Incident Investigation

Date:               October 2023

Issue:              No. 5

Subject:          Incident Investigation

This document forms part of the National Ice Centre’s organisational written safety policy arrangements.

Departments, services or teams may consider it appropriate to develop additional guidance and systems of work on specific work related activities.

Where proposals, additional guidance or changes to systems of work will have an impact on health, safety and welfare, this will be discussed and agreed at the Health & Safety Committee.

If you have any questions or require further information or support on the contents of this document, please contact the NIC Health & Safety Advisor or Corporate Safety Advice.

The purpose of any investigation should be to find out what occurred, the root cause including any contributing factors and to determine what actions if any should be taken to prevent it from happening again

An investigation is not a system to apportion blame.

The investigation must be thorough and structured to avoid bias and leaping to conclusions.  Don’t assume you know the answers prior to starting the investigation and attempting to identify solutions before you complete the investigation.

Good incident investigations involve a systematic and structured approach and should begin as soon as possible after the event has taken place.

This approach is not just good practice but sensible as the quicker that an investigation is started, the information and evidence will be more contemporary and relevant as this evidence becomes more difficult to identify and remember as time passes.

Most importantly for any incident investigation, if you can take pictures of the incident location, they provide a useful visual reference and can support the investigation process immensely.

A manager’s first priority is to ensure that appropriate treatment for the injured person has been provided.

The initial focus of the investigation process would normally require contact with relevant people who may be involved or be a witness to the incident to understand what has occurred.

For reference, the term ‘incident’ as it relates to this policy will be considered to include the following categories of unplanned event.

• Accidents;
• Violence incidents;
• Near misses and work related ill health.

Managers need to be aware that the responsibility for undertaking an incident investigation remains with the injured person’s line manager. 

Where the incident does not involve an employee, the responsible manager can allocate the duty of undertaking the incident investigation to a colleague with knowledge of the incident however, the manager needs to be assured that the person completing the investigation is competent to do so.

In all circumstances, the responsibility for an incident investigation lies with the manager of the service, premises or team. 

This responsibility extends to include all incidents which involve 3^rd parties including service users, members of the public or pupils.

The primary principal for undertaking an investigation is to consider the root cause of the incident and the associated reasons it have occurred and may include identifying the following matters:

• understanding how or why the issue occurred;
• consideration of how work was being done at the time of the incident;
• identification of the required controls and how they could be implemented to prevent a reoccurrence;
• identifying where systems, procedures and management deficiencies exist in order to improve them. This would also consider relevant documentation including risk assessments, permits to work and other safe systems of work;
• establishing the facts in order to review existing safety arrangements.

Managers need to be aware that in the event of any legal or civil action, all relevant documentation becomes ‘recoverable’ and you may have to justify your actions and comments including the results and conclusions of your investigation within a court. 

To assist in the process, managers should ensure that all documentation is retained and uploaded to the Incident Management System.

 All investigations must be formally recorded using the appropriate Nottingham City Council incident recording system and other health & safety templates as required. 

The detail of any investigation should be proportionate to the seriousness or potential seriousness of the incident.

All incidents involving the NIC must be recorded onto the On-Line Incident Management System.

Managers need to ensure that any documents, photos, or other information collected as part of a formal investigation is uploaded to this system which maintains a permanent record of the incident. 

The investigating officer / manager will then be required to complete the investigation on the system.

Where the colleague remains off work, the incident cannot be closed and this can be recorded within the comments section of the incident reporting system.

A number of automated reminders are sent by the system requesting managers to complete the investigation. 

Should the investigation not be completed within 6 months, the NIC Health & Safety Advisor will close the incident, identifying that any missing information / documents are retained on site.

The purpose of an investigation is to obtain the facts and normally, it is the manager of the injured person who will undertake the initial investigation. 

In certain circumstances, the line manager may not feel that they are competent or qualified to undertake the investigation and where this is the situation, the manager must identify another colleague to ensure that the investigation takes place.

Inspect the immediate scene and equipment (RIDDOR)

In all circumstances where the incident requires immediate notification to the Health & Safety Executive under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), the preservation of the scene where the incident occurred is required as long as it is reasonable and safe to do so. 

Where this is not possible or feasible due to other mitigating factors, record as much information and take photographs to aid the investigation process when it commences. 

Managers should consider the inspection of the incident location as possible after the incident occurs.

