made for each criterion – as simple as improvement noted or that work has been informed. The activity is not intended as another task, but as a tool to assist in identification of non-conformances. This is part of the process of continual improvement.
Audits
Audits are by purpose a thorough examination of the process of the Management System to look for opportunities to improve. The audit must be planned and the planning should consider:
- Audit personnel (internal or external or both), time, location, duration
- Auditor must have knowledge of Company Policy and legislative requirements, audit processes and reporting technique
- Audit topics -What target areas of compliance
- Authority to perform audit
- Audit document
The audit should not attempt to cover all areas/segments of the business at one time but ideally, should be segmented and undertaken monthly.
The audit process is to assess compliance with Legislative and Company requirements. The outcomes should provide vital information to the Management Committee. If an external auditor is to perform the audit then a knowledgeable person should accompany the auditor to provide information (an audit guide).
Performance Criteria
Efficiency and effectiveness.
Our goal is to reduce incidents in the workplace. We recognise that as we have not had accurate or enforced reporting procedures in place in the past it may now seem that we have a sharp increase in incidents. The truth is we are now identifying incidents. After the second safety meeting, the Committee shall identify criteria for self-assessment. The base material may include Safe Work Method Statements.
Management Review
Management as a matter, of course, shall review the effectiveness of Health, Safety and Welfare Corporate activities and Environmental responsibilities in the Company. It may be necessary to guide the Management Committee or seek the input and attendance of a Safety Consultant to steer the Committee in the right direction. Any improvement in the level of safety at work signifies continuing improvement. Management shall review the Management System at least every two (2) years to assess compliance, performance and practical application. Performance against policy and objectives will form part of Management Review as will verification of the system for continued relevance and currency and the organisations capacity, suitability and effectiveness to satisfy legislative requirements.
To achieve continuous improvement, performance will be regularly assessed against documented policies, procedures, objectives and targets by the Management Committee.
The Management Review will have a Notice of Meeting forwarded to relevant persons with an attached Agenda. The meeting will be minuted and the document filed in the meeting section of SMS. Stakeholders and persons with access can view the document online, it can be printed and emailed as required.
External Audit
Annually an external surveillance audit shall be undertaken to ensure compliance with our Management System and Legislative requirement to ensure we maintain Preferred Contractor status.
The audit is required to maintain Preferred Contractor status but should also be used as a tool to provide an impartial performance evaluation of our Integrated Management System. Any outcome should be considered by the Management Committee for possible recommendations for action.
Job specific audits will be conducted as required by the Policy and/or at request.
Management Committee Meeting
The Management Committee shall meet monthly. The Committee shall be comprised of at least one senior manager, department heads (supervisor, foreman), HSR if appointed and an equal number of workers and elected Health & Safety Representatives (HSRs). The Committee shall review the following information and documents, discuss the contents and make recommendations to management for change that will improve safety in the workplace. From time to time outside consultants may need to be consulted e.g. ergonomic specialists, health professionals, safety consultants etc – Use form ‘Monthly/Quarterly Management Meeting Agenda’. The Management Committee will ensure any legislative changes are addressed.
The Management Committee will have a Notice of Meeting forwarded to relevant persons with an attached Agenda. The meeting will be minuted and the document filed in the meeting section of MyHSEQ. Stakeholders and persons with access can view the document online, it can be printed and emailed as required. The meeting outcomes will be presented to Senior Management.
Adoption of Recommendations
Management shall review all recommendations of the Management Committee and consider how budgets can be allocated to implement the recommendations. Management may refer back to the Management Committee for assessment of anticipated costs of implementing their recommendation, or for alternative remedies where it is not financially feasible to implement the original recommendation. Ultimately the final decision rests with the person with authority to authorise expenditure.
Responsibilities
The investigation is conducted by staff from Human Resources, Workplace Health and Safety, HSR’s, WHS Coordinators or management 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’ in safety or investigations
- The area Health and Safety Representative (HSR) will always be asked if they wish to be involved in an investigation in the area they represent.