Investigating an incident

Purpose: reporting an incident says what happened. The investigation finds out why, and makes sure something is done so it does not happen again. Custos walks an incident through the steps and records who did what, so the company can show it handled the incident properly.

Who: Supervisors, Safety Managers and Org Admins. Workers can follow their own incident and add comments.

1. The steps

Every incident page has a progress bar at the top, and a line that says what to do next and who does it.

Step	What happens	Who
What happened	The reporter writes the report and submits it (a draft is not investigated). See Reporting an incident.	Reporter
Investigate	An investigator is named, records the findings and the root cause	Assigned person
Fix it	Corrective actions are created, done and verified	See Corrective actions
Close	The investigator requests closure; a Safety Manager approves it	Investigator, Safety Manager

The incident’s statuses are Draft, Submitted, Under investigation, Pending closure approval, Closed and Void.

2. Assign an investigator

Needs the right to assign investigations (Supervisors and above). A new incident waits for one: the dashboard tile Investigations not started shows these.

1. Open the incident and the Investigation tab.
2. Select Assign an investigator…
3. Choose the investigator and a due date: a day at the incident’s site, not before today there.
4. Optionally give a reason, then Assign.

The investigation starts at once. Later, Change investigator… hands it to someone else; the investigator can also Delegate. The investigators are listed under Investigators, with when and by whom.

Only the assigned investigator changes the incident (findings, root cause, requesting closure). Anyone who may assign investigators can change who it is, and Take it over… makes you the investigator.

3. Record the findings

Under Investigation → Findings → Record findings… give the facts the investigator found:

• Conditions (normal, wet or slippery, poor lighting, extreme temperature, high wind, noisy), the shift, and the time since the last break.
• Whether the task was routine, whether the person had the required training, whether a procedure existed and whether it was followed (Yes, No, Not known).
• The sequence of events, the immediate causes (unsafe acts and unsafe conditions from the lists), and contributing factors.

Save with Save findings. Edit findings… changes them while the investigation is open.

4. Record the root cause

The root cause is why it really happened, deeper than what you could see. Under Root cause → Record the root cause… choose a method:

• 5 Whys: write the problem statement in a sentence, then ask “why?” of each answer, one to five times, and stop at a cause you can act on. Finish with the root cause the answers lead to.
• Narrative: describe in your own words what led to it.
• Categories: pick one or more: management system, training, procedures, equipment or material, engineering or design, personal factors, environment.

Save with Save root cause.

5. Create the corrective actions

From the incident’s page create the actions that remove the root cause (Actions tab, Create action). You can create them at any time. Without any, the page asks you to request closure if nothing needs to be done. See Corrective actions.

6. Request and approve closure

The page lists Before it can close: the root cause is recorded, and every action is verified or cancelled.

1. The investigator selects Request closure.
2. A Safety Manager reviews the investigation and actions, then Approve closure, or Reject closure… with a reason. A rejected incident goes back to the investigator, with the reason shown on the page.

A closed incident can be Reopened… by a Safety Manager, with a reason.

7. Void an incident

A Safety Manager can Void… a draft, submitted or investigated incident, with a reason, for example if it was reported by mistake. Everything it recorded is kept, and the reason appears under Activity.

8. Comments and history

• Comments let anyone who can see the incident add what they remember, until it is closed. Use them for facts, not blame.
• Activity (history) shows every change: who, what, when. Medical details are hidden in it.

9. Regulatory cases

If the incident’s site follows a regulation (for example OSHA in the US), each injured person is a case to assess. See Regulatory decisions on incidents.

10. If something goes wrong

What you see	What to do
“Only the assigned investigator changes this incident”	Ask who assigns investigators to change the investigator, or use Take it over… if you may.
The closure button is missing	The checklist under Before it can close says what is missing.
A due date is refused	It must be today or later at the incident’s site, not in your own time zone.