Incident Investigation Reference Guide

Incident Investigation Reference Guide
(52E40 Incident Investigation Report)

INCIDENT INVESTIGATION REPORT
This form is provided to employers for the purpose of documenting the employers investigation into a workplace
incident. Please attach a separate sheet if necessary.
Call Centre
Phone 604 276-3100
Toll-free 1 888 621-SAFE (7233)
After-hours health and

safety emergency
Phone 604 273-7711
Toll-free 1 866 922-4357 (WCB-HELP)
Fax
604 276-3247
Mailing address
WorkSafeBC
PO Box 5350 Stn Terminal
Vancouver BC V6B 5L5
Employer name
Employer number
Employer head office address

City
Province
Postal code
Incident occurred ref: s. 3.4(a) Occupational Health and Safety Regulation (OHS Regulation)
Address where incident occurred
City (nearest)
Province
Date of incident (yyyy-mm-dd)
Time incident occurred
Injured person(s) ref: s. 3.4(b) OHS Regulation
Incident Investigation Report (continued)
a.m.
p.m.
Employer name
Last name
1)
Postal code
First name
Employer number
Job title/Occupation
Analysis
From the sequence of events, identify what events may have been significant in this incident occurring. An analysis of these
events will assist in determining the underlying or causal factors in the occurrence. Please refer to the Incident Investigation
Reference Guide for assistance when completing this report. The guide is available on WorkSafeBC.com.
2)
Witnesses ref: s. 174(4) Workers Compensation Act (WCA) and s. 3.4(c) OHS Regulation
Last name
First name
1)
2)
3)
Incident description ref: s. 3.4(d)(e) OHS Regulation
Briefly describe what happened, including the sequence of events preceding the incident. Please refer to the Incident
Investigation Reference Guide for assistance when completing this report. The guide is available on WorkSafeBC.com.
Statement of causes ref: s. 174(2)(a)(b) WCA and s. 3.4(f) OHS Regulation
52E40
List any unsafe conditions, acts, or procedures that in any manner contributed to the incident. Please refer to the Incident
W o r k e r s C om p e n s a ti o n B o a r d o f B . C.
52E40
Use this guide when completing the 52E40 Incident Investigation

Report, in conjunction with the requirements of the Workers
Compensation Act (WCA), Part 3 Division 10, and the Occupational
Health and Safety Regulation (OHS Regulation), section 3.4.
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(R04/13) Page 2 of 3
When is an investigation required?

Employers are required to immediately undertake an investigation into any accident or other incident that:
Is required to be reported under section 172 of the Workers Compensation Act, or
Resulted in injury requiring medical treatment, or
Did not involve injury to a worker or involve a minor injury that did not require medical treatment but had
the potential for causing serious injury, or
Was an incident required by regulation to be investigated.
Who should conduct the investigation?
Incidents must be investigated by people knowledgeable about the type of work involved at the time of the
incident.
If reasonably available, investigations must be carried out with the participation of one employer
representative and one worker representative.
What is the purpose of an investigation?

The purpose of an investigation is to determine the cause or causes of the incident, to identify any unsafe
conditions, acts, or procedures that contributed to the incident, and to recommend corrective action to
prevent similar incidents.
Who receives copies of the report?

Incident investigation reports required by the WCA must be provided to the joint health and safety committee
or worker representative as applicable, and to WorkSafeBC.
What follow-up action is required after an incident investigation?

After an investigation, the employer must without undue delay undertake any corrective action required to
prevent recurrence of similar incidents and must prepare a report of the action taken. The report must be
provided to the joint health and safety committee or worker representative as applicable. The follow-up report
does not have to be provided to WorkSafeBC unless requested by a WorkSafeBC officer.
Page 1 of 5
What information should be included in the investigation report?

