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Health and Safety Procedure - Incident Investigation

Section 1 - Background and Purpose

(1) Incident investigation is an important process to determine the events and factors that led to a hazard, injury, illness, incident or other system failure. 

(2) Through the process of conducting incident investigations, an understanding develops of the relationship among the events, and in doing so, provides clarity for organisational action in the effort to prevent reoccurrence. 

(3) The purpose of this Procedure is to provide a clear framework on how health and safety incidents are investigated so that necessary corrective actions and the lessons learnt are identified and implemented across the organisation in the effort to prevent reoccurrence. 

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Section 2 - Scope

(4) Refer to the Health and Safety Policy.

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Section 3 - Policy Statement

(5) Refer to the Health and Safety Policy.

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Section 4 - Procedure

Part A - Responsibilities

Managers and Leaders

(6) Provide the necessary resources to conduct incident investigations.

  1. Conduct and /or participate in incident investigation as required.
  2. Implement the corrective actions that are identified from the investigation where these are within their organisational authorities to do so.

Health, Safety and Environment (HSE) Team

(7) Provide oversight and monitor this procedure. 

  1. Identify the level of investigation required for each incident. 
  2. Conduct and / or participate in incident investigations. 
  3. Monitor to ensure the necessary corrective actions are implemented.
  4. Report on completed corrective actions.
  5. Communicate the corrective actions, broader trends and deeper insights to the University community.

All Staff, Students and Contractors

(8) Participate in incident investigations as required.

Part B - Incidents Requiring Investigation

(9) All Health and Safety incidents will be investigated. 

(10) The level of investigation will be determined by the incident rating as described using the University risk matrix and utilising the following:

  1. Typically, the following incident types will require full incident investigation:
    1. Incidents with high potential consequence
    2. Incidents of high consequence with material damage 
    3. Incidents resulting in Lost Time Injuries
    4. Incidents resulting in Serious Injuries
    5. Notifiable Incidents

(11) Incident investigation will be initiated as soon as possible after the incident is reported through either:

  1. University Hazard and Incident Reporting system 
  2. Internal notification process

(12) Incidents fall into the current categories:

  1. Significant incidents: fatality, severe injury, multiple injuries and casualties, major asset damage
  2. Serious incidents: serious injury, multiple casualties, asset damage
  3. Moderate incidents: injuries requiring medical attention, minor asset damage

Part C - Incident Investigation Methodology

(13) All incident investigation will follow the PEEPO contributing factors model in which causation is categorised as follows to identify where the failure/s has occurred.

(14) PEEPO contributing factors:

  1. People 
  2. Environment 
  3. Equipment 
  4. Process 
  5. Organisation 

(15) This methodology will identify a breadth of corrective actions to ensure that the underlying causes are comprehensively understood and addressed. 

Part D - Basic Incident Investigation

(16) The HSE Team will initiate basic incident investigation in conjunction with the relevant Manager / Leader. The incident investigation template will be utilised to capture and address:

  1. Incident details
  2. Summary description of the event
  3. Timeline of the event
  4. Immediate causes
  5. Analysis of underlying causes and contributing factors
  6. Actions

Part E - Full Incident Investigation

(17) The HSE team will lead a full incident investigation and, with the organisational leadership will establish an investigation team. Members of investigation teams will vary but may include:

  1. Person/s directly involved and/or witnesses
  2. Supervisor
  3. Health & Safety Representatives
  4. Other relevant staff, depending on the seriousness of the incident. 

(18) The Investigation Team will collect evidence relevant to the incident. This may include: 

  1. Physical evidence such as
    1. Photographs and or videos
    2. Samples of materials, broken components, equipment as necessary.
    3. Records such as 
    4. Records of maintenance, training, work instructions, work orders, permits to work
    5. Other relevant information such as temperature, lighting, ventilation, equipment condition and adequacy, hours worked.
    6. Any other evidence as deemed necessary to the investigation

(19) The Investigation Team will conduct interviews with both direct and indirect witnesses. 

  1. Interviews will remain confidential 
  2. Persons being interviewed may have a support person present 
  3. All staff have the right to refuse to be interviewed.

(20) Following the investigation, the lead investigator will use the incident investigation template to prepare an analysis of the incident and identify the corrective actions necessary to prevent reoccurrence. 

Part F - Corrective Actions

(21) Corrective actions will be implemented by Leaders / Managers that is within their organisational authorities to do so.

(22) Implementation of the corrective actions will be monitored by the HSE team to ensure their completion. 

(23) The HSE team will periodically review the corrective actions that are operational to ensure these are effective and/or identify where deficiencies exist for additional correction.

Part G - Lessons Learnt

(24) The wider lessons learnt though the corrective actions, broader trends and deeper insights will be communicated across the university community. This may include:

  1. OHS Consultative Committees
  2. Schools, Colleges and/or Divisions
  3. Health and Safety Representatives
  4. Wider University Associations 

Part H - Documentation

(25) All documentation relevant to an investigation will be electronically captured and kept in a retrievable file for a period of 10 years.

Part I - Education & Training

(26) Managers and leaders will be identified across the Schools and Divisions to complete incident investigation education and training.

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Section 5 - Definitions

(27) For the purpose of this Procedure:

  1. Hazard: A source of potential harm to people or a situation that can cause injury, illness and /or material loss to plant, property or the environment.
  2. Incident: An event where an injury, illness, property damage or near miss has occurred.
  3. Investigation Team: A group of people who are assisting an incident investigation.
  4. Lost Time Injury: A work related injury or illness involving compensation, where a full shift of work or more was not worked due to the illness or injury.
  5. Notifiable incident: A serious incident involving death or life threatening injuries that requires immediate notification to Worksafe or the equivalent authority. 
  6. Serious injury: An injury that has required hospital admission and ongoing medical treatment.