Module 1: The Basics of Incident Investigation

Welcome to the Incident Investigation and Reporting training program. This training will be provided in three separate modules. Each module is designed to teach you how to investigate workplace incidents by identifying what happened and what can be done to prevent similar incidents from happening again. You will learn what is meant by a workplace incident and how to accurately gather information and determine the facts. Then, you will learn how to use these facts to identify what led up to and caused the incident to occur. This module is the first of three and you should take each of the next two modules as soon as possible.
During this first module, you will learn about your role in the incident investigation program and the purpose of conducting incident investigations. To start, we will review what is meant by a workplace incident and what types of incidents you should investigate. It may take some time before you are fully comfortable with all of the steps but, with practice, you will become more effective at investigating workplace incidents.
As an investigator, you will be asked to respond to workplace incidents that may have resulted in injury. The investigation process includes gathering information from the incident site, conducting interviews with those involved, completing your agency’s incident investigation forms, and providing these forms and findings to management. Your findings will then be used to identify the direct and root causes for the incident and develop corrective actions and process improvements that will prevent similar incidents from occurring in the future.
The National Safety Council defines an accident as an undesired event that results in personal injury or property damage. Furthermore, they define the term incident as an unplanned, undesired event that adversely affects the completion of a task. Reviewing these two definitions, the term accident only involves events which result in damage to the person or property, but leaves out a tremendous amount of information that would help us identify problems before they occur. The term incident is better suited to describe the situations that we want to include within the investigation process because it allows for a broader range of events to be investigated, such as near miss events. The importance of near misses will be discussed a bit later in the training, but for now an effective incident investigation program should look into the following type of incidents: Fatalities, major injury and illness, minor injury and illness, property damage, and near misses. By investigating all types of incident, you will have a much better understanding of what is happening within the workplace and can better protect employees from having a serious injury or illness.
The primary reason for performing an investigation is to gather facts about the incident that highlight the true causes and to use this information to prevent future incidents from occurring. By preventing future incidents, you will keep skilled staff working longer without the need to retrain or rehire staff. When an employee is placed out on injury leave for weeks, months, or even years, the position cannot be filled and your staff or you have to complete the employee’s work. Additionally, investigating incidents will help us achieve compliance with workers’ compensation law health and safety requirements for the State of Pennsylvania.
One of the most important things to understand about an effective investigation program is that the focus should not be to place blame or fault on the employee. There may be a tendency to point fingers at the employee during the investigation process, but an effective program needs to go past this and focus on the management systems and processes in place and how they could have contributed to the incident and be changed for the better. By understanding both of these incident types, each one could have resulted in serious injury. So, why should only incidents that involve injury be investigated? The simple answer is that both need to be investigated, because a serious injury, if not a fatality, could have occurred from both events. Although near misses may seem trivial, they will be a key source of information for detecting problems early, so that fixes can be made before real problems develop.
Safety theory and workplace injury statistics suggest that the frequency of workplace incidents is distributed in the shape of a pyramid. Fatalities and severe injuries occur infrequently and are at the top of the frequency pyramid. If these types of events are the only incidents investigated, then the source of information will be very limited and it will be very difficult to actually understand what goes on within the workplace and what needs to be implemented to effectively prevent injuries from occurring. The pyramid also states that minor injuries and near misses take up a much larger portion of workplace incident frequency and, by including these within the investigation process, we stand a much greater chance of controlling similar events in the near future. Additionally, by focusing on minor injuries and near misses, we understand more about these types of events and if these events could have resulted in something more serious. By having this understanding early, we can put controls in place that reduces our risk of having a severe injury or workplace fatality. An incident investigation program will not effectively identify and evaluate unsafe acts and conditions as they happen. Other programs such as a safety inspection program or job safety analysis will be more effective at identifying these problems early; however, will not be covered during this training.
Employees often have a negative opinion of the incident investigation process because they may feel it is a fault finding exercise. Therefore, an investigation program needs to have buy-in from the employees to be effective. To improve awareness when you are conducting investigations, remind employees that the purpose of the investigation is to find out what went wrong and prevent similar incidents from occurring. Also, remind them that the information they provide will be held in confidence and used to prevent similar incidents. When an employee reports an incident, it is important to show interest and avoid appearing bothered by this new information, even if the issue seems trivial to you. If the employee feels that they are bothering you or the information they report is not investigated then they may not report this important information in the future.
To be a good investigator and assist in finding effective solutions, you must first believe that incidents are avoidable and preventable. An attitude that “things just happen” or “the employee is accident prone or clumsy” will stop you from finding the ultimate cause and fixing it. While it is true that some people are not as careful as others, stopping your investigation with this as a cause is a waste of time. In the workplace, it is management’s responsibility to train and coach employees to work safely. If you investigate these situations further, most of the time you will identify a procedural or training issue that allowed these behaviors to occur in the workplace. This is a very important part of this training. These opinions can stop the investigation before it starts. As an investigator, you must believe that all or at least most injuries can be prevented and investigations are the key to identifying solutions that will minimize the number of injuries that may occur.
Let’s review the information we have learned so far. An incident includes injury or near miss events. We investigate incidents to prevent reoccurrence of similar incidents. Employee participation is an important aspect for long term success.
The following questions are provided to verify your understanding and to give you credit for this module.

