Published in August 2013 by the Workplace

Safety and Health Council in collaboration with

Workplace Safety and
the Ministry of Manpower.

All rights reserved. This publication may not be

Health Guidelines
reproduced or transmitted in any form or by any
means, in whole or in part, without prior written
Investigating Workplace Incidents for SMEs
permission. The information provided in this
publication is accurate as at time of printing.
All cases shared in this publication are meant for
learning purposes only. The learning points for
each case are not exhaustive and should not be
taken to encapsulate all the responsibilities and
obligations of the user of this publication under
the law. The Workplace Safety and Health Council
does not accept any liability or responsibility to any
party for losses or damage arising from following
this publication.

This publication is available on the

Workplace Safety and Health Council
Website: www.wshc.sg
Email: [email protected]
Year of issue: 2013
Contents

1. Introduction 2
1.1 Why you should Investigate Incidents 2
1.2 Purpose of this Guide 2

2. What to Do when an Incident Happens 3

3. Investigation Guide 4
3.1 Who should Investigate? 4
3.2 How to Do it? 4

4. Investigation Kit 6

5. Reporting to the Ministry of Manpower 7

6. Sample Investigation Process 9

7. Other Resources 12

8. Annex
Annex A – Sample Checklist for Incident Investigation 13
Annex B – Sample Incident Investigation Form (Blank) 15
Annex C – Sample Incident Investigation Form 19

1
 1. Introduction 2. What to Do when an
Incident Happens

1.1 Why you should Investigate Incidents When an incident occurs, stay calm. Check the area for immediate danger and take steps such
as switching off machinery involved and moving any injured persons to safety if need be.
Incidents can be prevented or avoided if the situation(s) that caused the incident were known,
and action was taken. Risk assessment is a tool to identify the hazards and risks in your You can consult Figure 1 for the course of action to be taken.
work and the workplace. It is a safety management tool that must be used to prevent incidents
from occuring.
Incident
Injuries, damages to equipment, structures and interruptions to work operations due to incidents To notify
can be costly. Therefore, as part of a good safety management system, you need to investigate Commissioner
immediately?
incidents in a systematic way. This is to find out how they happened so that steps can be taken (see Section 5)
No Was anyone injured? Yes
to prevent similar incidents from happening in the future.

Even incidents that did not result in injury or damages should be investigated. This would help First aid /
workers regain confidence after the incident, and address any related worries. Control access to Call ambulance
the incident area
Check with Treatment, take
1.2 Purpose of this Guide insurance company photos of injury
This guide provides general guidance for incident investigation methods and their related tasks
like information gathering, analysis, implementation and review for simple or direct incidents. Information Check the Interview the
gathering incident area, injured person
take photos
For major incidents, the authorities (i.e., the Ministry of Manpower, Singapore Civil Defence
Force or the Singapore Police Force) will be involved. In such situations, please cooperate with Interview
the officers and follow their instructions. You can carry out your investigation while working witnesses
with them.

Analysis Submit iReport to

Analyse information MOM (see part 5)

Find root cause Claims and

compensation

Review and Review Risk

implementation Management System

Implement changes
and communicate

Figure 1: The Incident Investigation Process: What to do after an incident.

Refer to Section 5 of this publication, “Reporting to the Ministry of Manpower,” for details on the
types of incidents that need reporting and the amount of time you have to make the report.
2 3
 3. Investigation Guide • Note the position of tools and equipment; and the state of housekeeping and work
environment at the scene. Take photos if necessary.
• Interview each witness privately, asking open-ended questions.
• It is important to listen and not assign any blame at this point.

Part 2: Analysis
3.1 Who should Investigate? • Write down what happened during the incident.
The person leading the investigation should be one with authority to put in place immediate Safe Work Procedure
• Clearly record any unsafe acts and conditions.
corrective action when the investigation is completed. The person carrying out the investigation Unstuffing Container

must be neutral and not belong to the team involved in the incident. • Look through the information gathered.
1) Identify type of cargo coming into warehouse, monitor container arrival.

• Review current related documents, such as: 2) Ops direct container to designated bay.

–
Depending on the size and complexity of the incident, the investigation team can include – Safe work procedures (SWPs; see Figure 2);
3) Ops read UTS and identify type of cargo to unstuff.

E
4) Observe container for any sign of leakage.
people from different levels of the company (e.g., worker, supervisor, engineer, etc.).

