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The general duty of care for employers under the Occupational Safety and Health Act 1984 (the Act) requires employers to maintain safe and healthy workplaces and systems of work.
Investigating accidents and incidents to prevent recurrence helps to achieve safer workplaces.
Section 33 of the Act describes the functions of a safety and health representative. One of these functions is to carry out investigations of accidents or incidents resulting in injuries to people.
The main objective of an investigation is prevention. A good investigation aims to establish a series of events that should have taken place and compares it to what actually happened to identify areas that need changing.
The type of investigation conducted depends on the seriousness or complexity of the incident, but it is best done as a team so all parties can contribute their skills and expertise to achieve the best result.
The employer is responsible for putting an investigation team together.
Investigators are collectors of evidence and must base their conclusions on that evidence. Take the time to chose the right people to conduct the investigation.
The following people should be considered for the team:
Investigation procedures need to be systematic. For any investigation the team should:
After the initial investigation is complete the team should:
Look for causes, not blame. Systems fail for many reasons and the people involved are not always the cause of the incident.
Build a chain of events to identify all the causes. For the investigation to be successful it is necessary to establish the following information:
Investigate:
Investigate:
Investigate:
To conduct an effective accident/incident investigation, it is essential to look for the design, environment/work process, and behaviour components, such as plant, procedures and people, rather than trying to isolate a single cause.
Poor systems design may result in exposure to hazards such as:
How people function in the work environment depends on what they experience in it. Environmental factors may be both physical and social.
The way in which people do the job, the procedures they follow and the work process are important factors in incident investigation. Poor work process may lead to hazard exposure.
Examples include misuse of safeguards, improper use of tools and equipment, disregard of cautionary notices, failure to wear personal protective equipment, horseplay and poor standards of housekeeping. Poor practices may indicate that improved communication, further training or some other action, such as supervision, are necessary.
The common practice in industrial accident/incident investigation is to look for the cause of any accident/incident. Searching for a single cause of an accident/incident is restrictive. It focuses attention on only one, or at best a very few, of the essential factors while others, which may be more easily controlled, pass unnoticed.
This list of questions may assist investigators to establish the facts.
WHO
WHAT
WHEN
WHY
WHERE
HOW
Note: Care must be exercised in obtaining answers to some of these questions, as the investigator could be accused of apportioning blame.
This checklist may help the investigators when determining the recommendations.
Acknowledgements: This bulletin is based on information issued by the Resources Safety Division of the Department of Mining and Petroleum.
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