Why should accidents and incidents be investigated?

What are the benefits of investigating incidents?

Reasons swiss cheese model

An investigation can:

  •  yield information needed to
    • identify trends and problem areas
    • permit comparisons
    • satisfy legal requirements
  • identify the basic causes that contributed directly, or indirectly, to the unwanted event
  • identify deficiencies in the production and management system that permitted the incident to occur
  • suggest specific corrective action alternatives for the management system.

If mining operations do not undertake suitable investigations of incidents, opportunities for improvement may be lost. Without an understanding of the causes and contributing factors, there can be no learnings and improvements to safe work practices.

What should an investigation report cover?

To achieve the best outcomes from the investigation process, the following approach is recommended when preparing the report.

The report should:

  • be developed using an accepted investigation technique (e.g. ICAM or Taproot)
  • address the causation factors and sequence of events that resulted in the incident
  • outline the risk reduction measures taken and safety system improvements  to prevent a recurrence of the incident
  • consider the hierarchy of control when developing risk reduction measures to provide a long-term solution to the problem
  • be signed off by a safety representative and a company official, such as a line manager or safety professional.

Further information: This is the same guidance provided to companies who have been asked to undertake a site investigation and submit a report to a mines inspector. The report provided to the department is then be reviewed and the case closed or investigated further (by the company or department).

Why should safety and health representatives be involved in investigations?

One of the statutory functions of a safety and health representative is to be able to carry out an appropriate investigation following an incident.

A safety and health representative is an invaluable source of knowledge that can help those undertaking a site investigation. Representatives bring an understanding of workplace systems, health and safety, and experience in liaising with workers and supervisors.

Representatives may also be requested by a mines inspector to assist in a departmental investigation.

Investigating incidents - information sheet for safety and health representatives - 1058 Kb

This information sheet outlines procedures and principles on how an investigation will be run in an event of an incident.