Incident Investigation, Reporting and Root Cause Analysis
Domain scope
This domain tests incident classification, notification, evidence gathering and root cause analysis. You must separate immediate causes from underlying and root causes and make recommendations that prevent recurrence.
Core rules and concepts
- An incident is an unplanned event that did or could cause harm; an accident causes harm; a near miss does not but could have.
- Report internally and statutorily: the Factories Act requires notification of accidents and dangerous occurrences; the ECA handles compensation claims.
- Preserve the scene, secure evidence, interview witnesses separately, build a timeline and distinguish fact from opinion.
- Root cause analysis methods include 5 Whys, fishbone, fault tree, bowtie and ICAM. Use a method suited to the consequence and complexity.
- Recommendations should be SMART and follow the hierarchy of controls. Track them to closure and verify effectiveness.
Worked example
A worker slips on oil. The immediate cause is oil on the floor. Underlying causes include a missing drip tray, no spill kit and no inspection. The root cause is that maintenance ownership and the inspection schedule were absent. Recommendations: fit drip trays, introduce daily inspection, provide spill kits and assign a maintenance owner. Being more careful is not a control.
Traps
Blame the injured worker; stop at the immediate cause; accept unverifiable recommendations; fail to preserve evidence; and close actions without checking whether risk actually fell.