Question 1

What is an incident?

A. A serious injury or illness

B. A minor injury

C. A near miss

D. All of the above

Answer: D. All of the above

Question 2

True or False: Effective investigations start by placing the blame on the employee.

Answer: False

Question 3

True or False: Minor injuries and near misses are investigated to identify problems early and develop corrective actions as needed.

Answer: True

This concludes Module 1: The Basics of Incident Investigation.

Module 2: Conducting the Investigation

Welcome to Module 2 of the Incident Investigation and Reporting training series. The first module discussed the basics of incident investigation so you should be familiar with the purpose and terms used when discussing incident investigation. This module will center on how to conduct scene investigations and interviews to make sure that you gather critical information that will help you create an effective incident investigation report.
By the end of this module you will be able to plan for and coordinate investigation steps, evaluate the scene to gather pertinent information and evidence about what happened and conduct effective interviews with both employees and witnesses.
This module will provide an overview of how to perform an investigation, but not the specific processes that your agency uses to document and communicate your findings. Before you conduct an investigation, make sure to review agency specific procedures regarding incident investigation.
You’ll also need to understand how to report incident investigation reports and the timeframes for doing so, as well as understand other safety policies and procedures your agency uses. This will give you a better understanding of what could have gone wrong during an investigation.
Responding to incidents quickly is critical for gathering good information about what actually happened. Physical evidence tends to get cleaned up quickly and people forget important information the longer an investigation takes to occur. By preparing an investigation kit in advance, you can get to the scene faster to gather better information. Items you may want to include in your kit are agency specific and may include agency specific incident investigation forms. These should include Incident Investigation Report forms, incident statement forms which are used to document employee statements, the First Report of Injury/Worker’s Compensation Report form, or any other specific forms used by your agency to document incidents. A tape measure is to help clarify measurement details. Bags and containers for preserving physical evidence for a closer inspection at a later time.
The following is an overview of the steps involved in the incident investigation process. You may be involved with responding and coordinating medical attention, if necessary, securing the area to prevent further injury or damage, investigating the scene and conducting interviews, and documenting findings using the investigation report. Upon completion, the investigation report will be sent to management for further review and for development of a corrective action plan to fix hazards or deficiencies. You will most likely be involved with this process. These steps typically include evaluating the facts to determine direct causes and root causes, developing a corrective action plan designed to fix the hazards or deficiencies identified within the report, communicating and implementing the plan with specific individuals responsible for fixing the hazards or deficiencies, and following up to ensure action items on the plan have been successfully implemented and are working effectively. The supervisor is usually the first to know when a subordinate is injured and are typically close by to respond. They can evaluate the nature of the event and coordinate medical treatment if necessary. If hazards still exist on the scene, it is important to secure the scene so that no one else will be injured if entering the area. Once the scene has been secured and medical care has been provided, the supervisor should let others in management know by completing the first report of injury to communicate that an incident has occurred and that an investigation will be conducted.
As an investigator, you should first evaluate the scene and gather all information and evidence in order to gain an understanding of the incident. First, conduct a quick walk through examining the area and identifying points of interest that should be further evaluated. If there is any physical evidence, make sure to obtain a record by either taking a picture or physically removing it. Work with those at the scene to identify the basics of what happened and who was involved or witnessed the event. These individuals will then be interviewed to identify more information. Keep in mind that you must conduct scene investigations quickly because evidence will be lost after the area is cleaned up and returned to normal working order. Make sure to not delay and investigate the scene immediately.