PL
– Safety data sheets (SDSs; see Figure 3); 5) Put on chassis wheel choke.

6) Update container checklist.

The supervisor needs to be involved because he knows the work area and processes well; he – Maintenance logs; and

AM
7) Observe container floor board for any leakage.

8) Ventilate container for at least 15 min.

also represents the first-level management of the company. – Employee records. 9) Proceed to unstuff cargo safely.

• Check for gaps and lapses in the current system by

–S
10) Ensure no leakage and safe to unstuffy further.

comparing the unsafe acts and conditions during 11) Put cargo in staging area.

12) Check cargo for conditions, qty, label, marking.

Incident investigation should take place after the immediate tasks (first aid, sending the incident with the current documents. 13) Ensure empty container is clean.
injured to hospital, etc.) have been performed after the incident.
• Note: Well-known methods like the “Root Cause 14) Take picture of container.

15) Quarantine cargoes with serious conditions.

Analysis” or “Program Protection Plan” will not be
outlined in this publication.
3.2 How to Do it? Figure 2: Safe work procedures.
It is good to prepare a kit with instructions in advance so that there is no confusion when Part 3: Implement and review
investigation is needed. Go to Section 4 for details. • Choose corrective actions to plug the gaps you
identified.
• Discuss with management who would be in charge
Some insurance companies may need you to get permission from them before starting
any investigation work. Check with them if you are not sure. of implementing each control measure and record
it down clearly.
• Implement suitable control measures as soon

–
The investigation process has three main parts: as possible.

E
1. information gathering; • Review the effectiveness of the new control

PL
measures.
2. analysis; and

AM
3. review and implementation.

–S
Part 1: Information Gathering
• Stop work in that area.
• Cordon off the incident area and make sure that people who are not involved in the incident
do not remain there.
• Make sure that the area is safe for investigation (e.g., turn off the power to the machinery or
wear the necessary personal protective equipment [PPE] such as safety boots in areas with
sharp or broken objects on the floor). Figure 3: Safety data sheets.

4 5
 4. Investigation Kit 5. Reporting to the
Ministry of Manpower
Having a pre-prepared bag or box of items to use during incident investigation can help make Under the Workplace Safety and Health (Incident Reporting) Regulations, employers are required
things operationally smoother when an incident happens. Items in the kit should include: to report workplace accidents, dangerous occurrences and occupational diseases to the
• Investigation checklist or flowchart (see Annex A); Ministry of Manpower.
• Investigation form (see Annex B); and the following (see Figure 4) Accidents that need to be reported under the Regulations include:

Who and When to Report

Category What needs to be Who to Need to notify Need to submit

reported report Commissioner report within 10
immediately? days from accident/
diagnosis of
disease?
Employee was injured in Employer
an accident and:
• died; or Yes Yes
Work • was hospitalised for No Yes*
Safety boots or shoes Safety helmet and gloves Barricade tape accident more than 24 hours; or
• was given MC/ medical No Yes*
leave for more than 3
calendar days in a row.
A member of public or Workplace
self-employed contractor occupier
was injured and
Work
accident • died; or Yes Yes

• was sent to hospital Yes Yes

for treatment.
Employee contracted Employer No Yes
Measuring tape, scissors and Torch light and batteries Camera an occupational
masking tape Doctor who No Yes
disease in the List of
Occupational Diseases+. diagnosed
Figure 4: Items to be included in the pre-prepared incident investigation kit. the disease
Disease
Employee contracted Employer No Yes
a disease due to work
exposure to biological or
chemical agent.
Dangerous Any event in the List of Workplace Yes Yes
occurrence Dangerous Occurrences#. occupier

* If the employee subsequently dies from the injury, the employer must notify the Commissioner for Workplace Safety and
Health as soon as he knows of the death.
+ For a List of Occupational Diseases, go to http://www.mom.gov.sg
6 # For a List of Dangerous Occurrences, go to http://www.mom.gov.sg 7
 For more details on the types of incident that need reporting, go to:
http://www.mom.gov.sg/workplace-safety-health/incident-reporting/Pages/default.aspx 6. Sample Investigation Process
For examples on what needs to be reported, go to:
http://www.mom.gov.sg/workplace-safety-health/incident-reporting/Pages/what-to-report.aspx

