Incident investigation

procedure

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 CONTENTS

1. Purpose

2. Scope

3. Reference Documents

4. Terms and Definitions

5. Incident Investigation Process

5.1) Management of incidents

5.2) Responsibilities and authorities

i) Investigation Team

ii) Top Management and Management

iii) HSE Manager / Management Representative

iv) HSE Representative

v) All Employees

vi) Contractors / Suppliers / Third parties on premises, reporting to

the organisation

5.3) Conducting an Incident Investigation

5.4) Following Up on the Incident Investigation

6. Trend Analysis

7. Clause Maintenance
1. PURPOSE
The purpose of this procedure is to explain the steps and processes to be followed for the reporting,
recording, investigation, documenting and communicating of all incidents occurring in the organization.
Incidents are understood to be any unwanted, unforeseen event that interrupts organizational processes
and have a potentially negative impact or outcome on the organization. Following incidents, there must
be corrective and preventive actions taken to address the related non-conformances and prevent
recurrence, these will be dealt with in Clause 4.5.3.2 Procedure.

2. SCOPE
This procedure will not be formally applied to third parties or contractors, contract manufacturers,
suppliers or distribution centers etc. that are not operated by the organization directly. However, all
affiliates of the organization in any capacity will be required to comply with the minimum legal
requirements and as far as possible, international standards and best practice. With regards to reporting
of incidents, this clause does require contractors and third parties reporting to the organization to report
all incidents as required in the rest of the procedure.

3. REFERENCE DOCUMENTS
➢ OHSAS 18001: 2007 Specification
➢ All Related Clause Procedures (Especially Clause 4.3.1, 4.4.1,4.4.2 and 4.5.3.2 Procedures)
➢ Incident Register
➢ Incident Investigation Forms and Reports
➢ Incident statistics and measurements
➢ Non-conformance documentation

4. TERMS AND DEFINITIONS

Our Management System and documents use the same internationally recognized terms, vocabulary
and definitions given in OHSAS 18001:1999, OHSAS 18001:2008 and the local legislation.

Some specific definitions pertinent to this Procedure:

Injury on duty: This is an injury that occurs to employee whilst they are on duty, and results in the
person requiring some sort of treatment.
Minor Incident: This is an incident that occurs on premises during work hours and involves either
employee whilst they are on duty, property, facilities / infrastructure, the environment or production
processes. They result in the person requiring some sort of treatment for injury or illness, but that
treatment is only minimal and would be limited to First Aid treatment, in property being damaged but
repairable, in processes being interrupted briefly and the environment being polluted, but not
catastrophically.
Major Incident: This is an incident that occurs on premises during work hours and involves either
employee whilst they are on duty, property, facilities / infrastructure, the environment or production
processes. They result in the person/s being severely injured or ill, being booked off work, being disabled
or even killed. Property is damaged beyond repair, processes being interrupted for a persistent amount
of time causing massive delays; the environment being polluted catastrophically.
Disabling Injury: This is an injury that occurs to employee whilst they are on duty and causes the
death, permanent disability or any degree of temporary total disability beyond the day of the injury, to
that employee.
Near Miss: Definition provided in the OHSAS 18001 Specifications.
Root Cause: These are known as the basic causes of an incident, they are the job and
personal factors, such as inadequate engineering, lack of knowledge or skill, etc. They may also
be referred to as real causes or system defects. They are most frequently the result of an
inadequate safety system, inadequate system standards, and/or inadequate compliance with
standards.

Incident Analysis: Study of incident experience through compilation of related facts and
information about the nature of injuries or damage, and the causes for these. The purpose of the
analysis is to define trends and problem areas. This process usually involves determining the frequency
of occurrence, severity, nature of injury/damage, part of body injured, type of equipment, environment or
material damaged, impact of the incident etc. (See Trend Analysis below for more).