For the investigation process to be effective you must become familiar with how the work is performed. This will help you identify if the following items may have contributed to the incident: Placement of employees, tools and equipment, safety devices in place or in use, housekeeping of the area, weather, lighting, noise levels or other environmental conditions, or other clues such as skid marks, debris, puddles or other evidence. Taking detailed notes is a necessity when conducting your investigation. Remember, the incident scene will be cleaned up, so taking detailed notes is the only way you can document certain details from the area. If it is useful for the investigation, have measurements taken and diagrams made that help document potential key details from the site.
The next steps will be to interview employees and witnesses who were around when the incident happened. A key to conducting interviews is to put the employees mind at ease. Incidents can be stressful and may put employees on edge. It is important to calm fears and anxieties so that you get the most accurate story possible. When conducting interviews, you should conduct your interview in private area so that the employee feels comfortable talking about what happened during the incident. Sitting side by side to the employee helps reduce tension as this is a sign that you want to work with them and that this is not an interrogation. Never conduct interviews with multiple people at once, as this prevents some people from explaining the whole story. Before starting the interview make sure to keep the conversation informal. Small talk is a good ice breaker to relax the mood and help the interview run a bit smoother. Keep in mind that you always want to be sincere and professional with the investigation and remember that you are conducting an investigation that is looking into fixing a potentially hazardous situation. When starting the interview, it’s important to discuss the purpose of the investigation process to prevent any misunderstanding. Explain that the investigation is being conducted to identify what actually happened so that corrective actions can be put in place to prevent future injury. Avoid discussing blame or fault of the employee or their coworkers, as this can very quickly stop the employee from participating with the investigation. When conducting the interview start by asking open ended questions that require the person to explain what happened in their own words. Give the person time to think and form their own thoughts, avoid rushing them as this can fluster some people into not completing their full thought. Interviews should not be conducted as an interrogation and you should avoid intimidating the employee because it can result in them shutting down. It can be helpful to have the employee reenact or recreate the incident as they experienced it. Never let the employee do anything dangerous because this could result in another injury. As you ask questions, listen to their responses for inconsistencies. Make sure that you ask them to clarify any inconsistencies so that their statement is as accurate as possible. Keep in mind that people’s memories are not perfect, and will quickly forget important details. Try to conduct interviews as soon as you can so that the story is as accurate and detailed as possible. Documenting everything said during the interview can be very difficult, make sure to use short hand notation and only record important details. Once you have completed the interview, review what was discussed and have the employee confirm that this is accurate to what they saw or experienced. When asking questions make sure they are open ended questions such as the following:
- Where were you at the time of the incident?
- What were you doing at the time?
- What did you see or hear?
- What were the environmental conditions at the time, such as the weather or any noise?
- What was the injured employee doing at the time?
- In your opinion, what caused the incident?
- How might similar incidents be prevented in the future?
Before conducting an interview, prepare a list of questions; however, if the interview progresses to a point where these questions are not helpful then don’t feel that you have to use them. Also, avoid simple yes or no questions, as the person will often provide you more information by answering an open ended question. Interviewing is an art that takes time and practice, but a few things that you want to avoid include intimidating the witness, interrupting, prompting or asking leading questions, showing your own emotions, and jumping to conclusions. These methods will often shut the employee down from willingly provide their side of the story and will not yield good information that will be beneficial towards the investigation.
In summary, we have learned that, before conducting an investigation, make sure to review agency specific procedures and prepare an investigation kit so that you can quickly respond. Conduct your investigation as soon as possible by securing the scene to preserve any evidence, gathering evidence and take pictures from the scene, and interviewing affected employees and witnesses. When interviewing employees, put them at ease so that they provide accurate information.
The following questions are provided to verify your understanding and to give you credit for this module.

Question 1

Investigators must prepare for an investigation by:

A. Reviewing agency specific policies regarding incident investigation

B. Preparing an incident investigation kit

C. Identify who to notify and time frames

D. All of the above

Answer: D. All of the above

Question 2

True or False: When inspecting the scene, it is important to clean up any messy or displaced objects before you gather all of the facts.

