Pescador, Ophalyn Hope A.
Incident Investigation and Reporting
The scale of the response will be
dependent upon the seriousness of the
incident and could range from contacting a
first aider to contacting the emergency
services.
Stages in an Accident/Incident
Investigation
1. Deal with immediate risks
2. Select the level of investigation
3. Investigate the event
4. Record and analyze the results
5. Review the process
Dealing with Immediate Risks
 When accidents and incidents occur,
immediate action may be necessary
to:
 Make the situation safe and prevent
further injury.
 Help, treat and if necessary, rescue
injured persons.
Selecting the level of investigation
The greatest effort should be put into:
 Those involving severe injuries, ill-
health or loss.
 Those which could have caused much
greater harm or damage.
 These types of accidents and incidents
demand more careful investigation
and management time.
 Looking more closely at the underlying
causes of significant events.
 Assigning the responsibility for the
investigation of more significant
events to more senior managers.
Investigating the Event
The purpose of investigations is to establish:
 The way things were and how they
came to be.
 What happened – the sequence of
events that led to the outcome.
 Why things happened as they did
analyze both the immediate and
underlying causes.
 What needs to be done to avoid a
repetition and how this can be
achieved.
Recording & Analyzing the Results
 Recorded in a similar and systematic
manner.
IE 002 – IE32FA1
 Provides a historical record of the
accident.
 Analysis of the causes and
recommended preventative protective
measures should be listed.
 Completed as soon after the accident
as possible.
 Information on the accident and
remedial actions should be passed to
all supervisors.
 Appropriate preventative measures
may also have to be implemented by
such supervisors.
 Investigation reports and accident
statistics should be analyzed from
time to time to identify common
causes, features and trends not be
apparent from looking at events in
isolation.
Reviewing the Process
Reviewing the accident/incident investigation
process should consider:
 The results of investigations and
analysis.
 The operation of the investigation
system (in terms of quality and
effectiveness).
Root Cause Analysis Tools
Below is a list of tools that may be used by
employers to conduct a root cause analysis.
The tools are not meant to be used
exclusively. Ideally, a combination of tools
will be used.
 Brainstorming
 Checklists
 Logic/Event Trees
 Timelines
 Sequence Diagrams
 Causal Factor Determination
For simpler incidents, brainstorming and
checklists may be sufficient to identify root
causes. For more complicated incidents,
logic/event trees should also be considered.
Timelines, sequence diagrams, and causal
factor identification are often used to support
the logic/event tree tool.
Regardless of the combination of tools
chosen, employers should use these tools to
answer four important questions:
 What happened;
 How did it happen;
 Why it happened; and
Pescador, Ophalyn Hope A. Incident Investigation and Reporting IE 002 – IE32FA1
 What needs to be corrected.

Identification of Corrective or
Preventive Actions
There are three common misconceptions about
corrective and preventive action:

1. The standard calls for documenting every

occurrence of a nonconformity.

2. A preventive action is really just calling a

corrective action something different.
3. The major reengineering of a process, product
or service, or the introduction of a new process
or equipment, is not a candidate for preventive
action documentation.

One way to dispel these is by separating situations into

what I call a patch (a single occurrence of a
nonconformity that involves little risk and needs not be
recorded), a corrective action (a more serious
nonconformity involving some risk that requires action
to prevent recurrence and must be recorded), a
preventive action (a process that can be improved to
prevent occurrence of a nonconformity and is to be
documented) or a developmental action (a planned
change to introduce a new process or product in
response to strategic objectives, documented as a
preventive action).