5. INCIDENT INVESTIGATIONPROCESS
When incidents and non-conformities occur in the workplace, the organization will ensure that the event
is recorded, investigated if necessary and that measure are put in place to prevent the recurrence of the
event or similar events. These actions must be performed timorously in response to the nature and scale
of the incident and the potential impact it will have on the organization. This procedure outlines the
requirements for investigations to be performed in accordance with organizational and legal
requirements.
5.1) Management of incidents
Any person is able to identify a non-conformance and initiate a non-conformance report, this will be
called the General Incident Notification Form, and there is also an Injury and illness Notification Form.
These template reports will be available at points of use and can be completed by an employee. Once
complete the report must be submitted to the HSE Department via the HSE Representative or any
members of the HSE department.
All reports will be forwarded to the HSE Manager / Management Representative who will capture them
on the Incident Registers and then determine whether the non-conformance requires a Corrective or
Preventive action Request to be generated. The Incident Registers will be used for data creation and
trend analysis; it will also be discussed in the HSE Committee Meetings.
All incidents will be reported to management before the end of the shift, if not immediately. All employees
will be informed of this requirement during their Orientation / Induction training session and refresher
training will be conducted on an on-going basis.
As a minimum, the organizations incident management program will include the following:
• Near misses;
• First Aid Injuries;
• Complaints from external and internal parties;
• Minor incidents (including medical treatment cases and minor illnesses and
diseases);
• Major incidents (Including lost time incidents and disabling injuries / permanent
disability and major illnesses and diseases);
• Fatalities and multiple fatalities;
• Equipment related incidents (including machines running out of control, contact with
energised systems / equipment, release of substance under pressure etc.);
• Environmental incidents (including those that may affect the community and
neighbouring organisations, spills of hazardous substances, pollution to ground, air
or water systems);
• Those resulting in property damage and large financial loss.
5.2) Responsibilities and authorities
i) Investigation Team

Incident Investigation team members will be trained on incident investigation techniques.

The Incident Investigation Team will have the following responsibilities:
• To ensure that all incidents are investigated;
 • To collect evidence and information about the incident, directly following the
occurrence of the incident;
• Determining whether an incident requires further investigation in conjunction with the
Incident Investigation team and the HSE Manager / Management Representative;
• Performing the incident investigation as required as part of the incident investigation
team, interviewing employees and witnesses, and inspecting and analysing collected
evidence;
• Determining suggestions for corrective and preventive actions to be implemented
and including those in the report, as part of the incident investigation team and in
conjunction with the HSE Manager and responsible manager for the area where the
incident took place;
• Drafting and completing the Incident Investigation Report in conjunction with the
incident investigation team and submitting it to management for review within seven
days of the incident occurring.

The Incident Investigation Team members will have the following authority:
• To ask for and be given any maintenance record, operational procedure, work
instruction, calibration certificate or any other equipment documentation that
concerns the item being investigated, and make copies thereof;
• To ask for and be given any performance or measurement records concerning the
item being investigated, and make copies thereof;
• To inspect any incident investigation form that has been completed for previous
accidents that has occurred in the Department concerned, and make copies thereof;
• To make notes, sketches, take photographs and interview witnesses as needs may
be;
• To make recommendations to the employer as they see fit in conjunction with the
incident investigation team and the HSE Manager / Management Representative.

ii) Top Management and Management

Management will receive the Incident Investigation Reports and approve and initiate corrective and
preventive actions as they see fit, providing the resources to do so. In very serious incident situations,
that created catastrophic results, Top Management and Management will form part of the Incident
Investigation Team.
Management will also ensure that Reportable Incidents (Reportable to the authorities) are reported as
legally required by the HSE Manager / Management Representative within the specified time periods.
iii) HSE Manager / Management Representative
The HSE Manager / Management Representative has the duty of ensuring that all incidents are
investigated by the incident investigation team and that all reports are submitted within seven days. They
are the responsible person for initiating disciplinary action where this does not occur.
They will be responsible for assisting the incident investigation team in determining suggestions for
corrective and preventive actions and assisting in the investigation process where required. In very
serious incident situations, that created catastrophic results, the HSE Manager / Management
Representative will form part of the Incident Investigation Team.
The HSE Manager / Management Representative has the duty of reporting all Reportable Incidents
(Reportable to the authorities) as legally required within the specified time periods.
The HSE Manager / Management Representative is furthermore required to initiate corrective and
preventive actions stemming from the Investigation Report according to the required procedures in
Clause 4.5.3.2 Procedure.
 iv) HSE Representative

