An incident investigation is the account and analysis of an incident, based on information gathered by a thorough examination of all factors involved. All incidents at BCIT will be investigated.
The purpose of conducting an investigation is not to lay blame on anyone, but to determine the root cause(s) and prevent re-occurrence.
The investigation must be carried out by people who are knowledgeable about the type of work involved. The investigation team must be carried out by at least 2 people (employer representative and JOHSC worker representative).
Steps in investigating an accident
- Prepare for the investigation
- Secure the scene (when possible)
- Collect Information about what happened
- Develop the sequence of events
- Determine the causes
- Make recommendations for preventative and corrective actions
- Fill in the investigation information and corrective actions in IRIS
Finding root cause(s)
The primary aim of the investigation is to identify the factors that resulted in the incident in order to identify what behaviours, actions, inactions, or conditions need to be changed to prevent recurrence of similar harmful outcomes and to identify the lessons learned.
In most situations there will be multiple root causes that need to be corrected.
An open mind is necessary during incident investigations, assumptions and preconceived notions can mask valid causes or highlight erroneous causes.
The 5 Why’s Analysis is one of many incident investigative and root cause analysis tools. The goal is to find root cause(s) of an incident by continually asking “Why?”
Recommendations and preventative/corrective actions are assigned at the end of the investigation process, the intention is to rectify and improve any areas where improvement is required, and to eliminate or control hazards. Corrective actions have a direct relationship with the root causes of the incident. Usually there is at least one corrective action item linked to each of the causes/contributing factors.
By completing the corrective actions, not only are the areas that require improvement being corrected, but it allows the persons involved to take responsibility to prevent re-occurrence. Each corrective action item is assigned to a person with an expected completion date.
Once corrective actions have been completed, the person responsible will update the incident in IRIS.
All supervisors and JOHSC members will be required to take the online Incident Investigation Course on the Employee Learning Hub. This training will prepare supervisors as to when to complete incident investigations, how to effectively complete an investigation and how to enter the information into IRIS.
For more information read the Incident Reporting and Investigation Program.
If you require additional assistance, please contact BCIT Health, Safety and Environment Division.