Chapter 12.6.1: Investigations
Abstract
Incident investigation is an essential element of workplace safety and a core function for many generalist OHS professionals. However, reports suggest that significant investigation skill deficits exist. An overemphasis on analysing the actions of individuals results in findings of human error without adequate inquiry into the underlying systemic factors that led to those errors. This chapter and the accompanying Guide to Effective Investigations are designed to enhance the investigatory capability of OHS professionals. This chapter explores the influence of investigator lenses, biases and perceptions on the collection and interpretation of evidence and the role, benefits and limitations of causation models and methods. The investigation process is outlined, logic-based analysis is explained, and the development of recommendations and the investigation report is discussed. This chapter and the accompanying guide are based on the premise that, for generalist OHS professionals, the primary objective of investigating incidents should be organisational learning for future prevention.
Keywords
investigation, incident, accident, event, safety, evidence, analysis, witnesses, methods, models
Current Version: May 2024
Chapter 12.6.1: Investigations
Table of Contents
| 1 | Introduction |
| 1.1 | The need for improved investigation capability |
| 1.2 | Terminology |
| 1.3 | Scope |
| 1.4 | A case study example |
| 2 | Investigation as an OHS essential |
| 2.1 | Imperatives for systematic investigation of incidents |
| 2.2 | Sociotechnical system context |
| 2.3 | Optimising learning outcomes |
| 3 | Lens, bias and reasoning |
| 3.1 | Lens |
| 3.2 | Bias |
| 3.3 | Contextual reality |
| 3.4 | Analytical tools |
| 3.5 | Reasoning |
| 4 | Investigation process |
| 4.1 | Investigation preparation |
| 4.2 | Investigation management |
| 4.3 | Incident scene |
| 4.4 | Evidence |
| 4.5 | Witness and specialist input |
| 4.6 | Analysis |
| 4.7 | Technological representations and re-enactments |
| 4.8 | Conclusions, recommendations and reporting |
| 4.9 | Post-investigation review |
| 5 | Logic-based analysis |
| 5.1 | Evidence-informed enquiries |
| 5.2 | Theoretical and analytical models, methods and tools |
| 5.3 | Lines of enquiry |
| 5.4 | Proposed explanations |
| 5.5 | Logic representations and narrative development |
| 5.6 | Testing proposed explanations |
| 5.7 | Summary |
| 6 | Conclusions, recommendations and reporting |
| 6.1 | Conclusions |
| 6.2 | Recommendations |
| 6.3 | Investigation report |
| 7 | Quality assurance |
| 7.1 | Investigation process audits |
| 7.2 | Investigator capability |
| 8 | Postscript on organisational learning |
| 9 | Implications for OHS practice |
| 9.1 | Principles for effective investigations |
| 9.2 | Investigation of minor incidents |
| 10 | Summary |
| References |
Chapter 12.6.1: Investigations
Authors
Dr Geoff Dell GDOHM, MAppSci(OHS), PhD, MISASI, FAIHS
Geoff is a career safety scientist with 44 years of incident investigation experience across a wide range of
industries, including manufacturing, construction, mining, power generation, aviation, rail, road and maritime.
Having worked in aviation as senior safety manager at TAA/Australian Airlines/Qantas, he is a professional-grade
member of the International Society of Air Safety Investigators. In his time as Associate Professor at CQUniversity,
he co-developed and led the unique Bachelor of Accident Forensics and Graduate Diploma in Accident
Investigation programs. Geoff recently completed a three-year tenure as a Professor at the Technical University of
Ostrava Faculty of Safety Engineering and is presently Head of Aviation Safety for the biennial Avalon International
Airshow and a freelance incident investigator.
Dr Yvonne Toft DProf, MHlthSc, GDOHS, GCFlexLearn, MISASI
Professor, Faculty of Safety Engineering, VSB – Technical University of Ostrava, Czech Republic
Building on health and safety roles in mining and health, Yvonne has led research and teaching teams in areas
related to human factors engineering, OHS, accident forensics and investigation, operational systems safety, and
technology in public safety, industrial and transport related contexts for nearly 30 years. At CQUniversity, Yvonne
created and led the undergraduate and postgraduate OHS programs and co-created world-first innovative accident
forensics and investigation programs that featured the southern hemisphere’s first purpose-built crash lab for
accident investigation training and education.
Dr Ivan Cikara PhD, MOSH, MBA, AdvDipPublicSafety(Investigations)
Ivan has an extensive background in investigations spanning policing, where he specialised in investigations of
fatal crashes as a member of the Homicide Squad, and as a specialist investigator for the Public Transport
Authority. He has held executive positions in Federal Government and in general management, and group safety
roles in the transport, mining, and oil and gas sectors. Ivan completed his PhD in systemic investigations of heavy
vehicle crashes and has a number of peer-reviewed publications.
David Skegg MSSc, GD(OHM), GCGCTE, COHSProf, JP
David has extensive experience in OHS and incident investigation within organisations as a consultant and a
teaching scholar and educator across industrial short courses, and undergraduate and postgraduate courses, at
CQUniversity, Swinburn University, Monash University, and the Chinese University of Mining and Technology,
Beijing.
Shevaun Dell BA, BSc, GDPsych, MCrim, MForSc
Shevaun is an academic, researcher and consultant with more than 15 years of experience working in incident
investigation teams in various industries, including construction, oil and gas, power generation and heavy industry.
She has taught into tertiary education programs in the areas of accident forensics, safety science and psychology,
and consulted on policy initiatives, safety systems development and major events public safety.
Learning Outcomes
Learning Outcomes: Investigations
The OHS Body of Knowledge takes a conceptual approach which enables it to be applied in different contexts and frameworks.
To optimise its value for education and professional development learning outcomes have been developed for each technical chapter in the Body of Knowledge.
The learning outcomes as described give an indication of what should be the capabilities of an OHS professional; it is up to those developing OHS education programs, OHS professionals planning their CPD or recruiters or employers selecting or developing people for the OHS function to consider the required breadth vs. depth .
Please read the section on using the learning outcomes before delving into the leaning outcomes of the individual chapters.
The numbers against each learning outcome refer to the chapter number of the BOK download page. No learning outcomes have been developed for the chapters considered introductory or underpinning knowledge (that is chapters 1, 2, 3, 4, 5, 6, 7, 1, .13, 14, 15.)