The HSE Representative has the duty of assisting the Incident Investigation team in their investigation
and ensuring that all incidents are not only reported for their area but there were necessary, investigated
by the incident investigation team.
v) All Employees
All employees have the duty and obligation to report all incidents occurring in the workplace to their
supervisor or to the HSE Representative before the end of their shift. This can be a verbal or written
notification. Where a non-conformance was observed, the employee may be required to complete a non-
conformance report and where an incident occurred, an incident report must be logged. Further to this
employees are encourage to report all hazards identified and potential unsafe situations in the workplace
to their supervisor as soon as possible.
vi) Contractors / Suppliers / Third parties on premises, reporting to
the organisation
The organization will ensure that third parties are informed of the incident reporting procedures and
requirements of the organization. The third parties will be required to report all incidents to the
organization before the end of the shift. The third party may be required to complete an incident
investigation and submit reports of such to the organization within seven days, depending on the nature
of the incident that occurred.
5.3) Conducting an Incident Investigation
The incident investigation team must be given full co-operation by all witnesses, area / department
managers and supervisors; the must be provided the necessary equipment to perform their investigation
duties and a suitable area to meet privately with interviewees and the incident investigation team.
The scene of the incident may not be disturbed in any event unless it is to prevent further injury or
damage, to remove injured persons or if directed by emergency services or personnel.
Once the incident investigation team has determined that the incident requires further investigation, the
incident must be fully investigated by the investigation team.
The Incident Investigation Team must determine and capture the following through their investigation:
• Detail a comprehensive description of what occurred;
• Evaluate the compliance or non-compliance with laws and regulations;
• Results of examination of the incident location;
• Record of employee interviews;
• Evaluations of any equipment or materials involved the incident;
• Evaluations of the potential severity and probability of recurrence;
• Analysis of substandard acts and conditions;
• Determination of the root causes;
• Evaluation of the current controls in place;
• Incident Analysis;
• Suggestions for remedial actions (corrective/preventive actions);
• Determination of the actual and potential costs associated with the incident and the
remedial actions.

All of this above information will be captured in the Report to be submitted to management within seven
days of the incident occurring.

5.4) Following Up on the Incident Investigation

Once the Incident Investigation Team has submitted the report to Management, it is for Management to
authorise and initiate corrective and preventive actions. These will be created and logged by the HSE
Manager / Management Representative.
Once the recommendations have been authorized and approved for implementation by management,
the Risk Assessment Team will perform a Risk Assessment on the remedial. Once this has been
finalized, the corrective and preventive action request forms must be completed and the actions
performed in accordance with Clause 4.5.3.2 Procedures
The feedback from the report on system failures and deficiencies will be used to implement
improvements in line with the Continuous Improvement objectives.
Once the report is complete and the remedial actions have been implemented, employees of the
affected work area will receive briefings / information sessions regarding the results of the incident
investigation and remedial actions implemented.
Monthly HSE reports generated as part of Clause 4.5.1, must include information about completed
incident investigations and the implemented remedial actions. These reports as well as the incident
investigation reports and all associated documentation and evidence, as well as the corrective and
preventive actions documentation will be retained and filed as evidence of activities having been
performed and for record keeping compliance.

6. TREND ANALYSIS

As part of the monthly reports submitted in line with Clause 4.5.1 procedure, the HSE Manager /
Management Representative in conjunction with the HSE department must develop data and statistics
from the incidents occurring in the workplace. The HSE Manager / Management Representative will
determine what aspects of measurement will be included in this data and statistics.
This could be in several different forms and a combination of the following:
• Departmental comparisons over the year and month periods;
• Performance of the entire organisation over the year and month periods;
• Comparisons of the types of events occurring over the year and month periods;
• Comparisons of the root causes of events over the year and month periods;
• The development of a Frequency Rate of events (particularly Injury events) over the
year period;
• The development of a Frequency Rate of a ‘rolling’ year period;
• Comparisons of near-miss events to actual injury events over the year and months
periods;
• Injuries per body part etc.;
• Comparison of the age / experience level / pay grade of the employees who were
involved in events over the year and month periods.

Where possible Health statistics and data will be obtained from the Nurse, Doctor or medical facility and
included in these reports.
Once these have been generated, management in conjunction with the HSE department with review and
analyses the information to determine where trends appear and how these may indicate HSE
Management System deficiencies that could be improved. The analysis of the trends will be used by the
organization identify further improvement opportunities and to determine the success of remedial
measures, risk reduction and risk control activities.

7. CLAUSE MAINTENANCE

The appointed HSE Manager / Management Representative will be responsible for the entire document
control / management system. This responsibility includes the issuing and maintenance of all Clause
Procedures and any related working documents or forms.
As part of their existing duties, the HSE Manager has a further responsibility to co-ordinate and ensures
compliance to this Clause 4.5.3 (and sub clauses 4.5.3.1 and 4.5.3.2).