Answer: False

Question 3

Select all that apply: The following are effective interviewing techniques:

A. Intimidating the employee

B. Asking leading questions

C. Stopping an interview when you have all the information you need

D. Cutting off the employee to ask another question

E. None of the above

Answer: E. None of the above

You have completed Module 2: Conducting an Investigation.

Module 3: Documenting Incident Information

Welcome to Module 3 of the Incident Investigation and Reporting training program. This is the final module to complete the training series and will teach you how to document your investigation findings using an incident investigation report. The findings that you document within your report will be used by management to determine the root causes of the incident and to develop corrective actions that will prevent similar incidents from occurring in the future. By the end of this module, you will be able to document your investigation findings using the appropriate forms. You will also be able to use effective methods to prepare detailed reports so that future readers will be able to fully understand what happened and develop effective corrective action plans. Lastly, you will be able to determine if the direct cause was an unsafe act or condition.
The incident investigation report will document information gathered during the scene inspection and interview stages of the investigation. Every agency will have its own specific form and procedures for reporting. Make sure to review this before conducting an investigation as this training will only cover the basics of what is required in most investigation reports. When completing the investigation report you need to document everything you found about who was involved, what happened, when and where it happened, and, most importantly, why it happened. The accuracy of this report is very important because the information provided will be used to determine the root cause of the incident and the corrective actions that can be taken to ensure this incident will not occur again.
If completing the report by hand, print neatly so that everyone can understand what you wrote. If you are able, convert your findings into an electronic format so it is easier to read and communicate. When documenting your report, keep in mind that it may be read by multiple readers with different backgrounds. To avoid confusion, try not to use work area terminology or slang that is too specific to the operation. You should only document information in your report that you have verified as fact through interviews, scene inspections, and physical evidence. Avoid including your own opinions into this report, unless you feel they are important to document. The initial incident investigation report will document injured employee data, the incident description, and the direct causes. The next few slides will review examples of the information that will be gathered during these stages. We will use a common example of a person slipping and falling to help explain how to document an incident.
The two major questions that should be answered fairly quickly are “Where did the incident happen?” and “Who was involved?” Make sure to document the general location of the incident and any specific site details that will be helpful to the reader. Document all individuals involved with the incident, including the injured employee or employees, others who were affected, and those who witnessed the incident. Using the example of an employee slipping and falling, let’s review how to document this information with the following example: “Injured employee fell in the hallway just inside of the main entrance door. This was witnessed by Dave Phillips, the maintenance manager.” This statement tells us exactly where the incident occurred and who saw it happen. This concise sentence provides all the information needed by those who will be evaluating this report to go back to the scene or talk with witnesses further to learn more about the incident.
The next major question that needs to be answered is “What happened during the time of the incident?” You will want to document the specific events that took place. Make sure to provide sufficient detail to outline all actions performed by those involved during the incident. It’s important to develop a chronological sequence of events to help explain what happened. This is especially useful for events that have multiple individuals involved in the incident. Using our fallen employee example, here is a good description for what happened: “When employee entered the building and stepped from the floor mat to the tile floor, their foot slipped and they fell to the ground.”
The next major question that we should be able to answer is “What events led up to the incident?” You will need to provide information that gives a background to the reader so that they understand why certain actions were performed. You will also want to outline the specific contributing factors that led to the incident occurrence. Make sure to develop this into a chronological sequence of events. Using our example, a good answer for this question could be: “It was raining and the employee walked from their car to the building carrying an umbrella.” By answering this question, we now understand that the employee came in from the outside where it was raining. Knowing that it was raining will probably factor into the direct cause of how the employee slipped.
The next question you should answer is, “What is the direct cause of the incident?” Your answer should identify if the incident was an unsafe condition or unsafe act. An unsafe condition is caused by the physical environment such as walking surfaces, tools, or equipment. An unsafe act is caused by actions or inactions performed by the employee, co-workers, supervisors or other management that led to the incident occurrence. Using our example, the direct cause can be described as “The carpet was soaked and small puddles were on the tile floor beyond the carpet which created a slippery surface at the entrance way”. This description identifies that the carpet and water puddles created the slippery surface resulting in a fall, which is an unsafe condition. We will review how to determine the differences between unsafe conditions and unsafe acts in the next few slides.
