INC/General/TBT-INC-003

Incident Investigation Process

Incident Management & InvestigationGeneralIncident Investigation Process

Incident Investigation Process

Toolbox Talk Record

Ref: TBT-INC-003  |  Issue: 1  |  Date: March 2026
PresenterProject
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What?

  • Incident investigation identifies the root causes of accidents, near misses, and dangerous occurrences to prevent recurrence.
  • The goal is to find out what happened and why — not to assign blame to individuals involved in the incident.
  • Investigation must begin as soon as possible after the incident, while evidence is fresh and the scene is undisturbed.
  • The scene must be preserved until the investigation team has completed evidence collection, photographs, and measurements.
  • Witness statements should be taken individually, as soon as practicable, and recorded in writing with the witness's own words.
  • Root cause analysis methods such as 5 Whys, fishbone diagrams, and fault trees help identify underlying systemic failures.
  • Most incidents have multiple contributing factors — focusing on a single cause misses opportunities to prevent future events.
  • Corrective actions must be specific, measurable, assigned to a responsible person, and given a completion deadline.
  • Investigation findings and lessons learned must be communicated to the wider workforce through toolbox talks and safety alerts.
  • A follow-up review must confirm all corrective actions have been implemented and are effective in preventing recurrence.

Why?

Prevent recurrenceInvestigation finds the root cause — fixing it prevents the same incident from happening again to another worker.
Not about blameA blame culture stops people reporting and cooperating — effective investigation seeks understanding, not punishment.
Systemic improvementMost incidents result from system failures, not individual errors — investigation improves the systems that protect everyone.
Do Don't
  • Begin the investigation promptly while evidence is fresh and accessible.
  • Preserve the incident scene until all evidence is collected and documented.
  • Take individual witness statements in private, recording their own words accurately.
  • Use structured root cause analysis methods to go beyond the immediate trigger.
  • Identify all contributing factors, not just the single most obvious cause.
  • Define corrective actions that are specific, assigned, and time-bound.
  • Communicate findings to the workforce through toolbox talks and safety alerts.
  • Follow up to confirm corrective actions are implemented and working effectively.
  • Keep investigation records as permanent project documentation for future reference.
  • Treat the investigation as a learning opportunity, not a blame exercise.
  • DON'T delay the investigation — evidence degrades and memories fade rapidly.
  • DON'T disturb the incident scene before the investigation team has collected evidence.
  • DON'T take group witness statements — speak to each person individually and privately.
  • DON'T stop at the first obvious cause — dig deeper to find the root cause.
  • DON'T attribute the incident to a single factor when multiple causes contributed.
  • DON'T set vague corrective actions — they must be specific with a named owner and deadline.
  • DON'T keep investigation findings to yourself — share lessons to protect the whole workforce.
  • DON'T close the investigation until corrective actions are confirmed implemented and effective.
  • DON'T lose investigation records — they are essential for legal defence and future learning.
  • DON'T use the investigation to punish individuals — focus on fixing the system.

See also: Accident and Incident Reporting (RIDDOR) | Near Miss Reporting and Learning

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