The 4 Stages of an Incident Investigation

The 4 Stages of an Incident Investigation

So, your workplace has just experienced an incident resulting in the injury or illness of a worker. Now what?

The Occupational Safety and Health Administration (OSHA) recommends that employers conduct investigations of workplace incidents using a four-step system. This article provides an overview of how to conduct a thorough incident investigation after an incident has been reported. Employers can follow this workflow to be sure all stages of an investigation are completed appropriately.

No time to read? We've put together a complete guide to performing a comprehensive incident investigation that you can download and take with you.

Incident Investigations - Preserving/Documenting an Incident Scene

1. Preserve and Document the Incident Scene

An incident investigator's first priority should be to ensure that the incident site is safe and secure. In some situations, you may have to travel a significant distance to reach the place where an incident occurred. In those cases, you should immediately contact on-site management to make sure that company protocols are being followed.

As you approach the area, it's important to be cautious. Make sure you’ve equipped yourself with any personal protective equipment (PPE) that’s needed to enter the area, either because it’s normally required for workers in that space or because the incident has created a need for it.

Once you make it to the scene of the incident, verify that anyone injured has received appropriate medical assistance. You'll also need to confirm that any equipment involved has been de-energized.

Once everyone is safe, take photos or video recordings of the scene as soon as possible, before equipment or materials are moved. Prevent material evidence from being altered as much as possible. You can use cones, tape, and/or guards to protect sensitive areas. If work has resumed in the area, make sure it is not compromising the incident site in any way.

As you review the site, depending upon the circumstances of the incident, you may want to record items such as:

  • equipment and safety devices that were in use at the time of the incident,
  • positions of appropriate machine guards and controls,
  • housekeeping conditions of the area,
  • weather conditions,
  • or lighting or noise levels

Instead of fussing with paper forms, you also may want to consider using a Mobile EHS app to document your findings. Mobile incident recording apps (like Vector EHS's!) make it easy to take and link photos, pinpoint your exact GPS location, and allow you to quickly capture invaluable data without fussing with pen and paper.

Incident reporting form

2. Collecting Information

2.a Interviewing witnesses

Next, speak to on-site supervisors to collect names and contact information for all witnesses and involved employees and contractors. The information that witnesses provide is a crucial part of an incident investigation. If you can, try to interview witnesses as soon as possible. Witnesses will remember details with more clarity if you speak to them shortly after the incident occurred.

The following tips will help you to gather accurate information during your interviews:

  • Before the investigation interview is conducted, let the employee(s) know that they can have a labor representative present if preferable.
  • Interview witnesses individually. If the witness talks or listens to others describe what’s taken place they may subconsciously change their account.
  • If possible, try to interview witnesses in the same location the incident took place. This can help jog an employee’s memory, as well as allow them to point out specifically where something happened.
  • Conduct the interview in the language of the interviewee. Use a translator if necessary.
  • Emphasize that the goal of the investigation is to prevent future incidents from happening and is NOT to place blame.
  • Take notes and be thorough. You can also ask the witness if they would permit you to record the interview.
  • Use open ended questions. This prevents you from accidentally influencing the witness's answers.
  • Ask the witness to make a list of anyone they saw in the area before the incident occurred.
  • Ask the witness what they think could have prevented the incident.
  • Finally, summarize the information that you’ve received from the witness so that they can confirm their account or correct any inconsistencies. Be sure to thank the witness for their assistance.

Just as there are various schools of thought about how to conduct an incident investigation, there are also various schools of thought about how to conduct these interviews or even if you should conduct them, depending on the type of incident that's occurred. Some believe they are a great way to get raw, unfiltered information.

Others believe separating witnesses and conducting interviews in the manner described above runs the risk of frightening workers so that they won’t share the true story. Give these issues consideration, read up on alternative methods, and choose what’s best for your organization’s safety culture (or the
safety culture you want to help create).

Finally, keep in mind that while witness accounts are important, they aren’t the only source of data that needs to be examined and recorded. Depending upon the circumstances of the incident, you may also need to review and analyze information from training histories, maintenance schedules and logs, and inspection reports.

