Purpose
This guide establishes the process for reporting and investigating incidents in building operations. Every incident, including near misses, represents a failure in a control that could have caused injury, damage, or business disruption. Investigation identifies root causes so they can be eliminated.
Applicable Standards
- ISO 45001 — Occupational Health and Safety (incident investigation requirements)
- OSHA recordkeeping requirements (29 CFR 1904)
- Bangladesh Labour Act 2006 — accident reporting requirements
- Heinrich Safety Triangle — ratio model for incident prevention
Incident Classification
| Category | Definition | Response Time | Investigation Level |
|---|---|---|---|
| Fatality | Death of any person | Immediate | Full investigation, external authority notification |
| Major injury | Fractures, amputations, loss of sight, hospitalisation over 24 hours | Within 1 hour | Full investigation, authority notification |
| Minor injury | First aid treatment, no lost time beyond day of incident | Within 4 hours | Local investigation by line manager |
| Property damage | Damage to building, equipment, or third-party property | Within 4 hours | Investigation proportional to damage |
| Near miss | Event that could have caused injury or damage but did not | Within 24 hours | Review and trend analysis |
| Dangerous occurrence | Structural collapse, fire, explosion, gas leak, lift failure, electrical flashover | Immediate | Full investigation, authority notification |
Reporting Process
| Step | Action | Who | Within |
|---|---|---|---|
| 1 | Make area safe, provide first aid, call emergency services if needed | Anyone present | Immediate |
| 2 | Notify line manager / FM duty manager | Person involved or witness | Immediate |
| 3 | Preserve the scene (do not clean up until investigation complete) | FM / Security | Immediate |
| 4 | Complete incident report form | Line manager | Within 24 hours |
| 5 | Notify senior management and safety team | FM Manager | Within 24 hours |
| 6 | Notify authorities if legally required | Safety Officer / HR | Per legal requirement |
| 7 | Conduct investigation | Investigation team | Within 48 hours (start) |
| 8 | Implement corrective actions | Responsible persons | Per action plan |
| 9 | Close out and verify effectiveness | Safety Officer | Per action plan |
Root Cause Analysis
Root cause analysis goes beyond the immediate cause to find the underlying system failure. Common methods:
- 5 Whys — ask "why" repeatedly until the root system failure is identified. Simple and effective for most building incidents.
- Fishbone (Ishikawa) diagram — categorise causes into People, Process, Plant, Place, Procedures. Good for complex incidents with multiple contributing factors.
- Bow-tie analysis — maps threats, controls, consequences, and recovery measures. Good for high-consequence, low-probability events.
Example: 5 Whys
| Why | Answer |
|---|---|
| Why did the technician get an electric shock? | He touched a live conductor |
| Why was the conductor live? | The circuit was not isolated |
| Why was it not isolated? | No lockout/tagout was performed |
| Why was LOTO not performed? | The technician was not trained in LOTO |
| Why was he not trained? | No training programme exists for electrical maintenance staff |
| Root cause: | No LOTO training programme for maintenance staff |
Near Miss Reporting
Near misses are the foundation of incident prevention. The Heinrich Safety Triangle shows that for every major injury, there are approximately 300 near misses. Capturing near misses allows you to fix problems before someone gets hurt.
- Make it easy — simple form (paper or digital), no blame, minimal fields.
- Respond visibly — acknowledge every report, communicate what action was taken.
- Track trends — monthly analysis of near miss categories to identify systemic issues.
- Reward reporting — recognise individuals and teams who report near misses.
Incident KPIs
| KPI | Target | Red Flag |
|---|---|---|
| Lost Time Injury Frequency Rate (LTIFR) | Below 1.0 | Above 2.0 |
| Near miss reporting rate | Above 10 per month (large building) | Zero reports (under-reporting) |
| Investigation completion time | Within 5 working days | Over 10 working days |
| Corrective action closure rate | Above 90% on time | Below 70% |
| Repeat incidents (same root cause) | Zero | Any repeat |
References
- ISO 45001 — Occupational Health and Safety
- OSHA — Recordkeeping Requirements (29 CFR 1904)
- HSE — RIDDOR Reporting
- Bangladesh Labour Act 2006, Chapter VIII
Insights & Guidance
- 6 incident categories from fatality to near miss, each with defined response times and investigation levels.
- 9-step reporting process: make safe, notify, preserve scene, report, investigate, correct, close out.
- Root cause analysis (5 Whys, Fishbone) goes beyond the immediate cause to fix the system failure.
- Near miss reporting is the foundation of prevention. Zero near miss reports means under-reporting, not safety.
- Track LTIFR, near miss rate, investigation time, corrective action closure rate, and repeat incidents.
Without systematic incident reporting and investigation, the same failures repeat. Near miss reporting catches problems before they cause injuries. A culture of reporting is the single strongest predictor of workplace safety performance.
- Blame culture — people stop reporting incidents and near misses. Management loses visibility.
- Superficial investigation — stops at the immediate cause without reaching the root system failure.
- No follow-through — corrective actions identified but never implemented or verified.
- Incident report forms (completed within 24 hours)
- Investigation reports with root cause analysis
- Corrective action tracker with status and deadlines
- Near miss reporting forms and trend analysis
- Is the incident reporting procedure posted?
- Are near miss report forms accessible?
- Is there a visible corrective action board?
- How many incidents and near misses were reported last year?
- What is the corrective action closure rate?
- Can you show me the last 3 investigation reports?
- Serious incident investigation — independent safety consultant.
- Legal reporting obligations — legal counsel.
- Safety culture assessment — behavioural safety consultant.