The following sample incident investigation will provide

For incidents that require immediate notification:
an idea of how an investigation should be carried out.
Notify the Commissioner of Workplace Safety and Health by calling +65 6317 1111 or Note that this hypothetical situation does not take
sending a fax to +65 6317 1220.
into consideration the changing environment that an
Provide the following information when reporting: incident may occur in and serves only as an example of
• date and time of the incident; one of the many ways to carry out an investigation.
• place of the incident;
You heard a loud crashing noise just outside your office. You
• name and identification number of the injured or deceased, if any; ran out and saw Ah Meng, a technician, lying on the floor
• name of the employer and occupier; in pain.
• brief description of the incident; and Figure 5: Ah Meng fell while climbing
• name and contact details of the person making the notification. Who should investigate the incident? up the ladder.
• Earlier, you were tasked by the Manager to
investigate any incident that occurs in the office. This
For any incidents reportable under the Regulations, you are required to keep a record of any
was a straightforward fall from heights incident so
notification or report made under these Regulations. Each record made must be kept at the
you investigated the incident alone.
place of business for a period of at least 3 years from the time of report.

As an employer or occupier, if you fail to make a report as required under the Regulations, you Part 1: Information Gathering
will be liable to: A. Investigate and check the scene
• a fine of up to $5,000 for a first offence; • Ah Meng suffered some cuts and bruises on his arms and legs. You instructed Tian Beng,
• a fine of up to $10,000, or a jail term of not more than 6 months, or both for the second and who was trained in first aid, to attend to Ah Meng and ensure that he was taken care of.
subsequent offence. • You checked the accident area for any CCTV camera that may have captured the footage,
but there was none.
Any person who makes a false notification or report of any workplace accident, dangerous • As the ladder and the toolbox were the only items on the scene, you secured the accident
occurrence or occupational disease to the Commissioner will be liable to a fine of up to $5,000, area using the barricade tape to prevent people from entering.
or a jail term of not more than 6 months, or both.
• Tian Beng and Stephanie, an office worker, were the only two witnesses to the accident.
For more information on incident reporting, go to: • The ladder was leaning against the wall, while the toolbox was on the floor. A screwdriver
http://www.mom.gov.sg/workplace-safety-health/incident-reporting was found next to Ah Meng.
• The corridor was brightly lit, even though Ah Meng was supposedly changing one of the
light tubes. The condition of the floor was good as it was cleaned in the morning and the
corridor was not exposed to rain.
• You proceeded to take photos of the ladder, toolbox, screwdriver, the lighting tube Ah
Meng was supposed to change, and the view of the corridor from different angles.

8 9
 B. Interview (Refer to Annex B – Sample Accident Investigation Form for interview details) D. Recommendations and Key Learning Points
• Tian Beng had finished bandaging Ah Meng. You asked Tian Beng to keep the first aid kit Looking at the root cause analysis and company records, you see that the company’s training
then interviewed Ah Meng privately in your office. and maintenance programmes need to be strengthened. Employees also need to check ladders
before using them, this should be added to the SWP. You plan how to carry this out (e.g., source
• After Ah Meng’s interview, you then asked Tian Beng into your room for his account
for trainers, plan a system for ensuring maintenance for ladders). Safer work methods, like using
of the incident.
a step platform, are considered.
• Lastly, you proceeded to interview Stephanie to gain a better understanding of the incident.
Part 3: Review and Implement
Part 2: Analysis You inform the management about your plan and get approval to carry it out. You then inform
C. Write down the information all employees of this. The plan was implemented within a reasonable timeframe. The measures
You gathered the information and reviewed all related documents (e.g., maintenance logs) and you implemented are reviewed and revised accordingly to feedback from employees. Changes
proceeded to write down what happened (see Annex C). The “root cause analysis” showed that: to the measures are recorded and kept along with the original plan.

Analysis
Incident summary
Worker fell from ladder.

What happened during the incident?

Missed step on ladder.
Ladder was unsafe.

Cause analysis
Worker was distracted. Spreader was Rungs were
worn out. damaged.

Unsafe act by worker. Ladder was not maintained.

Root cause
Worker lacks training or awareness of risk. Company does not have a
maintenance programme.

