ISO 45001:2018

Incident Reporting & Investigation Procedure

 ISO 45001:2018
Incident Reporting & Investigation Procedure

Approval
The signatures below certify that this health and safety management system procedure has been reviewed and accepted, and
demonstrates that the signatories are aware of all the requirements contained herein and are committed to ensuring their
provision.

Amendment Record
This procedure is reviewed to ensure its continuing relevance to the systems and processes that it describes. A record of
contextual additions or omissions is given below:

Page No. Context Revision Date

ALL New procedure to align with ISO 45001:2018 E 06-01-2021

a) Intertek Logo replaced with Intertek Moody logo

ALL F 10-15-2023
b) Document Owner changed

Company Proprietary Information

The electronic version of this procedure is the latest revision. It is the responsibility of the individual to ensure that any paper
material is the current revision. The printed version of this procedure is uncontrolled, except when provided with a document
reference number and revision in the field below:

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 ISO 45001:2018
Incident Reporting & Investigation Procedure

Table of Contents
1 Incident Reporting & Investigation ________________________________________________ 3
1.1 Introduction & Purpose __________________________________________________________ 3
1.1.1 Process Turtle Diagram ____________________________________________________________________________ 3
1.1.2 References _________________________________________________________________________________________ 4
1.1.3 Terms & Definitions _______________________________________________________________________________ 4
1.2 Application & Scope ____________________________________________________________ 4
1.3 Responsibilities ________________________________________________________________ 4
1.4 Incident Response ______________________________________________________________ 5
1.4.1 First Response _____________________________________________________________________________________ 5
1.4.2 Preserve the Incident Scene _______________________________________________________________________ 6
1.4.3 Internal Reporting _________________________________________________________________________________ 6
1.4.4 Regulatory Reporting ______________________________________________________________________________ 7
1.4.5 Insurance & Claims Reporting _____________________________________________________________________ 7
1.5 Incident Investigation Planning ___________________________________________________ 7
1.5.1 Planning the Investigation _________________________________________________________________________ 7
1.5.2 Determine the Level of Investigation ______________________________________________________________ 8
1.5.3 Investigation Team ________________________________________________________________________________ 8
1.5.4 Incident Investigation Report ______________________________________________________________________ 8
1.6 Incident Investigation ___________________________________________________________ 8
1.6.1 General _____________________________________________________________________________________________ 8
1.6.2 Collect Information ________________________________________________________________________________ 9
1.6.2.1 Inspect the Incident Site_________________________________________________________________________ 9
1.6.2.2 Witness Interviews & Statements ______________________________________________________________ 10
1.6.2.3 Observe the Location ___________________________________________________________________________ 10
1.6.2.4 Review Relevant Safety Documentation _______________________________________________________ 11
1.6.2.5 Review the Task ________________________________________________________________________________ 11
1.6.2.6 Review the Materials ___________________________________________________________________________ 11
1.6.2.7 Check the Environment ________________________________________________________________________ 12
1.6.2.8 Interview Management _________________________________________________________________________ 12
1.6.2.9 Collect & Store Evidence _______________________________________________________________________ 12
1.6.3 Determine the Root-cause(s) _____________________________________________________________________ 12
1.6.3.1 General Assessment ____________________________________________________________________________ 13
1.6.3.2 Analyze the Contributing Factors ______________________________________________________________ 13
1.6.3.3 Find the Root-Cause ___________________________________________________________________________ 13
1.6.4 Implement Corrective Action _____________________________________________________________________ 15
1.6.5 Monitoring & Review _____________________________________________________________________________ 15
1.7 Training Requirements _________________________________________________________ 15
1.8 Communication & Participation __________________________________________________ 16
1.9 Forms & Records ______________________________________________________________ 16

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 ISO 45001:2018
Incident Reporting & Investigation Procedure

1 Incident Reporting & Investigation

1.1 Introduction & Purpose
The purpose of this procedure is to outline Intertek’s methodology to establishing the processes required for an effective
incident and near miss response program which methodically examines all undesired events that have or could have resulted
in physical harm to interested parties or result in damage to property. The intent of any resulting investigation is to establish
the facts and circumstances related to the event in order to determine the root-cause and develop remedial action to control
the risk.