2.b Complete an accident investigation form

Throughout your fact-finding, you should document what you’ve learned in an incident report that can be shared with key team members upon its completion.

Typically, incident or accident investigation forms contain the following data:

  • Worker characteristics (such as the age, gender, department, job title, experience level, tenure in company and current role, and training records of involved employees, as well as whether they are full-time, part-time, seasonal, temporary or contract workers);
  • A description of the injury or illness, including the part(s) of body affected and degree of severity;
  • The location of the incident;
  • Conditions at the scene such as temperature, light, noise, weather;
  • A summary of events leading up to the injury/illness, the task that the worker was performing when the incident occurred;
  • Root causes of the incident

Want a more effective way to complete incident investigations? Vector EHS's Incident Reporting Module allows you to store all incident data, conduct accident investigations, and determine root causes.

Learn More Incident Investigation Tools

3. Determine Root Causes

Once you’ve gathered all the necessary information, you can start performing a root cause analysis. This process allows you to discover underlying or systemic, rather than immediate, causes of an incident. Remember, correcting only an immediate cause may fix a symptom of a problem, but not the problem itself.

A simple, yet effective, way to identify root causes of an incident is to use the “Five Whys” method. In their fact sheet on root cause analyses, OSHA offers a helpful illustration of the “Five Whys” technique. In the agency’s example, a worker slips on the plant floor and falls.

An investigator using the “Five Whys” method would ask the following questions.

  1. Question: Why did the worker slip and fall?
    Answer: There was oil spilled on the plant floor.
  2. Question: Why was the oil on the floor in the first place?
    Answer: The source of the oil was a nearby piece of equipment.
  3. Question: Why did the equipment leak?
    Answer: There was a defect in its valve system.
  4. Question: Why wasn’t the leak detected?
    Answer: The system wasn’t inspected regularly, so the problem was not discovered and repaired.
  5. Question: Why wasn’t the valve system inspected?
    Answer (and root cause): The valve wasn’t logged appropriately in the maintenance system.

In this example, it took 5 whys to get to the root of an issue, but in practice, you may find yourself asking more or fewer questions to reach your conclusion.


4. Implement Corrective Actions

Finally, develop a corrective action plan to resolve the immediate and root causes of the incident.

Each corrective action listed in your incident report should have a person assigned as the responsible party for the task, a set completion date, and a place to mark the completion of the item.

You should have some way to track if and when all corrective actions have been put into place. If you don’t track the completion of these corrective
measures, it’s easy for one (or several) to never get done.

Have Supervisors Sign-off

Once you've finished preparing your report, the final step is to ensure that it is signed off by the supervisor who was on duty during the incident. Depending on the nature of the incident, you may also want to have witnesses and other involved parties review and sign off on the form as well.

These individuals should recheck the accuracy of all details before signing, and their contact information should also be recorded on the form should there be additional questions to answer later.

Once you've collected all the necessary signatures from involved parties, your incident investigation should now be complete and you can share your findings with management and workers.

Before communicating results, you should first determine who should get a copy of incident investigation reports, what format these reports should be in, and how quickly these reports should be created and distributed. In addition, you should also have determined what kind of information gets relayed to managers and general employees, and how that information is made public.

You may choose to not distribute the full incident investigation report in its original form to all workers. However, you should still communicate key findings of the report to the workers at the site.

How can safety management software help?

Vector EHS Management's easy-to-use forms make it simple to collect data for multiple types of incidents, including near misses, vehicle and environmental incidents, and employee and non-employee injuries.

Users can analyze trends, perform root cause analysis, and assign corrective actions to better understand the causes of near misses and prevent serious incidents from occurring. With Vector EHS's automated reports and email alerts, responsible parties can receive reminders and status updates of open issues so that corrective actions are completed in a timely fashion.

Vector EHS's public web form also enables all of an organization’s stakeholders to report near misses and other types of incidents via a simple web link. Users can even report incidents using a mobile device or tablet with Vector EHS mobile app.

Want to Know More?

Reach out and a Vector Solutions representative will respond back to help answer any questions you might have.