Incident Reporting, Investigation, Recording and Root Cause Analysis
Definitions and reporting
An incident is any unplanned event; an accident causes harm; a near miss had the potential. Report internally immediately and in writing within the shift or 24 hours; report externally - serious injuries and dangerous occurrences to the Factory Inspectorate, compensation claims to the NSITF. Report near misses too: they are free lessons.
Investigation
The purpose is prevention, not blame. Secure the scene, collect the four Ps (People, Position, Parts, Paper), interview witnesses separately and early, and build a timeline. Separate immediate causes (unsafe act, unsafe condition) from root/system causes (design, training, supervision, procedures, procurement, culture). Techniques: 5 Whys, fishbone (Ishikawa), fault tree, events and causal factors, barrier/bow-tie analysis.
Corrective action
Actions should fix the system, not just the person, and should follow the hierarchy of control. Make them specific, with an owner and a date, then verify effectiveness.
Metrics
- LTIFR = (lost-time injuries × 1,000,000) ÷ hours worked.
- TRIR uses total recordable cases with the same formula.
- Severity rate uses days lost.
Traps
Stopping the 5 Whys at "human error" - that is a symptom, not a root cause. Blaming the injured person. Closing actions on paper without verification. Not recording near misses, so the metrics look good while risk stays high.
Rule of thumb
For every incident ask "what failed in the system that allowed this?" and produce at least one control that does not depend on the worker remembering.