Process Turtle Diagram

With what With who

• Workers
• ISO 45001 requirements • Health & Safety Manager
• Investigation reports Representative
• Regulatory requirements • Lead Investigator
• Top management

Input Activity Output

Establish how events transpired • Additional controls

leading to the outcome, why • Tool-box-talks
things happened by analyzing the • Documented information
• Legal requirements Impact controls
immediate and underlying causes •
• Incident reports Communication
and determining actions to avoid •
• Witness statements New practices
repetition •
• Incident investigation • Regulatory reporting
• Hazard ID register
• Risk assessments

How With what measure

• Investigation planning • Incident frequency rate

• Investigation process • Completed corrective action
• Root-cause analysis • Risk mitigation scores

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 ISO 45001:2018
Incident Reporting & Investigation Procedure

References
Standard Title ISO Clauses Manual Sections
BS EN ISO 45001:2018 OH&S management system requirements 10.2
10.2.1
BS EN ISO 45002:2023 Guidance on managing occupational health 10.1

Terms & Definitions

Term Definition
Incident A work-related event in which an adverse event has occurred, or could have occurred
Near miss An incident, under different circumstances could have caused injury, illness or damage
First aid case A minor injury; scratch, cut, burn, etc. that can be treated by first aider or equivalent
Medical treatment An injury or illness that requires treatment by a health care professional
Lost time injury An injury or illness prevents a person from doing work for 1 to 3 days after the incident
Fatality A death resulting from a work-related injury or occupational illness

1.2 Application & Scope

The scope of this procedure applies to all incidents that are associated with current health and safety requirements. This
procedure is applied when taking action to investigate and mitigate the causes and consequences arising from incidents and
includes the initiation and completion of corrective actions and confirmation of the effectiveness of actions taken. This
procedure requires that all proposed corrective action is reviewed through the risk assessment process prior to
implementation.

1.3 Responsibilities
Top management are responsible for:

1. Promoting a continuous improvement culture by facilitating processes to investigate incidents that view human
errors, process failure or component failure as an opportunity to learn;
2. Reviewing findings from investigation reports to ensure as far as reasonably practical that recommendations are
appropriate and adequately address improvements to the identified risk(s);
3. Reviewing and approving the classification of High Potential Incidents in consultation with relevant managers or
subject matter experts;
4. Allocating appropriate resources to investigate assigned incidents within designated timeframes;
5. Approving investigation report findings within their area of responsibility.
Line Managers and Supervisors are responsible for:

1. Where a notifiable or high potential incident has occurred, ensure as far as reasonably practical that the incident
scene is preserved and any emergency response taken to control the incident is documented;
2. Supporting affected personnel and prevent reoccurrence following an incident;
3. Participating and actively contribute to the investigation process as required;
4. Providing workers involved in the incident or investigation processes with support as required;

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 ISO 45001:2018
Incident Reporting & Investigation Procedure

5. Communicating information in relation to key learning’s to staff and actions identified through incident
investigations.
The Lead Investigator is responsible for:

1. Conducting and leading the investigation in accordance with this procedure;

2. Leading the investigation to determine the immediate and underlying causes;
3. Compiling the investigation report using the template;
4. Reviewing documented recommendations with the relevant Line Manager/Supervisor so that all are accepted and
agreed to by the relevant parties;
5. Submitting the investigation report within the allocated timeframe;
6. Recording investigation outcomes to enable the analysis of incidents, contributing factors, corrective actions and
effective risk analysis;
7. Reporting findings as relevant.
Workers are responsible for:

1. Participating in incident investigations;

2. Cooperating and assisting with implementation of improvement actions ensuing from investigations.
1.4 Incident Response
First Response
It is Intertek’s aim to investigate all injuries, incidents and near misses as thoroughly as possible. Having done this,
recommendations are made to correct both the immediate and root-causes of the incident. The recommendations are then
implemented and at subsequent audits, checks are made to ensure that the recommendations are still being enforced to
ensure the incident(s) are not repeated.

