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Health and Safety Procedure - Incident Investigation

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Section 1 - Key Information

Policy Type and Approval Body Administrative – Vice-Chancellor
Accountable Executive – Policy Chief Operating Officer
Responsible Manager – Policy Senior Manager, Health and Safety
Review Date 13 February 2026
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Section 2 - Purpose

(1) 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 consistently across the University.

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

(3) Conducting an incident investigation will facilitate a deeper understanding of the relationship between factors that contributed to an event, and in doing so, will provide clarity and direction for both immediate and broader actions that need to be taken to prevent a reoccurrence.

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Section 3 - Scope

(4) This Procedure applies to:

  1. all staff, students, and contractors
  2. all Health and Safety incidents
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Section 4 - Key Decisions

Key Decisions
 Role
Identify the level of investigation required for an incident and conduct full investigations for notifiable incidents.
 Health and Safety (H&S)Team
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Section 5 - Policy Statement

(5) This Procedure forms part of the Health and Safety Policy suite which governs its application.

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Section 6 - Procedures

Part A - Responsibilities

Managers and Leaders

(6) Managers and leaders are responsible for providing the necessary resources to conduct incident investigations and must:

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

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

Health and Safety Team

(8) The Health and Safety team provide oversight, monitor this procedure and will:

  1. Identify the level of investigation required for an incident
  2. Conduct full incident investigations for notifiable incidents
  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

(9) Staff, students and contractors must participate in incident investigations as required.

Part B - Incidents Require Investigation

(10) All Health and Safety incidents will be investigated. The level of investigation will depend on the potential and actual consequence of the incident.

(11) Typically, the following incident types will require full investigation:

  1. Incidents with high potential consequence
  2. Incidents of high consequence with material damage
  3. Incidents resulting in Serious Injuries
  4. Notifiable Incidents to Worksafe Victoria and other regulatory bodies.

(12) Community Sport injuries will typically be excluded from investigation, unless University assets are implicated in the incident.

(13) Investigations will be undertaken by managers/leaders for all lower consequence incidents.

(14) Investigations will be initiated as soon as possible after the incident is reported through either:

  1. the University Hazard and Incident Reporting system; or 
  2. direct notification to the Health and Safety Team.

(15) All documentation relevant to an investigation will be electronically captured, kept in a retrievable file, and archived by the Health and Safety Team.

Part C - Investigation Methodology

(16) All incident investigations will follow the PEEPO contributing factors model through causation is categorised to identify where the failure/s has occurred.

(17) PEEPO contributing factors:

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

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

Part D - Basic Investigation

(19) The Health and Safety team will provide oversight when a basic investigation is conducted by the relevant Manager/Leader. The basic investigation template will capture and address:

  1. Incident date and time, location and person/people involved
  2. Summary description of the event
  3. Immediate causes
  4. Analysis of contributing factors
  5. Corrective actions

Part E - Full Investigation

(20) The Health and Safety team will work with the affected area to establish an Investigation Team, who will conduct a full investigation. Members of an investigation team will vary, though may include:

  1. Person/s directly involved and/or witnesses of the incident
  2. Manager/leader of the area
  3. Health & Safety Representatives
  4. Other relevant parties, such as subject matter experts.

(21) The Investigation Team will collect evidence relevant to the incident, this may include physical evidence such as: 

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

(22) 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.

(23) 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

(24) Corrective actions will be implemented by Leaders/Managers that are within their organisational authority to do so.

(25) Implementation of the corrective actions will be monitored by the Health and Safety team to ensure their completion. 

(26) The Health and Safety 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

(27) 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. Departments, Schools, and Divisions
  3. Health and Safety Representative forums
  4. Wider University groups
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Section 7 - Definitions

(28) 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. Notifiable incident: A serious incident that requires immediate notification to Worksafe Victoria or other equivalent authority. 
  5. Serious injury: An injury that has required hospital admission and ongoing medical treatment.
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Section 8 - Authority and Associated Information

(29) This Procedure is made under the La Trobe University Act 2009.

(30) Associated information includes:

  1. Health and Safety (intranet)