INCIDENT
REPORT
An incident investigation report should answer the WHO, WHERE, WHEN, WHAT, WHY,
andINVESTIGATION
HOW questions
with regard to the incident.
This form is provided to employers for the purpose of documenting the employers investigation into a workplace
This formPlease
is provided
for theif purpose
of documenting the employers investigation into a workplace
incident.
attachtoaemployers
separate sheet
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incident.
attach
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intoaddress
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Call
After-hours
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and
Fax
Mailing
incident.
attach
separate sheet
necessary.
Call Centre
After-hours
health and
Fax 276-3247
Mailing address
incident.
Please
attach a separate sheet
ifemergency
necessary.
Phone
604
276-3100
safety
604
WorkSafeBC
Call
Centre
After-hours
health and
Fax
Mailing
address
Phone
604
276-3100
safety 604
emergency
604 276-3247
WorkSafeBC
Toll-free
1 888
621-SAFE (7233)
Phone
273-7711
PO
Box 5350
Stn Terminal
Call Centre
After-hours
health and
Fax 276-3247
Mailing
address
Phone
604
276-3100
safety
emergency
604
WorkSafeBC
Toll-free 1 888 621-SAFE (7233)
Phone 604
273-7711
PO Box 5350
Terminal
Toll-free
1 866
922-4357 (WCB-HELP) 604 276-3247
Vancouver
BCStnV6B
5L5
Phone
276-3100
safety
emergency
WorkSafeBC
Toll-free604
1 888
621-SAFE (7233)
Phone
604
273-7711
PO
Box 5350
Terminal
Toll-free
1 866
922-4357 (WCB-HELP)
Vancouver
BCStnV6B
5L5
Toll-free
1 888
621-SAFE (7233)
Phone 604
273-7711
PO
Box 5350
Terminal
Toll-free
1 866
922-4357 (WCB-HELP)
Vancouver
BCStnV6B
5L5
Employer
name
Employer
number
Toll-free 1 866 922-4357 (WCB-HELP)
Vancouver
BC V6B 5L5
Employer name
Employer number
Employer name
Employer
number
INCIDENT INVESTIGATION
REPORT
Employer
nameoffice address
Employer number
Employer head
Employer
head
office address
City form is
Province
Postal
code
This
provided
to employers for the purpose of documenting
the employers investigation
into
a workplace
City
Province
Postal code
incident.
Please attach a separate sheet if necessary.
City
Province
Postal code
CityCentre
Postal
Call
After-hours health and Province
Fax
Mailingcode
address
Incident
Health and Safety Regulation (OHS Regulation)
Phone 604occurred
276-3100 ref: s. 3.4(a) Occupational
safety emergency
604 276-3247
WorkSafeBC
Incident
occurred
ref: s. 3.4(a) Occupational Health and Safety Regulation (OHS Regulation)
Toll-free
888 621-SAFE
(7233)
Phone 604Health
273-7711
Address1where
incident
Incident
occurred
ref:occurred
s.
3.4(a) Occupational
and Safety Regulation (OHS Regulation) PO Box 5350 Stn Terminal
Address where
incident
Incident
occurred
ref:occurred
s. 3.4(a) Occupational
Health
and Safety
Regulation (OHS Regulation) Vancouver BC V6B 5L5
Toll-free 1 866
922-4357
(WCB-HELP)
Address where incident occurred
Address
where
(nearest)
Province
Postal
code
City
Employer
nameincident occurred
Employer
number
City (nearest)
Province
Postal code
Province
Postal code
City (nearest)
(nearest)
Province
Postal code
City
(yyyy-mm-dd)
Time
incident occurred
Date
of incident
a.m.
Employer
head office
address
a.m.
p.m.
a.m.
p.m.
(yyyy-mm-dd)
Time
incident
occurred
Date
of
incident
a.m.
City
Province
Postal code
p.m.
Injured
person(s) ref: s. 3.4(b) OHS Regulation
p.m.
Injured person(s) ref: s. 3.4(b) OHS Regulation
Last ref:
name
First name
Injured person(s)
s. 3.4(b) OHS Regulation
Last ref:
name
First name
Injured
Regulation
Incidentperson(s)
occurred
ref:s.s.3.4(b)
3.4(a)OHS
Occupational
Health and Safety Regulation (OHS Regulation)
Last name
First name
1)
name
First name
1)
Address where Last
incident
occurred
1)
2)
1)
2)
Province
Postal code
City (nearest)
2)
Witnesses
ref: s. 174(4) Workers Compensation Act (WCA) and s. 3.4(c) OHS Regulation
2)
Witnesses ref: s. 174(4) Workers Compensation Act (WCA) and s. 3.4(c) OHS Regulation
name
Witnesses ref: s. 174(4) Last
Workers
Compensation Act (WCA) and s. 3.4(c) OHS Regulation First name
(yyyy-mm-dd)
Time
incident
occurred
Date
of
incident
a.m.
name
Witnesses ref: s. 174(4) Last
Workers
Compensation Act (WCA) and s. 3.4(c) OHS Regulation First name
Last name
First name
1)
p.m.
Last name
First name
1)
1)
2)
Injured
person(s) ref: s. 3.4(b) OHS Regulation
1)
2)
Last name
First name
2)
3)
2)
3)
1)
3)
Incident
description ref: s. 3.4(d)(e) OHS Regulation
3)
Incident
description ref: s. 3.4(d)(e) OHS Regulation
2)
Briefly
describe
what happened,
including
theRegulation
sequence of events preceding the incident. Please refer to the Incident
ref: s. 3.4(d)(e)
OHS
Incident
description
Briefly describe
what happened,
including
theRegulation
sequence
of events
theguide
incident.
Please refer
to the Incident
Incident
description
ref:
s. 3.4(d)(e)
OHS
Investigation
Reference
Guide
for
assistance
when completing
thispreceding
report. The
is available
on WorkSafeBC.com.
Briefly
describe
what
happened,
including
the sequence
of events
preceding
theguide
incident.
Please refer
to the Incident
Investigation
Reference
Guide
for
assistance
when
this
report.
is available
on WorkSafeBC.com.
Witnesses
ref:
s. 174(4)
Workers
Compensation
Act completing
(WCA)
and s.
3.4(c)
OHSThe
Regulation
Briefly
describe
what happened,
including
the sequence
of events
theguide
incident.
Please refer
to the Incident
Investigation
Reference
Guide for
assistance
when completing
thispreceding
report. The
is available
on WorkSafeBC.com.
Investigation Reference Guide
for assistance when completing this report. The guide is First
available
on WorkSafeBC.com.
Last name
name
WHO, WHERE, & WHEN