When an incident occurs, immediate action is taken in order to make the situation safe and prevent further injury and to help,
treat and if necessary, rescue injured persons. The first person aware of an incident must act, where safe to do so, to prevent
further harm to people, product quality or supply, the environment, property, reputation or a combination of these, and then
must:

1. Immediately notify the relevant Health & Safety Representative, Line Manager or Supervisor;
2. Immediately telephone Intertek’s Incident Hotline (Where available);
3. Preserve the incident scene, refer to section 1.4.2 for specific details.
The responsible Health & Safety Representative, Line Manager or Supervisor upon being notified of the incident will provide
direction to staff to complete the following actions:

1. Assess the situation and provide assistance and resources where necessary;
2. Confirm that appropriate action has been taken to the extent practicable to prevent further harm;
3. Determine the actual and potential severity of the incident and notify the incident hotline and other relevant
stakeholders;
4. Follow the relevant incident and emergency response plan when it is an emergency situation;

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 ISO 45001:2018
Incident Reporting & Investigation Procedure

5. Where a notifiable or high potential incident has occurred, preserve the incident scene to obtain any relevant
evidence;
6. Document any initial response taken to control the incident.
When summoning emergency assistance via telephone, the caller must keep calm, avoid panic and clearly state the following
information:

1. Location of the incident;

2. Nature of the incident, how many persons are injured, any fire or hazardous chemical spillage;
3. Nature of the incident, the seriousness of the injured e.g. bleeding or bone fracture;
4. Name, department, telephone number of the caller.
The injured person should not be moved unless his location exposes him to further risk of injury. The general approach to a
seriously injured person is to render comfort, and only treatment that is necessary to preserve life until trained medical help
arrives. After the incident, details should be given to the attending emergency services personnel in order to assist them for
follow-up action.

Preserve the Incident Scene

Preserving the incident scene enables the collection of evidence to ensure the outcomes of the investigation are factual and
enable the identification of causes. In the case of a notifiable or high potential incident, the first person aware or any other
worker involved must facilitate events at the incident scene so that equipment, plant, process, machinery or other associated
plant connected with the incident are not disturbed without the permission of the Health & Safety Representative, Line
Manager or Supervisor.

Internal Reporting
Incident reporting is through the use of Intertek’s iHSE System, as well as, incident reporting and investigation forms where
appropriate. All Health & Safety Representative, Line Managers and Supervisors are required to use these forms, which must
be forwarded and progressed by the Health & Safety Representative. All incidents must be reported:

1. The witnesses or the person is involved in an incident or near miss must complete the report in the iHSE System
however where this is not possible, they should complete the Incident Report Form and forward to the Health &
Safety Representative, Supervisor or management within 24 hours;
2. The responsible manager will report the injury to the insurer or enforcing authority (if applicable) within the
statutory reporting timeframes;
3. The Health & Safety Representative, in consultation with Supervisors and workers will ensure immediate interim
action is taken as required to minimise risk within the workplace;
4. The Lead Investigator investigates the incident and reviews any concerns that are raised using the iHSE System
however where this is not possible, they should complete the Incident Investigation Report. and forward to the
Health & Safety Representative, Supervisor or management within 24 hours. The level of investigation is determined
at this stage;
5. The Lead Investigator carries out necessary interviews and reviews documentation (within the investigation team – if
full investigation is warranted);

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 ISO 45001:2018
Incident Reporting & Investigation Procedure

6. The Health & Safety Representative, Line Managers or Supervisors complete the final section in the iHSE System or
Incident Investigation Report as necessary;
7. The Health & Safety Representative or Supervisors completes the necessary risk management documentation;
8. Corrective actions are implemented according to the risk action plan;
9. All documentation must be kept on file for easy access and retrieval, if required;
10. All incidents are reviewed by Top management and the Health & Safety Representative on a regular basis.
The injured person (after treatment by a First Aider or other medical agency), or the people involved then complete the
appropriate sections within the iHSE System or the Injury or Incident Report Form, as appropriate, and passes it to the Health
& Safety Representative or Team Leader for immediate investigation. It is essential that this occurs within the same shift or
work period that the incident happened.