10 11
 7. Other Resources Annex A – Sample Checklist for
Incident Investigation
• Investigating Accidents and Incidents – A Workbook for Employers, Unions, Safety Representatives First response
and Safety Professionals
http://www.hse.gov.uk/pubns/priced/hsg245.pdf Action Done? Remarks
First aid for injured (if any). 
• The Safety Library – Accident Investigation Control access to the scene. 
http://www.thesafetylibrary.com/lib/accidentanalysis/accidentinvestigation.php
Shut off power to machinery (if needed). 
• A Guide to Workplace Safety and Health (Incident Reporting) Regulations Record names of witnesses. 
http://www.mom.gov.sg/legislation/occupational-safety-health/Pages/default.aspx

Notification
• Singapore Civil Defence Force – Guidelines for Company Emergency Response Plan
http://www.scdf.gov.sg/content/dam/scdf_inter/Guidelines%20to%20ERP.pdf Action Done? Remarks
Police or Civil Defence (if needed). 
Facilities manager. 
Safety officer or manager. 
Ministry of Manpower (if needed, e.g., death or

hospitalisation, see Section 5).

Scene investigation
Action Done? Remarks
Make sure that area is safe for investigation. 
Wear PPE (if needed). 
Taken note of:
• environment (lighting, floor, etc.); 
• housekeeping; and 
• location of equipment. 
Took relevant photos of scene, equipment, and so on. 

Interviews
Action Done? Remarks
Assure interviewees of the “no blame” approach. 
Interview injured person (if any). 
Interview witnesses. 
12 13
 Analysis Annex B – Sample Incident
Action
Use form to do cause analysis.
Done?

Remarks
Investigation Form (Blank)
Come up with recommendations and key

learning points.
For all incidents
Come up with corrective actions and plan how Incident details

to carry them out.
Location  Injury
Get management approval and carry out plan. 
Date  Property damage
Time  Near miss
Date approval given: Done by:

Date of implementation of Work activity involved

corrective actions: Signature:

Date of completion of Confirmed by:

implementation:
Next review date: Signature:

Incident description

14 15
 Equipment, tools or PPE involved (include serial numbers, if any): Witness’s account
Name Contact no.

Name Contact no.

For use only where there is an injury

Particulars of injured person Name Contact no.
Name Age
Department
Job title
Injury description
Scene observations

Injured person’s account

16 17
 Analysis Annex C – Sample Incident
Incident summary
Investigation Form

For all incidents

What happened during the incident?
Incident details
Location Admin office corridor ✓
 Injury
Date 14/3/2010  Property damage
Time 2:45pm  Near miss
Cause analysis

Work activity involved

Changing corridor light tube.

Root cause

Incident description
Ah Meng was found lying on the floor of the admin office corridor. He had been standing on a
ladder to change the fuse of the light tube of the corridor.
Corrective measure(s) to prevent repeat of incident

Person to put this in place Due date

Date of
Investigator’s name
investigation

18 19
 Equipment, tools or PPE involved (include serial numbers, if any): Witness’s account
Ladder, toolbox, screwdriver. Name Chew Tian Beng Contact no. 9xxxxxxx
No PPE worn, no Safe Work Procedure (SWP). He saw some ceiling lights blinking and wanted to tell Ah Meng about them. When he
walked closer, he saw Ah Meng climb down the ladder, miss a step and fall off the
ladder’s 4th last step (1.5m).

Name Stephanie Seah Contact no. 8xxxxxxx

She saw Ah Meng climbing down his ladder when she came out from the office and said
hello to him. When Ah Meng turned his head quickly to see who was talking to him, the
sudden movement caused the ladder to wobble. Ah Meng then missed a step on the ladder
For use only where there is an injury and fell down.
Particulars of injured person Name Contact no.
Name Tan Ah Meng Age 30
Department Facilities
Job title Technician
Injury description
Bruising on the arms and legs. Scene observations
Corridor was reasonably well-lit, floor was clean and dry.

Injured person’s account

Ah Meng said he climbed up the ladder to replace the lighting tube fuse.
When he climbed down to reach his toolbox, he missed a step on the ladder and
fell to the ground.

20 21
 Analysis
Incident summary
Worker fell from ladder.

What happened during the incident?

Missed step on ladder.
Ladder was unsafe.

Cause analysis
Worker was distracted. Spreader was Rungs were
worn out. damaged.

Unsafe act by worker. Ladder was not maintained.

Root cause
Worker lacks training or awareness of risk. Company does not have a
maintenance programme.

Corrective measure(s) to prevent repeat of incident

Conduct ladder safety lessons for workers.
Use logbook to track ladder’s age and repairs, add in SWP for workers to check ladders
for damages before using.
Person to put this in place Chew Teck Chong Due date June 2010
Date of
Investigator’s name Wang Ah Kim 20/3/2010
investigation

22