Incident investigation/ Incident report process
Incident (Accident) investigation and incident report process is an integral element of the health and safety management system. It is a reactive measure adopted to monitor the effectiveness of the health and safety management system.
Incidents includes: Accident, near miss, dangerous occurrences, etc.
Our interest in this article is on Accident.
Accident is an unwanted, unplanned and unexpected occurrence which could result to lost of life, damage to properties and equipments, or destruction of the environment.
Since most accidents that occur on site are being attributed to either unsafe acts or unsafe conditions; and are over 90% caused by human error.
It is necessary to investigate and report every accidents and near miss. The main aim of incident (Accident) investigation and reporting is to find out why the accident happened and also prevent its re-occurrence. Hence, incident investigation is said to be a fact finding exercise and not a fault finding exercise.
Accident investigation and reporting should always be carried out by a competent person.
Steps for Incident investigation/ Writing Incident report
Accident investigation is carried out in majorly three (3) phases:
- Fact finding phase:
This phase involves visiting the accident scene to gather fact about the accident.
How to gather facts
- Physical examination of the accident scene: Here, a meticulous observation of the accident scene is required. Spatial arrangement of materials and equipments are assessed together with the position of machines and the available work-space. Pictures are taken which can be reproduced as hard evidence. On this note, the accident scene should not be allowed to be altered until the necessary evidence has been acquired.
- Interviews: People that were around the scene as at the time of the incident or has an idea about the job that was being carried out are worthy witnesses for the accident investigation.
Witnesses are divided into three (3):
Primary witness: This is the person(s) directly involved in the accident. It is very important to interview him if he is in a good state.
Secondary witness: The person(s) that were around the accident scene or close-by as at the time of the accident.
Tertiary witness: Any person(s) that was/were part of the job or had an idea of the job, even thought they were not at the scene of the accident when it occurred.
While interviewing the witnesses, always try to keep them away from each other, so that they will not have an opportunity to plan for a common response which could hamper the investigation outcome.
- Report writing:
Report should be clear and concise. Simple and understandable grammar should be used while writing report.
Report writing is mostly divided into six (6) parts:
- Incident description: This area carries a brief summary of what really went wrong and how it happened. It also covers where and when it happened with the people involved in the accident.
- List of findings: From your fact-finding phase, you should have been able to come up with concrete facts relating to the accident. These facts should be enumerated here.
- Immediate cause: This is the direct cause of the accident, i.e, what really transpired which resulted to the accident. Example, The worker tripped over an electric cable.
- Underlying/root cause: This gives an insight into the unseen cause of the accident which led to the immediate cause. Example, The workers were not trained on safe handling of electrical equipments.
- Recommendations: This area will require your problem solving skill to be able to give a good recommendation to prevent re-occurrence of such accident. Recommendations should commiserate with the consequence of the hazard. When the cost of preventing the consequence of an hazard is higher than the cost equivalent of the consequence of the hazard, then, such recommendation is poor.
- List of documents: These are documents that will back-up the investigation. These documents could be regulations, MSDS, medical reports, accident statements, pictures, etc.
The result of the investigation should be communicated to the relevant authority for adequate and prompt implementation of the recommendations.