Where witnesses to the accident/incident are available, the Health & Safety Representative, Line Manager or Supervisor will
ensure that statements are taken from those who saw what happened. This must be done as soon as possible after the event,
within the same shift, consistent with returning the scene to a position of safety, where possible, in order to capture details of
what happened before hearsay or speculation become involved.

Regular reporting is necessary to inform and provide assurance to Top management and other key stakeholders, that incidents
and near misses are being appropriately captured. Reporting is based on trends and current data captured from the iHSE
System / Incident Report Form.

Regulatory Reporting
Intertek complies with all the statutory reporting requirements. These arrangements oblige the organization to report the
details of certain incidents to the relevant enforcing authority. Any reportable injury, disease or dangerous occurrence, or any
incident where the environment outside the Works boundary has been affected, or Local Authority Emergency Service(s) have
been involved, or Neighbour or media interest has been attracted, and:

1. Incidents resulting in loss of life which are reported immediately;

2. Incidents resulting in a worker taking a number of days off work due to injury;
3. Incidents involving damage or potential damage to dangerous items of plant.
Where an incident is classified as a Major incidents/illness (work related) each location must evaluate the reporting
requirements for the local jurisdiction.

Insurance & Claims Reporting

Intertek’s insurer is notified of any significant incident which could give rise to a claim. Any such incidents are also reported
to our Insurers and any subsequent investigation and relevant documentation is submitted on request.

1.5 Incident Investigation Planning

Planning the Investigation
The objectives of planning are to establish the scope, means and timeframes of the investigation, identify the resources and
tools required for investigation and to assess and control the risks associated with the investigation activities. The Lead

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 ISO 45001:2018
Incident Reporting & Investigation Procedure

Investigator will develop an action plan for each investigation which includes plans to collect information from within the
following categories:

1. People – information relating to witnesses and personnel associated with the incident;
2. Environment – information relating to weather, workplace, incident scene;
3. Equipment – information relating to vehicles, plant, tools, infrastructure;
4. Procedures – information relating to documents, reports, charts, maps;
5. Organisation – information relating to training, communication, resources, culture and management.
Determine the Level of Investigation
Each incident is assessed against the actual and potential consequence. This assessment is done in consultation with the
appropriate responsible party or subject matter expert to determine the level of the investigation to be completed. Included
are the required documentation templates for reports appropriate to the level of investigation.

The investigation ensures that if an occurs, the appropriate and corrective actions are planned, risk-assessed, initiated and
recorded. The results of any action taken is recorded and where changes in procedures are required, appropriate records are
amended.

Investigation Team
A Lead Investigator and an investigation team, including affected workers, the Health & Safety Representative and the Health
& Safety Agents (as required) is appointed. The composition of the investigation team is commensurate with the actual and
potential of the incident so as to be able to determine root-causes, contributing factors and the identification of appropriate
corrective actions.

Incident Investigation Report

The Lead Investigator follows the requirements for reporting incidents using the report template. The incident investigation
report constitutes an accurate and objective record of the incident and provides complete and accurate details and explicit
statements of:

1. The investigation team’s methodology for the investigation;

2. Facts pertaining to the incident;
3. Analytical methods used and their results;
4. Findings of the investigation team, including the causal factors of the incident;
5. Agreed recommendations and associated corrective actions to prevent recurrence of the incident;
6. Feedback and key lessons learnt.
1.6 Incident Investigation
General
The purpose of the investigation is to establish how events transpired that led to the outcome, to establish why things
happened as they did by analyzing the immediate and underlying causes and determining actions to avoid repetition.

