The function of an investigation is to establish all the factors involved in the incident and determine appropriate actions to prevent a recurrence.
A PCBU must ensure, so far as is reasonably practicable, that workers are safe from injury and risks while at work. This requires safe systems of work to be in place.
The risk management processes outlined in the Code of Practice – How to Manage Work Health and Safety Risks should be used to identify and control risks.
The risk management process involves four steps:
- Identify hazards – find out what could cause harm.
- Assess risks, if necessary – understand the harm that could be caused by the hazard, how serious it could be and the likelihood of it happening.
- Control risks – implement the most effective control measures for the circumstances.
- Review control measures – ensure control measures are working as planned by reviewing and revising them as necessary. This is especially important following an incident.
As a first priority, ensure that any person who has sustained an injury has received appropriate first aid or medical attention.
Secure the scene, make the incident area safe and keep people not providing immediate and urgent assistance away from it.
The scene of an incident should remain undisturbed until all of the facts are collected. Check with one of our inspectors before removing anything from the scene for further examination and analysis.
If there has been a death or serious injury, the site should not be altered in any way without the permission of one of our inspector or police officer. Co-operate with emergency services personnel, our inspectors and specialists taking evidence or measurements.
PCBUs must notify SafeWork SA of fatalities, serious injuries and illnesses, as well as dangerous incidents that arise, as soon as they become aware of the incident. This is a legal obligation. We may also elect to conduct an investigation into an incident that falls outside these parameters.
All serious work-related injuries and incidents must be reported to us by telephoning 1800 777 209 (statewide – 24 hours). In some circumstances, we may ask for confirmation of details to be provided in writing within 48 hours.
If you are unsure whether or not to report any work-related injuries or incidents to us, contact our Help Centre on 1300 365 255 for advice.
Record physical evidence first. This evidence may be subject to rapid change or obliteration and should therefore be the first information recorded.
Collect and photograph information such as:
- location of the injured worker(s) at the time of the incident
- equipment in use at the time
- substances in use at the time
- safety devices or controls used at the time
- position of appropriate guards
- position of controls for any machinery involved
- damage to equipment
- state of housekeeping in the area
- environmental conditions (such as weather, lighting, noise levels, temperature).
Take notes of the scene. Photographs, sketches and diagrams may also be useful. Careful study of these later may reveal conditions or contributing factors initially missed.
Take notes about:
1. events leading up to the incident
- systems of work being used
- instructions given, any variations from instructions
- workplace conditions, such as housekeeping, floor surfaces, stair treads, handrails
- the exact location of the incident
- any materials being used or handled
- the type of transport or equipment being used
- any information at all which may provide clues about contributory factors.
2. the incident itself
- the state of the system and the actions that occurred at the moment of the incident
- the person(s) directly involved and those involved at a distance
- the tools, equipment, materials and fixtures directly involved.
3. what happened after the incident
- the injuries or damage which directly resulted
- the events leading to consequential injury or damage
- the persons involved, including those who rendered first aid
- any problems dealing with injuries or damage.
Gather the procedures and safety requirements for the area and tasks being performed.
Compile a maintenance history of any plant or equipment involved.
Review all potentially useful information about the workplace, equipment and procedures, including designs, specifications, drawings, and information from manufacturers and suppliers.
Personally interview everyone involved, including the injured worker(s) if possible, witnesses, nearby workers and anyone in the area at the time. Conduct interviews as soon as possible after the incident.
Interview each person separately. Put them at ease and approach the interview in a non-threatening and non-judgemental manner. Explain that the purpose of the investigation is to prevent a recurrence and identify underlying causes.
Ask each person to describe what they saw and heard leading up to and at the time of the incident. Let the person talk without interrupting them. Ask open-ended and probing questions to fill in the details, such as “Could you expand on this process?” or “Can you tell me about the operation of the equipment?”.
Confirm that your understanding of the person’s account is accurate. End the interview on a positive note, thanking them for the information provided. Ask them to let you know if they recall anything further that may assist.
Analyse the investigation details gathered and write a report that can be acted upon to control the identified risks and hazards.
Other information to record
1. PCBU and workplace
- PCBU name
- Industry of PCBU
- PCBU location
- Location where incident occurred
- Work Health and Safety Committee
- Number of workers
- Number of hours worked
2. Injured person
- Personal characteristics
- Name of injured worker/s
- Date of birth
- Preferred language
Basis of employment
- Shift arrangements
- Full-time, part-time, permanency of employment
- Employment arrangements
- Experience in task
- Proportion of shift worked
3. Incident details
- Date of incident or report of disease
- Time of incident
- Training provided
- Description of incident
- Cause of incident
4. Outcome of injury or disease
- Preventative action proposed and taken
- Rehabilitation status
- Fatality, injury, permanency
- Resumption of work
- Time lost from work
- Nature of injury or disease
- Bodily location or injury or disease