Employer information
Location where incident occurred
Date and time of the incident
Injured person(s)
Other person(s) involved in
the incident, and witnesses
1)
2)
WHAT
3)
Incident description ref: s. 3.4(d)(e) OHS Regulation
Briefly describe what happened, including the sequence of events preceding the incident. Please refer to the Incident
A brief description of the incident,

including the sequence of events
that preceded the incident.
52E40
52E40
52E40
52E40
W o r k e r s
W o r k e r s
W o r k e r s
W o r k e r s
52E40
W o r k e r s C om p e n s a ti o n B o a r d o f B . C.
C om p e n s a ti o n
Board
Board
Board
Board
of
of
of
of
B . C.
B . C.
B . C.
B . C.
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A sequence of events should highlight all of the events prior to the incident. This may include events from
the day of the incident, however, may also extend back to years prior (e.g., installation of new machinery,
changing ownership of company, product changes, etc). In addition, if activities which occurred after the
incident, such as first aid or the evacuation process, need to be analyzed for future improvements you can
include those events in your sequence.
When developing a sequence of events diagram, each event should:
Indicate one action or decision (e.g., worker stops forklift on loading ramp A).
Never include something that did NOT happen (e.g., worker should have, could have, would have ),
as these actions or decisions cannot be analyzed (e.g., worker should have parked on level ground).
Helpful to include date and time of action/decision.
Sequence of events diagram (sample)
Worker stops
forklift on
loading ramp A
Page 2 of 5
Worker exits
forklift
Worker runs over

to truck driver on
loading ramp B
Forklift begins
to roll

Employer name
WHY
Employer number
Analysis
From the sequence of events, identify what events may have been significant in this incident occurring. An analysis of these
events will assist in determining the underlying or causal factors in the occurrence. Please refer to the Incident Investigation
Reference Guide for assistance when completing this report. The guide is available on WorkSafeBC.com.
The sequence of events illustrates what