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The investigation, undertaken by the Lead Investigator will determine what control measures were absent, inadequate or not
implemented and so generate remedial action for implementation to correct this. Intertek investigates incidents using the
iHSE System or the Incident Investigation Report

in order to:

1. To determine the true and accurate circumstances which led up to, and contributed to the event;
2. To prevent the event occurring again, potentially with even greater repercussions.
Some incidents may require more detailed investigation and analysis, the risk analysis identifies when a more detailed
investigation technique is used.

Collect Information
1.6.2.1 Inspect the Incident Site
The Lead Investigator collates clear and accurate information to begin the investigation process. It is important when
investigating incidents not to allocate blame. If attempts are made to apportion blame, people who might otherwise provide
useful information and guidance on remedial action needed, will simply become defensive. The results could affect:

1. Witnesses not revealing all of the circumstances and events surrounding the incident;
2. Deliberate obstruction or provision of false information and;
3. The removal of relevant information, documents or evidence.
The Lead Investigator must remain impartial and objective if all of the causes are to be established. For the incident
investigation to be successful in identifying all of the causes of the incident, it will be necessary to establish the events and
circumstances leading up to the incident. The types of events and circumstances leading up to the incidents, which are relevant
for the investigation, may include:

1. The system of work currently in place;

2. The instructions given for the work;
3. Variations from instructions or safe work systems.
Workplace conditions such as lighting, floor surfaces, stair treads and handrails, warning signs, and temperature and weather,
if the incident occurred outside the exact location of the incident, with sufficient detail for the area to be readily identified by
somebody else reading the report.

1. Materials in use or being handled;

2. Type of equipment in use;
3. State of the work system and the actions which occurred at the moment of the incident;
4. People directly involved, and those involved at a distance;
5. Tools, equipment, materials and fixtures directly involved;
6. Time the incident occurred.
Facts of events immediately after the incident; relevant facts from events which occurred immediately after the incident may
include:

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Incident Reporting & Investigation Procedure

1. Injuries or damage resulting directly from the incident;

2. Events leading to consequential injury or damage;
3. People involved, including those rendering aid;
4. Problems in dealing with the incident.
In the investigation of the events leading up to an incident, there will be a number of basic factors to consider. They are
important in determining causation. The basic factors comprise elements which must exist to enable the sequence to continue,
and hence the damage to occur.

These elements contribute to all incidents. In conducting an effective incident investigation, it is essential the Lead Investigator
looks for each of these components, and not to look for any single cause:

1. Design Factors – poor systems design may result in exposure to hazards such as unguarded dangerous parts of
machinery, ineffective safety devices or inadequate ventilation.
2. Environmental Factors – The production system environment has a direct effect on safety behavior. How people
function in the work environment depends on what they experience in it. The environmental factors may be both
physical and psychosocial.
3. Behavioral Factors – behavioral factors can result in exposure to hazards. Examples of behavioral factors are the
misuse of safeguards, the improper use of tools and equipment, ignoring cautionary notices, failure to wear personal
protective equipment, horseplay or poor standards of housekeeping.
The reasons that lie behind the disregard for accepted safe systems of work and safety practices, procedures or rules are
examined. Such behavior is not accepted within the organization.

1.6.2.2 Witness Interviews & Statements

The Lead Investigator interviews the person(s) involved and witnesses to the incident is of prime importance, ideally in familiar
surroundings so as not to make the person uncomfortable.
1. The interview style is important with emphasis on prevention rather than blame;
2. The person(s) should give an account of what happened in their terms rather than the investigators;
3. Interviewees should be separated to stop people from influencing each other;
4. Questions when asked should not be intimidating as the investigator will be seen as aggressive and reflecting a
blame culture.
The physical and mental condition of those directly involved in the incident must be explored. Some factors will be more
permanent; others may vary from day to day:
1. Were employees experienced in the work being done?
2. Had they been adequately trained?
3. Were they physically capable?
4. What was the status of their health?
5. Were they under stress (work or personal)?
1.6.2.3 Observe the Location

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 ISO 45001:2018
Incident Reporting & Investigation Procedure

