Investigation of Occupational Accidents and Diseases Is a Practical Guide for Labour Inspectors designed to equip labour inspectors with the necessary skills to conduct
effective investigations into occupational accidents, occupational diseases, and other undesired events (such as dangerous occurrences and near-miss/incidents) that could have led to personal injuries affecting workers or members of the public. It should be borne in mind that occupational accidents, diseases and other undesired events are preventable.
Conducting an effective investigation will identify not only causal factors but actions that would have prevented the event from occurring.
The guide provides inspectors with information on the importance of, and a suggested methodology for, conducting effective investigations and compiling reports. While the ILO understands that other methodologies for conducting investigations are available, it believes that following the methodology presented below will help inspectors to identify all the immediate and root causes of the event under investigation. This, in turn, will enable inspectors to help employers, enterprises, and worker representatives to identify appropriate prevention/risk control measures to prevent a recurrence of the actions
that led to the event being under investigation, thereby improving occupational safety and health (OSH) management.
The guide was developed in conjunction with the ILO International Training Centre in Turin following a workshop on conducting occupational accident and disease investigations,
which was attended by constituents from Brazil, Italy, Norway, Portugal, Romania, The United Kingdom and the United States of America and technical specialists from the
Labour Administration, Labour Inspection and Occupational Safety and Health Branch of
the international labour office.
Investigation of Occupational Accidents and Diseases Book’s cover
What is an investigation?
An investigation into an occupational accident, disease or dangerous occurrence (near-miss)
- identifies how and why an undesired event (accident, contraction of a disease, dangerous occurrence, near miss) occurred; and
- establishes actions required to prevent a similar event, thereby leading to an improvement in occupational safety and health management.
- Investigations carried out by labour inspectors should also identify, with regard to the event under investigation:
- all those with legal obligations – e.g. the enterprise, managers, workers, suppliers etc.;
- the applicable legislation, whether it has been violated and any associated enforcement decisions; and
- actions required to ensure that the enterprise complies with all relevant OSH legislation.
The investigation is reactive because an event must occur before it can be investigated. The labour inspector must determine not only what the result of the event was, but also how and why it occurred so that control (safety) measures can be identified and implemented to prevent its recurrence, thereby improving safety and health management. In addition, part of the inspector’s job is to ensure that employers and workers comply with national legislation, including OSH legislation, legal issues relating to the investigation must be addressed.
Any investigation must answer six basic questions, the 5Ws and 1H:
Who was injured, suffered ill health or was otherwise involved in the event under investigation?
Where did the accident occur?
When did the accident occur?
What happened at the time of the accident?
How did the accident occur?
Why did the accident occur?
The Contents of Investigation of Occupational Accidents and Diseases
- Abbreviations IV
- Definitions IV
- Preface V
- Introduction 1
1.1 What is an investigation? 1
1.2 What makes a good investigation? 2
1.3 What gets investigated? 5
- Skills required by investigators7
2.1 Interviewing skills 8
2.2 Questioning witnesses 10
- Main stages of an accident investigation 13
3.1 Preparations before starting the investigation13
3.2 Gathering information15
Arrival at the site19
Prior to leaving the site20
3.3 Analysing the information21
3.4 Identifying preventive/risk control measures25
3.5 Implementing an action plan 26
3.6 Completing the report/documenting the information27
- Accident investigation checklist29
- Investigation report 33
Case study: Employee injured while operating a circular saw bench37
Step 1: Actions to take upon receiving notification of the accident 37
Step 2: Gathering information38
Step 3: Analysing the information43
Step 4: Identifying preventive/risk control measures45
Step 5: Implementing an action plan46
Step 6: Investigation report 46
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