Incident Investigation & Root Cause Analysis

The Incident Investigation and Root Cause Analysis Procedure defines the mandatory steps all supervisors, joint health and safety committee members, and management must follow after any workplace incident. The goal is not to assign blame — it is to identify systemic failures in equipment, training, procedures, or supervision and to implement corrective actions that prevent recurrence. This policy applies to all employees, contractors, and subcontractors operating under company control.

All investigations must be initiated within 24 hours of the incident. The investigation team must include at least one person trained in RCA methodology (e.g., 5-Why, Fishbone, or Fault Tree Analysis). Findings, corrective actions, and closure timelines must be documented on the corporate Incident Investigation Report (Form IIR-01) and reviewed by the H&S committee within 14 days.

This procedure applies to all company-operated sites, including head offices, satellite branches, manufacturing facilities, construction projects, service vehicles, and any off-site work locations where employees or subcontractors are performing work on behalf of the organization. All incident types are covered:

• Near miss — any unplanned event that did not cause injury or damage but had the potential to do so.
• First-aid incident — minor injury requiring basic first aid with no medical treatment beyond first aid.
• Medical treatment injury — any injury requiring treatment by a physician beyond first aid (does NOT include simple diagnostic procedures).
• Lost-time injury (LTI) — injury resulting in time away from work beyond the day or shift of the incident.
• Serious injury or fatality — immediately reportable to the regulatory authority (e.g., WorkSafeBC Section 172 or OSHA 1904.39).
• Property damage / environmental spill — damage exceeding $5,000 or any release reportable under environmental regulations.

All contractors and third-party workers under company supervision must follow this procedure. Subcontractors with their own equivalent investigation program may use their system if approved in writing by the company Safety Director.

• 1Immediate reporting: All incidents must be reported to the immediate supervisor within 1 hour. Serious incidents (LTI, fatality, major property damage) must be reported to the Safety Director within 1 hour and to WorkSafeBC / OSHA within the legally prescribed timeframes (24–48 hours depending on jurisdiction).
• 2Preserve the scene: Except to rescue injured persons or prevent further harm, the incident scene must not be disturbed until a lead investigator has completed an initial assessment and photo documentation. Violation of scene integrity may result in disciplinary action up to termination.
• 3Investigation team composition: The investigation team must include: (a) the supervisor of the affected area, (b) a worker H&S representative or JHSC member, and (c) a person trained in RCA (internal or external). For serious incidents, a senior operations manager must also be included.
• 4Root cause identification: Superficial causes (e.g., "human error") are not acceptable as root causes. The investigation must identify at least one underlying system failure — in training, engineering controls, procedures, supervision, or maintenance — using a recognized RCA method.
• 5Corrective action closure: Each root cause must have a corresponding corrective action with an assigned owner and target completion date. All actions must be tracked to closure via the company incident management system. Actions cannot be closed without verification of effectiveness by the H&S committee.
• 6Annual trend analysis: The Safety Director must aggregate all investigation findings and corrective actions annually (Q1) to identify recurring patterns and recommend program-level improvements to the executive leadership team.

• Workers & Witnesses: Report any incident immediately to their direct supervisor. Cooperate fully with the investigation team. Provide truthful and complete statements. Do not disturb the scene. Workers who are involved in the incident have the right to have a worker representative present during any investigatory interview.
• Supervisors: Initiate the incident notification chain. Secure the scene and ensure no further harm occurs. Escalate serious incidents to the Safety Director within 1 hour. Participate on the investigation team for incidents within their area of responsibility. Implement interim corrective actions within 48 hours where necessary to prevent immediate recurrence.
• Joint Health & Safety Committee (JHSC): Select or approve the worker representative for the investigation team for all incidents resulting in or having potential for serious injury or fatality. Review completed investigation reports and corrective action plans at the next regular JHSC meeting. Verify closure and effectiveness of corrective actions within 30 days of the target completion date.
• Safety Director / H&S Manager: Oversee all high-severity investigations personally. Ensure RCA methodology training is current for all investigation team members. Maintain the corporate Incident Investigation Register. Conduct the annual trend analysis and present it to leadership. Liaise with WorkSafeBC / OSHA inspectors during external investigations.
• Operations Managers / Executives: Provide resources — including budget, personnel time, and external expertise — required to complete investigations effectively. Review and approve corrective action plans with financial implications. Drive closure of overdue corrective actions. Hold supervisors accountable for compliance with this procedure.