The incident site is inspected and recorded by the Lead Investigator (digital photographs/video recordings) as soon as possible
after the incident. Particular attention must be given to:
1. Positions of people;
2. Personnel protective equipment (PPE);
3. Tools and equipment, plant or substances in use;
4. Orderliness/tidiness.
1.6.2.4 Review Relevant Safety Documentation
Documentation provides invaluable information on how and why the circumstances leading to the incident arose.
Documentation to be looked at includes:
1. Written instructions;
2. Procedures;
3. Hazard register;
4. Briefing records/tool-box-talks register;
5. Competence records;
6. Risk assessments.
The validity of these documents may need to be checked by interview. The main points to look for are:
1. Are written instructions adequate and satisfactory?
2. Were procedures followed on this occasion?
3. Were people trained and competent to follow the risk assessment?
4. Were records of inspections, tests and surveys undertaken before the event?
1.6.2.5 Review the Task
Review the actual work procedure being used at the time of the incident:
1. Was a safe work procedure used? - ‘If not, why not?’
2. Had conditions changed to make the normal procedures unsafe? - ‘If so, how?’
3. Were the appropriate tools, materials available? - ‘If not, why not?’
4. Were they used? - ‘If not, why not?’
5. Were safety devices working properly? - ‘If not, why not?’
6. Was lockout used when necessary? - ‘If not, why not?’
1.6.2.6 Review the Materials
Seek out possible causes brought about by the equipment and materials used and ask:

1. Was there an equipment failure?

2. What caused it to fail?
3. Was the equipment poorly designed?
4. Were hazardous substances involved?
5. Were they clearly identified?
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6. Was a less hazardous alternative substance possible and available?

7. Was the raw material substandard in some way?
8. Should personal protective equipment have been used?
9. Was it used?
1.6.2.7 Check the Environment
The physical environment; especially sudden changes to that environment, are factors which need to be identified. Note that
it is the situation at the time of the incident that is important. For example:
1. What were the weather conditions?
2. Was poor housekeeping a problem?
3. Was it too hot or too cold?
4. Was noise a problem?
5. Was there adequate light?
6. Were toxic gases, dust, fumes present?
1.6.2.8 Interview Management
Top management holds the legal responsibility for the safety of the workplace and therefore the role of the Supervisor and
higher management must always be considered in an incident investigation. Answers to any of the preceding questions
logically lead to further questions such as:
1. Were safety rules in effect?
2. Were they being enforced?
3. Was adequate supervision given?
4. Had hazards been previously identified?
5. Had procedures been developed to overcome them?
6. Were unsafe conditions corrected?
7. Was regular maintenance of equipment carried out?
8. Were regular safety inspections carried out?
Using this model as guide in incident investigation prevents looking at facts in isolation and assists in trying to uncover all
possible causes. While this checklist is only a sample of questions, other more pertinent questions can be asked to better
focus on the true root-cause.

1.6.2.9 Collect & Store Evidence

The Lead Investigator coordinates the collection, labelling, and preservation of physical evidence. All evidence is documented
and stored together in a secure location to allow for retrieval within the iHSE System. The Incident Investigation Report may be
also be used for this purpose. The relevant Health & Safety Representative, Line Managers and Supervisors establish a
quarantine area for any failed equipment or components and tag or label all failed equipment or components as ‘out of
service’.

Determine the Root-cause(s)

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 ISO 45001:2018
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1.6.3.1 General Assessment

Root-causes generally reflect management, design, planning, organizational and/or operational failings (e.g., employees were
not trained adequately; a damaged guard had not been repaired). The Lead Investigator must review and verify the data to
ensure accuracy and objectivity. The initial information obtained is then organised into the following categories:

1. People – information relating to witnesses and personnel associated with the incident;
2. Environment – information relating to weather, workplace and incident scene;
3. Equipment – information relating to vehicles, plant, tools, infrastructure etc.;
4. Procedures – information relating to documents, reports, charts, maps etc.,
5. Organisation – information relating to training, communication, resources, culture and management.
Collect all information and facts which surround the incident. Immediate causes are obvious and easy to find. They are brought
about by unsafe acts and conditions and are the ACTIVE FAILURES. Unsafe acts show poor safety attitudes and indicate a
lack of proper training. These unsafe acts and conditions are brought about by the so called ‘root-causes’ and are the LATENT
FAILURES and are brought about by failures in organisation and the management’s safety system.