happened leading up to, and possibly after,
the incident. In order to understand why
the incident occurred, events in the sequence
need to be analyzed.
When analyzing:
1. Choose events that were either undesirable or somehow contributed to the incident occurring. In the
example above, one event has been selected for further analysis. This event is shown in bold.
2. The analysis then involves asking why repeatedly until you end up at a workplace factor (e.g., tools,
equipment, process, procedures, environment, communication, etc.).
3. Avoid stopping at personal factors, such as he/she was complacent, he/she was not paying
attention, and/or he or she did not follow procedures, as they provide a limited opportunity to
improve safety in the workplace.
4. Ensure that your conclusions are based on information compiled during the investigation, and therefore
are objective, and not based solely on ones personal opinion
of the situation. Objective information
52E40
will come from interviews, paperwork, observations, analysis of equipment, etc.
(R04/13) Page 2 of 3
Analysis of an event (sample)

Worker stops
forklift on
loading ramp A
Why?
Loading ramp B
was full
Why?
Worker was
complacent*
* The worker forgetting is a personal factor.
This is often where the investigation stops.
Scheduling
error
Why?
Quick expansion
of business
Page 3 of 5
Why?
Scheduling
software
limitations
Why?
Varying staff
involved with
scheduling
process
HOW
An incident investigation report should
recommend corrective actions, based on
contributing or causal factors, to prevent the
same or similar incidents from recurring. Some
points to remember when you are investigating:

Avoid focusing on what you feel the workers

should have been able to anticipate. Our
goal as investigators is to understand why
the workers actions made sense to them at
the time. Understanding why it made sense
to the worker will help you to identify what
workplace factors need to be changed to
reduce the likelihood of recurrence.
There is often more than one cause, or
contributing factor, to an incident occurring.
Drawing conclusions prematuraly can limit
the information you collect, thereby limiting
your ability to identify other causes or
contributing factors.
Analyze the information until you identify
workplace factors. Remember that stopping
at personal factors limits the opportunity to
improve workplace safety.
52E40
Employer name
(R04/13)
Page 2 of 3
Employer
number
Recommendations ref: s. 174(2)(c) WCA and s. 3.4(g) OHS Regulation

Identify any corrective actions that have been taken and any recommended actions to prevent similar incidents.
Recommended corrective action
Action assigned to
Completion date
or expected
completion date
(yyyy-mm-dd)
1)
2)
3)
4)
Employer name
Employer number
Persons conducting investigation ref: s. 3.4(h) OHS Regulation

Recommendations ref: s. 174(2)(c) WCA and s. 3.4(g) OHS Regulation
Date signed
Representative of
Name (please print)
Signature (optional)
Identify any corrective actions that have been taken and any recommended actions to prevent similar incidents.(yyyy-mm-dd)
Employer
Worker
1)
Employer
Recommended corrective action
Action assigned to
Completion date
or expected
completion date
(yyyy-mm-dd)
Worker
Other
Date Incident Investigation Report submitted to WorkSafeBC ref: s. 175(2)(b) WCA

(yyyy-mm-dd)
2)
APPROVAL AND SUBMISSION

The names of the worker and employer
representatives that conducted the
investigation must be provided on the form.
If the employer wishes to have these persons
sign the report, it must be printed then signed,
as the form will not accept digital signatures.
Employers must submit a copy of their
incident investigation reports to WorkSafeBC.
The date provided should indicate the date the
report was submitted by email, fax, or any other
means.
Follow-up action and report
Section
176 of the Workers Compensation Act states:
3)
(1) Following an investigation under this Division, the employer must without undue delay undertake any corrective action
required to prevent recurrence of similar incidents.
(2) As soon as is reasonably practicable, the employer must prepare a report of the action taken under subsection (1) and
4) (a) provide the report to the joint committee or worker representative, as applicable, or
(b) if there is no joint committee or worker representative, post the report at the workplace.
Note: If the recommended corrective actions specified in the report have been implemented by the time it was prepared and
submitted to WorkSafeBC, and the report was subsequently distributed or posted as required, compliance with section 176(2)
Persons
conducting
investigation
s. 3.4(h) OHS
Regulation
has been met.
In cases where
the incidentref:
investigation
report
was submitted prior to the corrective actions being
implemented, or those actions differ from the corrective actions recommended in the report, a separate follow-up
report
must
Date
signed
Representative
ofor posted, in accordance
Name (please
print) 176(2).
Signature (optional)
be prepared
and distributed
with section
(yyyy-mm-dd)
Please
refer to the Incident Investigation Reference Guide for assistance when completing this report. The guide is available
Employer
on WorkSafeBC.com.
Worker
52E40
Employer
Worker
Other
(R04/13) Page 3 of 3
Date Incident Investigation Report submitted to WorkSafeBC ref: s. 175(2)(b) WCA