The last piece of information that should be documented is if any machines, equipment or tools were used before or during the incident. Not all incidents will have tools or equipment involved, so listing Not Applicable is an option. You should document all the equipment and how it was being used during the time of the incident. Try to determine if the equipment was appropriate for the job, if it was being used correctly, or if it was damaged. All of this information can later be used to determine the root cause of the incident. If applicable, make sure to document the specific machinery or equipment used, so that if corrections or repairs need to be made you can quickly determine which piece of equipment needs to be fixed. There was no equipment used during our slip and fall example so this section would be listed as not applicable.
Let’s go over the concept of unsafe conditions and unsafe acts in more detail. Unsafe conditions are unsafe physical conditions of the workplace and can include wet or slippery walking surfaces, narrow or congested work areas, defective tools and equipment, unguarded moving parts or machines, and poor housekeeping. When identifying an unsafe condition, make sure that you provide more information into how this condition was allowed to exist, which is a critical piece of the puzzle. This provides information that will help with the root cause analysis and longer term fixes will have a greater impact on the agency.
Unsafe acts are actions or inactions taken by the employees, supervisors and management that were the direct cause of the incident. Examples of unsafe acts are improper lifting, loading, or positioning of materials, not wearing necessary protective equipment, speeding or ignoring other safety rules, failing to follow established procedures, using equipment that is known to be defective or damaged, using equipment or tools improperly, texting while walking or driving, and taking shortcuts. It needs to be emphasized that although unsafe acts involve specific employee actions, the investigation should not immediately conclude that an employee is at fault. The employee may have acted in a certain manner that resulted in injury, but the investigation must find out why and what motivated the employee to take this action. Identifying this will provide better information towards longer term organizational fixes.
Let’s think about two examples and try to determine if it is an unsafe condition or unsafe act. Take a few moments to consider whether a hole in the ground of the work area is an unsafe act or condition. The hole is an unsafe condition as it is directly associated with the walking or working surface. Unsafe conditions are typically easy to identify; however, the more important part is to look into why the hazard was allowed to exist. Talking with those who work in that area should help you to identify what caused the hole in the floor. Take a few moments to consider whether a man stacking two ladders to reach the top of a hedge to trim it is an unsafe act or condition. The man is obviously acting unsafely, and his action could have injured himself or his coworker, and although we want to document that performance of this action, we also want to understand why he performed this action. Oftentimes we will find multiple contributing factors that motivated the employee to take an action. For example, the employees were not provided the proper equipment either not a tall enough ladder or the job required a man lift, the employees were not trained on safe usage of a ladder, or there was no supervision of the employees and they were improperly motivated to get the job done at all costs.
Once your findings are documented in the investigation report the next steps of the investigation are to communicate the initial investigation findings to those responsible for evaluating this further. Make sure to follow your agency’s specific procedures for reporting investigations. Work with those responsible for evaluating the investigation further to determine root causes of the incident and what actions are needed to correct the incident. Once a corrective action plan has been developed, it will be delegated to those within the work area to implement certain controls that will prevent future incidents from happening. Procedures should also be in place to monitor the progress made towards the completion of the corrective actions to confirm that they are being implemented and are effective at preventing future incidents.
In summary, Incident Investigation reports are used to document and share investigation findings. When completing these reports, provide enough details so that future readers can fully understand what happened. It is important to document unsafe acts and unsafe conditions that directly caused the incident, so that the underlying or root causes can be determined and corrected.
The following questions are provided to verify your understanding and to give you credit for this module.

Question 1

True or False: It is important to document the who, what, where, when, and why of the incident.

Answer: True

Question 2

True or False: An unsafe condition is an action or inaction of supervisors or employees that results in an incident.

Answer: False

Question 3

When documenting your findings, it is important to:

A. Provide clear and concise information about what happened

B. Write the report so that everyone can understand

C. Communicate reports to parties that can make change within the organization

D. All of the above

Answer: D. All of the above

Thank you for completing all 3 modules of the Incident Investigation and Reporting training program.

This version of the course is intended for individuals who require an accommodation for a disability. Once you have fully reviewed the information in this training, contact your Human Resources Office to request credit for completing this course. You will not receive credit for completing this course until you do so.