1.6.3.2 Analyze the Contributing Factors

Following the collation of all facts related to the incident the factors that contributed to the incident must be identified.
Investigation outcomes are considered around non-contributing factors, absent/failed defences, individual/team actions,
team/environmental conditions and organisational factors. Upon identification of the findings, recommendations for
corrective actions are developed.

After analyzing the causes, the Health & Safety Representative reviews the incident, step-by-step, from the moment of the
occurrence, listing the causes as they happened in each step and ensure that any conclusions are supported by direct evidence
(physical or documented) or based on eyewitness accounts, or if it is based on assumptions. This serves as a final check on
discrepancies which should be explained or eliminated.

1.6.3.3 Find the Root-Cause

Finding the root-cause goes beyond the obvious proximate or immediate factors; it is a deeper evaluation of the incident.
This requires persistent ‘digging’, typically by asking ‘Why’ repeatedly. Conclusions such as ‘worker was careless’ or ‘did not
follow safety procedures’ do not reveal the root-causes of the incident.

To avoid these incomplete and misleading conclusions in the investigative process, the Lead Investigator must to continue to
ask ‘why?’ as in, ‘Why did the employee not follow safety procedures?’ If the answer is ‘the employee was in a hurry to
complete the task and the safety procedures slowed down the work’, then ask ‘Why was the employee in a hurry?’.

The more and deeper ‘why?’ questions asked, the more contributing factors are discovered and the closer the investigation
reveals the root-causes. If a procedure or safety rule was not followed, why was the procedure or rule not followed?

1. Did production pressures play a role, were those pressures permitted to jeopardize safety?
2. Was the procedure out‐of‐date or safety training inadequate?
3. If so, why had the problem not been previously identified, or, if it had been identified, why had it not been
addressed?

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If an investigation is focused on finding fault, it will always stop short of discovering the root-causes, because it will stop at
the initial incident without discovering their underlying causes. The main goal must always be to understand how and why
the existing barriers against the hazards failed or proved insufficient, not to find someone to blame.

The questions listed below are examples of inquiries that an investigator may pursue to identify contributing factors that, in
turn, can lead to root-causes:

1. If a procedure or safety rule was not followed, why was the procedure or rule not followed? Was the procedure out
of date or safety training inadequate? Was there anything encouraging deviation from job procedures such as
incentives or speed of completion? If so, why had the problem not been identified or addressed before?
2. Was the machinery or equipment damaged or fail to operate properly? If so, why?
3. Was a hazardous condition a contributing factor? If so, why was it present? (e.g., defects in equipment, tools and
materials, unsafe condition previously identified but not corrected, inadequate equipment inspections, incorrect
equipment used or provided, improper substitute equipment used, poor design or quality of work environment or
equipment);
4. Was the location of equipment, materials and worker(s) a contributing factor? If so, why? (e.g., the employee was
not supposed to be there, insufficient workspace, ‘error‐prone’ procedures or workspace design);
5. Was lack of personal protective equipment (PPE) or emergency equipment a contributing factor? If so why? Was
PPE incorrectly specified for job or task, inadequate PPE, PPE not used at all or used incorrectly, emergency
equipment not specified, available, properly used, or did not function?
6. Was a management program defect a contributing factor? If so, why? Was there a culture of improvisation to
sustain production goals, failure of a supervisor to detect or report hazardous condition or deviation from the job
procedure, supervisor accountability not understood, supervisor or worker inadequately trained, failures to initiate
corrective actions recommended earlier?
Potential root-causes that are under our control are validated. We apply the following validations to our answers for root-
causes by asking the following questions for every possible root-cause identified at all levels of the 5-Whys:

1. It there any proof, something you can measure or observe, to support the root-cause determination?
2. Is there any history or knowledge to indicate that the possible root-cause could actually produce such an incident?
3. Is there anything ‘underneath’ the possible root-cause that could be a more probable root-cause?
4. Is there anything that this possible root-cause requires in order to produce the incident?
5. Are there any other causes that could possibly produce the same incident?

