Conducting an HSE investigation
HSE investigations identify the immediate causes of an incident or near-miss (what happened) and the underlying causes (why it happened). Addressing only the immediate causes risks repeat accidents; resolving underlying causes helps prevent recurrence.
8D is an ideal process for HSE investigations
The Eight Disciplines (8D) method is a robust investigation and problem-solving framework used across many industries. It fits HSE work well by guiding teams to contain hazards, analyse root causes, implement corrective actions and prevent recurrence:
- Containment of the problem
- Root cause analysis
- Problem correction (corrective actions)
- Problem prevention (system changes)
HSE investigation workflow
Discipline 0 (D0): Summary
Name the HSE investigation clearly to support communication (e.g., incident descriptor and date). Write a short factual summary that will title the investigation report.
Discipline 1 (D1): Investigating team
Define the cross-functional team (process owner, HSE, supervisors, SMEs). Record names, roles and relevant competencies.
Discipline 2 (D2): Description of incident
Describe workplace conditions, machines, tools, materials and methods that caused or contributed to the incident. Examples:
- The guard had been removed from the machine, allowing the operator’s hand to contact the rotating part.
- The floor was cracked, causing the operator to trip.
- Current practice requires reaching into the tumbler, creating a splash hazard.
- Water dripping from the ceiling made the walkway slippery.
Discipline 3 (D3): Immediate remedial actions
First, remove immediate risk to prevent repeat occurrences. List actions and status:
- Isolated and quarantined the machine
- Erected warning signage and briefed staff
- Issued safety glasses to the operator
- Installed temporary barriers around the area
Discipline 4 (D4): Actual/probable root causes
Ask why the immediate causes occurred and identify underlying systemic causes. For example, if a handrail failed due to loose fixings, why were fixings loose? Keep asking “why” until systemic issues are exposed.
- The guard was removed to increase throughput to meet targets.
- The specified floor material was unsuitable for the environment.
- Mandatory use of safety glasses was omitted from training.
- Roof damage from walkway debris led to water ingress.
Discipline 5 (D5): Permanent corrective actions
Identify and justify solutions that address root causes. Use brainstorming techniques if helpful. (If you link externally, add rel="nofollow noopener".)
- Route the job to the correct guarded machine (e.g., X263455).
- Replace the floor with a suitably durable surface.
- Add safety-glasses requirements to training and SOPs.
- Add roof/walkway protection to prevent debris.
Discipline 6 (D6): Solution deployment
Create an implementation plan with owners and due dates. Capture evidence (photos, sign-offs, measurements) that actions are effective.
Discipline 7 (D7): Procedure & system changes
Define the tasks necessary to prevent recurrence. Consider:
- Updating the management system (QHSE manual, risk assessments)
- Updating company standards and procedures
- Updating the audit plan and checks
Apply improvements to similar areas/processes where relevant.
Discipline 8 (D8): Summarise and close
Close the investigation, share lessons learned, and recognise the team. Communicating success builds support for future HSE improvements.