Incident Investigation, Reporting and Root Cause Analysis
The investigation process
Know the difference between an incident (unplanned event), a near miss, an accident (incident causing harm) and an unsafe condition/act. Understand the sequence: secure the scene, preserve evidence, gather facts, interview witnesses, analyse causes, recommend actions, report and follow up. Learn causal models - the 5 Whys, fishbone (Ishikawa), fault tree and the loss causation model - and the distinction between immediate causes (unsafe acts/conditions) and root causes (management system failures). Understand statutory reporting duties and internal reporting timelines.
Traps
- Stopping at the immediate cause ("worker was careless") instead of the root cause.
- Blaming individuals rather than examining system failures.
- Interviewing witnesses as a group; they should be interviewed separately.
- Confusing a near miss with a minor accident.
- Recommending actions without owners, dates or verification.
Worked example / rule of thumb
A worker slips on an oil spill. Immediate cause: spill not cleaned. 5 Whys: Why? No one reported it. Why? No reporting route. Why? No near-miss system. Root cause: missing reporting and housekeeping management. Rule of thumb: ask "why" until you reach a system you can fix.
Practical skills
Write a SMART corrective action, distinguish corrective from preventive action, and explain how investigation findings feed back into risk assessment.