Incident/Problem:
Identify and verify the root-cause(s). Identify all potential causes which could explain why the incident occurred. Isolate and verify the
root-cause(s) by testing potential causes against the incident description and data.
Why did the incident occur? Why was that?

Why 1

Why 2

Why 3

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 ISO 45001:2018
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Why 4

Why 5

Root-cause (The lowest level of cause that can be counter measured)

Implement Corrective Action

Corrective actions to address the root-cause(s) of an incident are taken from the hierarchy of controls and may include the
following remedial actions; eliminating hazards; substituting with less hazardous materials; redesigning or modifying
equipment or tools; developing procedures; improving the competence of affected workers; changing the frequency of use;
using personal protective equipment.

The timeframe for close-out of proposed actions by Health & Safety Representative, Line Managers and Supervisors is agreed
upon by all parties and documented. Timing and priority are based on the risk of reoccurrence involved. Workers are consulted
in determining the recommended actions and solutions where required.

The Health & Safety Representative closes out the corrective action when satisfactory resolution has been achieved and when
objective evidence of close out has been obtained through inquiry, observation, inspection or audit.

Monitoring & Review

Incidents are reviewed during health and safety meetings in order to identify any trends that might reveal areas for
improvements. The Health & Safety Representative is responsible for the collection, examination and analysis of all incident
data in order to establish incident trends and near miss situations in order to direct incident correction or prevention activities
to areas of concern. This process enhances risk and incident reduction across the sphere of operations.

Intertek uses the information gained from incident statistics to measure trends over a period of time so that the organization
has an indication of whether it is improving, stable or deteriorating with regards to health and safety performance. The incident
investigation process is examined from time to time to check that it consistently delivers information in accordance with the
stated objectives and standards.

When reviewing the effectiveness of the incident investigation process we consider the results of investigations and their
analysis, and the operation of the investigation system in terms of quality and effectiveness. This is achieved by checking
samples of investigation forms to verify the standard of investigation and the judgements made about causation and
prioritisation of corrective actions.

1.7 Training Requirements

Where the root-cause requires and risk assessment identifies that training is required as part of the corrective action, training
is provided before the affected process or activity restarts after the incident.

The Health & Safety Representative ensures that adequate training, including simulations and drills is provided to staff to
implement these procedures.

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 ISO 45001:2018
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The Lead Investigator must complete a Lead Investigator training course. Health & Safety Representative, Line Managers and
Supervisors ensure there are adequate numbers of trained incident investigators available.

The Human Resources Manager retains records of training received by staff on implementation of this procedure.

1.8 Communication & Participation

Communication and participation are important elements in each step of Intertek’s and incident investigation. Effective
communication and participation are essential to ensure that those responsible for implementing controls, and those affected
by the process, understand their responsibilities.

1.9 Forms & Records

Incident reports are circulated throughout our organization so that corrective actions can be implemented and other people
benefit from the lessons learned and recommendations made. As a minimum, incident reports are sent to the Health & Safety
Representative, Line Managers and Supervisors for dissemination to their respective teams.

In addition, copies of summaries are forwarded to all relevant worksites for posting on bulletin boards and for discussion at
safety meetings. All documentation and records generated by this procedure is retained and managed in accordance with the
Control of Documented Information Procedure.

The Director of Health & Safety controls the hard copies of documents such as codes of practice, enforcement actions,
improvement or prohibition notices, technical memoranda, and regulatory permits, etc.). Obsolete documents retained for
legal and/or knowledge preservation purposes are suitably identified.

. Supporting documentation:

Ref# Title & Description

Online Tool iHSE System
QA-205 Incident Report
QA-208 Incident Investigation Report

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Incident Reporting & Investigation Procedure

Organization Title/Subject Number

Intertek Industry Services Incident Reporting & Investigation QP-14
Owner Approved by Date (mm/dd/yyyy) Revision
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