IM9 - Incident Investigation

Purpose

To ensure that the causes of incidents and accidents can be addressed and the chances of a similar incident reoccurring can be eliminated or minimised

Description

Upon receiving an incident, near miss or hazard report, the owner or operator of an Aquatic Facility should determine if an investigation is required. This should be based on:

• Severity, or potential severity of the incident
• The level of risk
• The number of stakeholders involved
• The complexity of contributing factors

The owner or operator should ensure that all ‘notifiable incidents’ as per the Incident Reporting guidelines are investigated and reported to your state/territory regulator.

If an investigation is required it should commence as soon as is practicable.

Persons Investigating

The investigation should be conducted by persons not involved with the incident and may be external to the organisation. The lead investigator may assemble a team to assist with the investigation, which may include, but is not necessarily limited to:

• Local supervisor or manager
• Persons involved in the incident
• Appropriate ‘expert’ (Aquatic Risk Consultant)

Procedures

Upon receiving an incident, near miss or hazard report, the owner or operator of an Aquatic Facility should determine if an investigation is required. This should be based on:

Initial Investigation

Investigation procedures need to be systematic. The investigation team should:

• Act as soon as possible after the incident;
• Visit the scene before physical evidence is disturbed;
• Not prejudge the situation;
• Not remove anything from the scene;
• Enquire if anyone else has moved anything; and
• Take photographs and/or sketches to assist in reconstructing the incident.

After the Initial Investigation

After the initial investigation is complete the team should:

• Identify, label and store all evidence. For example, tools, defective equipment, fragments, chemical samples etc;
• Interview each witness separately;
• Ascertain if there have been any “near hits” in similar circumstances;
• Record all sources of information;
• Keep records to show that the investigation was conducted in a fair and impartial manner;
• Review all potentially useful information, including design specifications, operating logs, purchasing records, previous reports, procedures, equipment manuals, job safety analysis reports, records of training and instruction of the people involved and experiences of people in similar workplaces/industries; and
• Reconstruct the incident (while ensuring that another incident doesn’t occur) to assist in verifying facts, identify what went wrong and what can be done to prevent it happening again

Determine Contributing Factors

Contributing factors should be determined in accordance with root cause analysis principals and grouped into four categories:

• People – eg: supervision, experience, training, fatigue
• Organisational/ procedural – eg: no or inadequate risk assessment, inadequate procedures, no induction process for new staff or contractors
• Equipment/materials – eg: equipment failure, appropriate tools/equipment not available
• Environmental conditions/physical environment – eg: raining or low light conditions, housekeeping

Recommendations

Recommendations should be made to address the contributing factors and are aimed at eliminating or minimising risks associated with this or similar incidents, near misses or hazards. Recommendations should:

• Be based on best practice where possible (using Regulations, Codes and Practice, Industry Standards and appropriate benchmarking)
• Be feasible and within the management’s control to fix
• Give both short and long term actions if required
• Where possible give alternate approaches to addressing contributing factors

The owner or operator of an aquatic facility should facilitate a meeting which includes risk managers, duty managers, the emergency planning committee and relevant supervisors and staff.

The purpose of the meeting is to review the recommendations made in the investigation report and develop an action plan for the implementation of recommendations. This action plan should include:

• Details of which recommendations are to be implemented and how they are to be implemented/actioned
• Details of any additional actions arising from the discussions by the stakeholder group
• Individuals who will be accountable for the implementation and monitoring of each recommendation
• Completion dates for the implementation of each recommendation
• Dates for follow up and/or review of actions

Note: Responsibility for actioning an item cannot be delegated to a person from another department without the liaison and consent of that person.

A complex incident involving more than one stakeholder group, department and/or faculty, may have more than one action plan directed at different work areas and/or managers.

Implementing Action Plan

The owner or operator of the aquatic facility should ensure the implementation and monitoring of recommendations on the action plan by the dates stipulated on the plan.

Review

The recommendations/actions must be reviewed post implementation to:

• Ensure that they are effective in reducing risks
• Ensure that the implementation has not created additional hazards

The owner or operator of the aquatic facility should ensure that this review takes place and that the date of the review is documented on the action plan.

References

• Incident Investigation Guidelines – Work Safe ACT
• Investigating accidents and incidents – WA Department of Commerce