Topic 4.3 WHS Incident Investigation and Root Cause Analysis
Reporting an incident is only the first step in effective workplace health and safety management. Following any significant incident, injury or near miss, organisations should undertake an appropriate investigation to understand why the event occurred and identify strategies to reduce the likelihood of similar incidents in the future.
Incident investigations should focus on learning rather than assigning blame. Most workplace incidents result from multiple interacting factors rather than the actions of a single individual. By examining environmental conditions, organisational systems, equipment, communication and human factors, Occupational Therapists and organisations can identify opportunities to strengthen workplace health and safety systems while improving outcomes for both clients and assistance animals.
The depth of an investigation should be proportionate to the seriousness of the incident, recognising that even minor events and near misses may reveal important weaknesses in workplace systems.
The Purpose of Incident Investigation
The primary purpose of an incident investigation is to determine why an event occurred and how similar events can be prevented.
Effective investigations help organisations to:
- identify contributing factors
- evaluate existing risk controls
- determine whether procedures were followed
- identify opportunities for improvement
- strengthen workplace health and safety systems
- improve client safety
- protect assistance animal welfare
- reduce future risks.
The objective is not to identify fault, but to understand how workplace systems can be improved.
When Should an Incident be Investigated?
Not every workplace incident requires a formal investigation of the same depth.
Factors influencing the level of investigation include:
- seriousness of injury
- potential for future harm
- involvement of an assistance animal
- legislative reporting requirements
- repeated occurrence of similar incidents
- organisational policies
- public interest
- complexity of the event.
Near misses should also be investigated where they identify significant weaknesses in existing safety systems.
The Incident Investigation Process
Although organisational procedures vary, most investigations follow a structured process.
This generally involves:
- securing the area where appropriate
- providing immediate assistance
- preserving relevant evidence
- gathering factual information
- identifying contributing factors
- determining root causes
- recommending corrective actions
- monitoring implementation
- reviewing outcomes.
Investigations should be completed as soon as reasonably practicable while information remains accurate.
Gathering Information
Accurate information forms the foundation of an effective investigation.
Sources of information may include:
- incident reports
- witness statements
- photographs
- environmental inspections
- equipment records
- maintenance logs
- CCTV footage where available
- veterinary reports
- medical documentation
- organisational policies
- risk assessments
- training records.
Information should be collected objectively and documented accurately.
Interviewing Witnesses
Witnesses may provide valuable information regarding the sequence of events and factors contributing to an incident.
Interviews should:
- occur as soon as practical
- be conducted respectfully
- encourage open discussion
- avoid leading questions
- focus on factual observations
- avoid assumptions or blame.
Witnesses should feel comfortable reporting what they observed without fear of criticism or punishment.
Contributing Factors
Workplace incidents are rarely caused by a single event.
Contributing factors may include:
Human Factors
Examples include:
- fatigue
- inadequate training
- distraction
- communication difficulties
- physical limitations
- cognitive overload.
Environmental Factors
Examples include:
- poor lighting
- slippery surfaces
- excessive noise
- overcrowding
- inaccessible environments
- adverse weather conditions.
Equipment Factors
Examples include:
- damaged harnesses
- poorly fitted equipment
- defective mobility aids
- inadequate maintenance
- inappropriate assistive technology.
Organisational Factors
Examples include:
- unclear procedures
- inadequate supervision
- staffing shortages
- poor communication
- insufficient training
- ineffective risk assessments.
Animal Factors
Examples include:
- illness
- fatigue
- pain
- behavioural changes
- inadequate preparation
- inappropriate task expectations
- environmental stress.
Each contributing factor should be considered when developing recommendations.
Root Cause Analysis
Root cause analysis is a structured approach to identifying the underlying reasons an incident occurred.
Rather than asking, “Who made the mistake?”, root cause analysis asks:
- Why did this happen?
- What conditions allowed it to happen?
- Which workplace systems failed?
- How can recurrence be prevented?
Understanding root causes allows organisations to address systemic issues rather than only treating the immediate symptoms of a problem.
Common Root Cause Analysis Methods
Several structured approaches can be used to investigate incidents.
The Five Whys
The Five Whys technique involves repeatedly asking “Why?” until the underlying cause is identified.
For example:
A client fell while working with their assistance dog.
Why?
The client tripped over the lead.
Why?
The lead became tangled around mobility equipment.
Why?
The environment provided insufficient turning space.
Why?
The assessment area had not been evaluated before commencing activities.
Why?
No environmental assessment procedure had been completed.
This process identifies the need for improved environmental assessment rather than focusing solely on the fall itself.
Fishbone (Cause-and-Effect) Diagrams
Fishbone diagrams categorise contributing factors into areas such as:
- people
- procedures
- equipment
- environment
- organisational systems
- animals.
This approach helps investigators examine multiple interacting causes rather than assuming a single explanation.
Developing Corrective Actions
Following an investigation, organisations should implement actions that reduce future risk.
Corrective actions may include:
- updating workplace procedures
- modifying environments
- replacing equipment
- providing additional education
- increasing supervision
- reviewing client support plans
- adjusting assistance animal workloads
- improving communication processes.
Recommendations should address identified root causes rather than focusing solely on individual behaviour.
Monitoring Corrective Actions
Corrective actions should be reviewed to ensure they have been effectively implemented.
Monitoring may include:
- follow-up workplace inspections
- review of incident trends
- consultation with stakeholders
- reassessment of risks
- evaluation of revised procedures
- observation of workplace practice.
If corrective actions do not achieve the intended outcomes, further review may be required.
Learning from Investigations
Incident investigations should contribute to organisational learning.
Lessons learned may inform:
- policy revisions
- staff education
- workplace design
- emergency planning
- risk assessments
- supervision practices
- assistance animal training protocols
- organisational quality improvement initiatives.
Sharing lessons learned, while maintaining confidentiality, helps strengthen workplace health and safety across the organisation.
Key Practice Principle
Incident investigations should seek to understand systems rather than assign blame. By identifying contributing factors and addressing underlying causes, Occupational Therapists can support continuous improvement, strengthen workplace health and safety systems, protect assistance animal welfare and reduce the likelihood of future incidents. Effective investigations transform adverse events into valuable opportunities for learning, improving practice and promoting safer participation for all stakeholders.