📖 Introduction
In occupational health and safety management, incidents are not just unfortunate events—they are learning opportunities.
Every accident, near miss, or dangerous occurrence provides valuable insights into weaknesses within the
health and safety management system. By conducting a thorough incident investigation,
organisations can identify root causes, implement corrective actions, and prevent similar events from happening again.
This lecture explains the importance of investigating incidents, the systematic steps involved, and how
incident investigations contribute to continuous improvement within the workplace.
It also outlines the legal, moral, and financial reasons why employers must take investigations seriously.
🎯 Learning Outcomes
- Understand why incident investigation is essential for workplace safety.
- Explain the difference between immediate, underlying, and root causes.
- Learn the step-by-step process of investigating workplace incidents.
- Recognise the benefits of reporting and learning from near misses.
- Understand how investigations support legal compliance and organisational reputation.
⚖️ Why Investigate Incidents?
Organisations investigate incidents for legal, moral, and financial reasons:
Legal Reasons:
In many countries, occupational safety regulations require employers to investigate
and record workplace accidents and dangerous occurrences. A proper investigation demonstrates compliance
with health and safety law, reducing the risk of penalties, fines, or prosecution.
Moral Reasons:
Every worker deserves a safe workplace. Investigating incidents shows genuine care for employees’ wellbeing.
It prevents recurrence, reduces suffering, and promotes a positive safety culture
where staff feel valued and protected.
Financial Reasons:
Workplace incidents can lead to medical costs, lost productivity, insurance claims, equipment damage,
and reputational harm. A simple near miss report can save thousands of dollars by identifying risks
before they escalate into costly accidents.
🔍 Types of Causes in Incident Investigation
A professional investigation looks beyond the obvious. Incidents often have multiple contributing factors.
The NEBOSH framework highlights three categories of causes:
- Immediate Causes: Unsafe acts or unsafe conditions directly leading to the incident
(e.g., worker not wearing PPE, slippery floor). - Underlying Causes: Organisational weaknesses that allow unsafe conditions or acts to occur
(e.g., lack of training, poor supervision, inadequate maintenance). - Root Causes: The deepest systemic failures, often related to management systems,
culture, or inadequate risk assessments (e.g., absence of a clear safety policy, weak leadership commitment).
👉 Effective investigations aim to reach the root cause, not just correct the immediate fault.
Otherwise, problems may resurface in the future.
📋 The Incident Investigation Process
Incident investigations should be systematic, structured, and documented.
A typical process involves the following steps:
- Initial Response: Secure the area, provide first aid if necessary, and make the site safe
to prevent further harm. - Gather Information: Collect evidence, take photographs, draw sketches, and preserve equipment
involved in the incident. - Interview Witnesses: Speak to those directly involved and observers. Gather objective accounts
while memories are fresh. - Analyse Information: Identify what happened, how it happened, and why it happened
using tools such as the “5 Whys” or fishbone diagrams. - Identify Causes: Classify causes into immediate, underlying, and root categories.
- Develop Recommendations: Suggest corrective and preventive measures such as training,
engineering controls, or improved supervision. - Report Findings: Document findings in a clear, structured report that can be shared with
management and workers. - Follow-up: Ensure corrective actions are implemented, reviewed, and monitored for effectiveness.
⚠️ The Importance of Near Miss Reporting
A near miss is an unplanned event that did not cause harm but had the potential to do so.
Investigating near misses is just as important as investigating accidents because they highlight system weaknesses
before real damage occurs. For example, a falling tool that narrowly misses a worker is a warning sign of
inadequate tool storage or poor housekeeping.
Encouraging near miss reporting creates a proactive safety culture where workers actively participate
in identifying and controlling hazards before they escalate.
🏢 Example Case
At a construction site, a worker slipped on an oil spill and fractured his arm.
The immediate cause was the oil on the floor. The underlying cause was poor housekeeping procedures,
and the root cause was inadequate training and lack of a proper spill management plan.
After the investigation, the company introduced spill kits, staff training, and routine inspections.
As a result, slip and fall incidents reduced by 70% within six months.
📝 Mini Quiz (Self-Check)
- What are the three types of causes in incident investigation?
- Why should near misses be reported and investigated?
- List five key steps in the incident investigation process.
🔑 Summary
- Incident investigations identify immediate, underlying, and root causes of accidents and near misses.
- Legal, moral, and financial reasons make investigations essential for all organisations.
- A structured approach helps prevent recurrence and strengthens the health and safety management system.
- Near miss reporting is a powerful tool for proactive hazard control.
- Investigations support a positive safety culture and continuous improvement in workplace safety.
🚀 What’s Next in IG1
Lecture 9: Health and Safety Auditing
In the next lecture, we will explore auditing processes, internal vs external audits, and their role in
continuous safety improvement.