Health, Safety and Environment Monthly Message

All incidents and near misses should be subject to local investigation, with the level and nature of each investigation dependent on the severity of the incident and likelihood of recurrence for each event. Blaming individuals is ultimately fruitless and sustains the myth that incidents and cases of ill health are unavoidable when, in fact, the opposite is true. Well though-out control measures, combined with adequate supervision, monitoring and effective management will ensure that work activities are safe. An incident may result in more serious consequences should it happen again, therefore the primary aim of any investigation will be to prevent any reoccurrences.

These general considerations should be applied to all manner of incident investigations, which may include but may not be limited to: incidents which have resulted in injuries or the potential for injuries; incidents which have resulted in damage to property or equipment, or which had the potential to do so; or environmental incidents which have resulted in pollution or the potential for pollution.

The benefits of conducting effective incident investigations include:

  • Identifying why existing control measures failed and what improvements or additional measures are required;
  • Planning to prevent such incidents from reoccurring;
  • Identifying areas where the relevant risk assessments require reviewing;
  • Improving future risk control arrangements in the workplace.

Colleagues undertaking incident investigations within their Institute or Professional Service Department should consider the following questions to guide their analysis during the process:

  • How the event happened and what equipment was involved?
  • What effect difficulties in using the equipment had?
  • What activities were being done at the time?
  • Any abnormal working conditions?
  • Whether safe working procedures were adequate and whether they were followed?
  • The nature of the injuries or other harm?
  • How the injuries occurred?
  • How well known the risk was and whether control measures were adequate?
  • The influence of work organisation, workplace layout and/or the materials in use?
  • Whether maintenance and cleaning were good enough?
  • Whether the people involved were competent and suitable?
  • Whether there was enough safety equipment?

The primary purpose of all incident investigations should be to identify and address the following causes of the incident:

  1. Immediate Causes – agent of injury or ill health (e.g. object, substance, etc.);
  2. Underlying Causes – unsafe acts and/or unsafe conditions (e.g. guarding removed, ventilation switched off, etc.);
  3. Root Causes – failure from which all other failings grow, often removed from the incident or adverse event.

Following the identification of these causes, colleagues should use their findings to implement actions to prevent future or further occurrences. This can be achieved by ensuring that corrective action is taken, learning is widely shared, and any necessary improvements are put into place. 

For further information and guidance for conducting incident investigations, please contact the Health, Safety and Environment Team at or on extension 2073.