Required Information

Managers should ensure that information where relevant is collated on the following:

• Who was involved and their exact location at the time of the incident;
• Witnesses directly involved or others in the vicinity;
• What happened? Try to examine all accounts to establish this;
• When did the incident occur? Is there any significance about the time e.g. lunch time or end of the day;
• Where exactly did the incident happen;
• Were conditions normal, has anything changed;
• Environmental conditions;
  • Weather;
  • Dry;
  • Damp;
  • did it contribute.
• Work equipment (i.e. tools) involved, any personal protective equipment and its condition.

Interviewing the injured person and witnesses to the incident

Where the manager considers that the incident will require the taking of a formal witness statement, the manager must make arrangements for these to take place.

To ensure that the witness statement is fit for purpose, managers should ensure that all statements are completed using the ‘Witness Statement’ template. 

Managers must ensure the following has been considered whilst conducting a witness statement that:

• If the injured person or witness wants someone to accompany them, this should be allowed unless there is good reason to believe that this would impede the This initial investigation is to identify and record the facts of the incident and how it occurred;
• Any interviewing should, where possible, be done in familiar surroundings so as not to make the person being interviewed feel uncomfortable. If the person is not too seriously injured then the incident location is ideal as they can explain what occurred;
• This should be an interview to determine the facts and must not be used as an opportunity to apportion “blame”;
• Witnesses should be interviewed individually and asked for relevant and factual supporting information.

Documentation, training and procedures

Managers will need to consider what relevant documentation is in place that is relevant to the incident. 

This could include any of the following:

• Formalised working procedures and proof that they were understood and followed by the injured person;
• Relevant risk assessments and other safety management documentation in relation to the incident should be viewed and the identified control measures need to be considered to identify if they were being followed or appropriate and then included within the investigation process;
• Considering what supervision levels and training that the injured person and other persons involved have received and identification of relevant training records;
• Details of any previous similar incidents or reported near miss incidents should be examined;
• Compliance with policies, procedures or documentation that is relevant to the incident.

Managers need to appreciate that incidents do not just happen, in every case there is a root cause which the investigation is there to identify.

Incidents normally result from either of the following primary factors:

• Unsafe Act

Unsafe acts are considered to be the relevant human factors such as lack of knowledge, distractions, misunderstanding, over (or under) confidence, horseplay or lack of supervision

• Unsafe Condition

Unsafe conditions cover aspects such physical hazards such as slippery floors, defective equipment or poor storage. 

Contributory Factors

An Incident may have multiple contributory factors that may be a combination of both unsafe acts and unsafe conditions.

The managers investigation must aim to identify the root cause (or causes) of the incident, not just the immediate causes. 

The immediate causes are normally very apparent to the person investigating as it will often include issues such as defective equipment, inappropriate working methods, inadequate lighting, inappropriate equipment etc.

The root cause is the primary aim of the investigation and these causes may be less obvious and often require more consideration to identify, often indicating a failure in the safety management system.

Typical root cause’s may include:

• Failure to provide adequate supervision;
• Lack of staff training and awareness;
• Failure to identify hazards and assess risks;
• Insufficient communication/written procedures;
• Lack of available resources leading to short cutting;
• Staff not following procedures or methods of work.

Example of the root cause:

An incident occurs where an employee falls down stairs, the immediate cause may be worn or damaged treads.  

The manager investigation may well identify the root causes of that incident to be identified as:

• No maintenance system in place;
• No system of premises inspection;
• Lack of management awareness of the need to carry out regular inspections;
• Insufficient staff training to carry out inspections and maintenance;
• Insufficient resources to carry out maintenance.

The investigation must determine the cause in order that remedial actions can be established to prevent the incident from occurring again. 

This investigation may also require communication with other parts of the organization including the NIC Health & Safety Advisor & Corporate Safety Advice.

Once the investigation is complete and the root cause(s) is established, remedial action or changes may need to be developed and implemented by the manager to prevent a reoccurrence.

Remedial action may be short and/or long term and may involve changes to the physical environment – e.g. making changes to room layouts or procedural changes such as increased supervision or provision of training.

Managers are responsible for devising an action plan to implement the defined remedial action. The actions should be implemented according to the plan and where a detailed plan is created, particularly where finance and project planning is required, this plan should be reviewed regularly.

Record findings

The findings of every incident investigation must be formally recorded.  In most cases it will be appropriate to record the findings of the incident investigation using the ‘Incident Management System’.  

If a more detailed investigation is required, then this information may be completed on a separate investigation sheet which must then be uploaded to the system.

Communicate findings

The main findings of any incident investigation may include changes to working practices, equipment etc, must always be communicated to all colleagues that may be affected.  

A specific section of the Incident Management System considers feedback to employees and should be completed.