2024 – Module 8: Near Miss and Incident Reporting/Investigation

Expectations

8.1 The workforce must be aware of and follow the organization and regulatory authority’s definition of a recordable/reportable incident and their obligation to report incidents.

8.2 All incidents, including near misses with significant potential, must be investigated to identify a root cause and steps to prevent reoccurrence.

8.3 Organization-assigned investigators (e.g., safety and health professionals, etc.) must be trained in effective incident investigation and root cause analysis.

8.4 Lessons learned must be communicated to all impacted personnel.

8.5 Demonstration of leading indicators to drive improvement (e.g., root cause analysis, inspection records, close calls, behavior observations, etc.)

These videos are from the 2021 handbook modules and are applicable to the new modules.

Near Miss and Incident Reporting/Investigation Overview

It is critical for all employees to understand, identify, and report recordable/reportable incidents. Integrity in reporting and timely investigation are critical steps for preventing future occurrences. After reporting, management should investigate all incidents, including relevant near misses, to establish root causes. Identifying root causes helps capture and document lessons learned for management review and communication to employees to prevent future incidents. Laws and regulations result in two incident categories that mandate different types of reporting:

1. Incidents reportable to regulatory authorities: All safety and health incident investigations that are mandated to be reported should be promptly examined to identify means to prevent reoccurrence and communicated to the respective regulatory authorities.
2. Incidents that are non-reportable to regulatory authorities: Non-reportable safety and health incidents should also be investigated, analyzed, and corrective actions developed and integrated into the SHMS. Such incidents include near miss events, property damage, and any operational, maintenance, or process integrity incidents that could have a negative outcome.

The Role of Reporting and Investigations 

Incidents cannot be investigated if they are not reported. Consequently, all personnel should know what a reportable incident is within each company, as defined by regulatory requirements and company policy. All personnel should report an incident to management promptly.

The quality of any root cause analysis is directly related to the quality of the incident investigation.

Companies should ensure personnel are adequately trained to conduct required investigations or maintain close coordination with external resources capable of doing so. Incident investigation should focus on fact-finding, not fault-finding, to identify root causes.

Resources

8.1

• HR Acuity – Workplace Incident Report Template
• SafetyIQ – How to Write an Incident Report – With Examples

8.2

• OSHA Incident Investigation Webpage

8.3

• National Safety Council – Incident Investigation Course
• Preventing an Opioid Overdose: Know the Signs. Save a Life. | Overdose Resource Exchange (ORE) | CDC

8.4 & 8.5

• LinkedIn – How do you foster a culture of continuous improvement and learning from incidents?
• CyberSheath – Lessons Learned in Incident Response