(yyyy-mm-dd)
Follow-up action and report
Section 176 of the Workers Compensation Act states:

(1) Following an investigation under this Division, the employer must without undue delay undertake any corrective action
required to prevent recurrence of similar incidents.
(2) As soon as is reasonably practicable, the employer must prepare a report of the action taken under subsection (1) and
(a) provide the report to the joint committee or worker representative, as applicable, or
(b) if there is no joint committee or worker representative, post the report at the workplace.
Note: If the recommended corrective actions specified in the report have been implemented by the time it was prepared and
submitted to WorkSafeBC, and the report was subsequently distributed or posted as required, compliance with section 176(2)
has been met. In cases where the incident investigation report was submitted prior to the corrective actions being
implemented, or those actions differ from the corrective actions recommended in the report, a separate follow-up report must
be prepared and distributed or posted, in accordance with section 176(2).
Please refer to the Incident Investigation Reference Guide for assistance when completing this report. The guide is available
on WorkSafeBC.com.
52E40
Page 4 of 5
(R04/13) Page 3 of 3
Tips
Avoid focusing on what you feel the workers should have been able to anticipate. Our goal as investigators is
to understand why the workers actions made sense to them at the time. Understanding why it made sense
to the worker will help you to identify what workplace factors need to be changed to reduce the likelihood
of the incident recurring.
If you develop a theory about what happened early in the investigation, ensure you do not collect data to
prove the theory. There is more than one cause, or underlying factor, and by narrowing the data you are
collecting early on in the investigation you limit your ability to identify other causes or contributing factors.
Definitions
Sequence of events: A chronology of actions/decisions leading up to, and possibly occurring after, an incident.
Unsafe acts: An unsafe act is an action, or lack of action, made in the presence of a hazard. For example, a
worker uses a grinder without a guard, works on energized equipment, or doesnt wear PPE, etc.
Unsafe conditions: May include things like the work environment (e.g., congested work area, poor
housekeeping, poor visibility) or equipment (e.g., lack of safeguarding, poor maintenance).
Procedure: When looking at the procedures, there are some important considerations:
1. Were procedures present?
2. Were procedures utilized?
3. Were procedures applicable to this equipment, work task, etc.?
4. Were the procedures adequate?
5. Were the procedures understood?
Some of the questions that may come from the above considerations:
Were the procedures written?
How were the procedures communicated to the worker?
Where is the procedural information kept?
How long ago was the information communicated?
Were the procedures understood by the worker (e.g., procedures provided in English to workers with
English as a second language)?
How do you know that the procedures were understood?
Have there been any changes to the equipment, product, or work process since procedures were
implemented? These changes may affect ones ability to continue to follow the procedures.
Are there any maintenance issues with the equipment? Often, if machines are not maintained regularly,
workers will adapt the way they perform their task in order to ensure the equipment continues to run.
Can they follow procedures and still complete the job
Page 5 of 5

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Incident Investigation Reference Guide

(52E40 Incident Investigation Report)

After-hours health and

Employer head office address

Date of incident (yyyy-mm-dd)

Time incident occurred

Injured person(s) ref: s. 3.4(b) OHS Regulation

Incident Investigation Report (continued)

Statement of causes ref: s. 174(2)(a)(b) WCA and s. 3.4(f) OHS Regulation

Use this guide when completing the 52E40 Incident Investigation

When is an investigation required?

Who should conduct the investigation?

What is the purpose of an investigation?

Who receives copies of the report?

What follow-up action is required after an incident investigation?

What information should be included in the investigation report?

WHO, WHERE, & WHEN

A brief description of the incident,

Worker runs over