This part of the Directive enhances and supplements Part XV (Hazardous Occurrence Investigation, Recording and Reporting [HOIRR]) [] of the COHSR and should be read in that context.

16.1 Employer Responsibilities

16.1.1 The employer shall develop, in consultation with the appropriate health and safety committee, hazardous occurrence investigation procedures and methodologies that include the process for selecting and appointing qualified persons to conduct investigations.

16.1.2 Health and safety committee members must be informed within 24 hours of any hazardous occurrence.

16.2 Objectives

16.2.1 Develop and implement appropriate investigative and analytical techniques and methodologies to identify the direct causes of hazardous occurrences.

16.2.2 Make recommendations for preventative and corrective measures to eliminate, reduce or protect against the risk of accidents and incidents.

16.2.3 For the purpose of this provision, “hazardous occurrence” means, but is not limited to, a workplace incident that results in:

  1. a disabling injury or illness;
  2. a fire, explosion, loss of consciousness or other incident for which there is a potential for injury or illness; or
  3. a minor injury.

16.3 Timely and Effective Hazardous Occurrence Investigations

16.3.1 A qualified person shall begin an investigation of a hazardous occurrence as soon as possible after the occurrence is reported.

16.3.2 The health and safety committee shall be informed of any hazardous occurrence and the name of the qualified person appointed to investigate no more than 24 hours after the occurrence is reported.

16.3.3 The procedure for conducting an investigation shall include the selection of an appropriate methodology and, as a minimum, shall include the following steps:

  1. planning and preparation;
  2. identifying and gathering facts (use of a methodology);
  3. analyzing and assessing facts;
  4. determining direct causes - unsafe conditions or acts;
  5. recommending appropriate preventative and corrective measures to eliminate, reduce or protect against risks;
  6. verifying in consultation with the health and safety committee or its representative the recommended corrective measures and their effectiveness and an acceptable period for implementation; and
  7. writing a report setting out the qualified person’s observations and recommendations.