Overview
Guide incident investigation, root cause analysis, corrective action management, and continual improvement per ISO 45001:2018 Clauses 10.1, 10.2, and 10.3. Validates investigation methodology, CAPA completeness, hazard feedback loop, and legal reporting alignment.
ISO 45001 Clause 10.2 explicitly requires that investigation findings feed back into hazard identification (Clause 6.1.2) — this is not optional. The distinction between correction (immediate action to address consequences) and corrective action (systemic action to eliminate root causes) is a key auditor expectation. This skill produces a complete investigation procedure and CAPA register that close the loop from incident to prevention.
What It Covers
- Incident classification — fatalities, serious injuries, lost-time injuries, medical treatment injuries, first-aid cases, occupational diseases, near-misses, property damage, environmental releases with legal reporting thresholds
- Investigation methodology — structured root cause analysis using 5-Why, Fishbone/Ishikawa, TapRoot, ICAM, or equivalent methodologies
- Correction vs corrective action — clear distinction between immediate containment and systemic root cause elimination
- CAPA register — tracking incidents, corrections, corrective actions, owners, target dates, and effectiveness reviews with INC-NNN and CA-NNN identifiers
- Hazard feedback loop — mandatory link from investigation findings back to hazard identification (Clause 6.1.2)
- Continual improvement — trend analysis, benchmarking, lessons learned sharing, and safety culture initiatives (Clause 10.3)
Output Documents
| Document | Purpose |
|---|---|
| Incident Investigation Procedure | Complete investigation procedure covering classification, reporting, investigation methodology, root cause analysis, and corrective actions |
| Corrective Action Register | CAPA register tracking all incidents with corrections, corrective actions, owners, dates, and effectiveness reviews |
Example Conversation
You: We’re SafeBuild Construction, 200 employees, 3 construction sites. We need an incident investigation procedure and corrective action register for ISO 45001. We had a near-miss last week where a scaffold plank fell from the 6th floor.
Agent: I’ll develop your investigation procedure and CAPA register. That scaffold near-miss is a good real example to work through. First, let me establish your incident classification framework, then we’ll use the near-miss to demonstrate the investigation process. What are the legal reporting requirements in your jurisdiction?
You: We’re in New South Wales, Australia. SafeWork NSW requires notification of deaths, serious injuries, and dangerous incidents. A falling object from height is a notifiable dangerous incident.
Agent: Correct — under the WHS Act 2011, a falling object that could have caused serious injury is a notifiable incident to SafeWork NSW. You must notify the regulator immediately by phone and preserve the scene. Here’s the classification framework I’ll build:
Category Example Legal Reporting Internal Response Time Fatality Workplace death Immediate notification to SafeWork NSW + preserve scene Immediate Serious injury Amputation, head injury, spinal injury Notify SafeWork NSW immediately Within 1 hour Dangerous incident Falling object, collapse, gas exposure Notify SafeWork NSW immediately Within 2 hours Lost-time injury Fracture requiring time off Internal reporting Within 24 hours Medical treatment Laceration requiring stitches Internal reporting Within 24 hours Near-miss Falling scaffold plank (your incident) Internal reporting Within 24 hours Property damage Equipment collision Internal reporting Within 48 hours For investigation methodology, I’ll use the 5-Why analysis as the primary tool for most incidents, with Fishbone/Ishikawa diagrams for more complex incidents involving multiple contributing factors. Let me demonstrate with your scaffold near-miss.
You: That would be helpful. The plank just slid off. Luckily no one was below because the exclusion zone was in place.
Agent: Good that the exclusion zone worked — that’s a control that prevented an injury. Here’s the 5-Why analysis:
Incident INC-047: Scaffold plank fell from Level 6 to ground level
- Why did the plank fall? — The plank was not secured with toe boards and was placed loosely on the scaffold frame
- Why was it not secured? — The scaffolder placed it temporarily while moving materials and did not return to secure it
- Why was it left unsecured? — No requirement to secure planks immediately upon placement; no buddy check system
- Why is there no immediate-securing requirement? — The safe work procedure (SWP-012) only requires securing at “completion of scaffold erection,” not during progressive build
- Why was the procedure written that way? — The procedure was adopted from a template without being tailored to progressive construction scenarios
Root cause: Safe work procedure SWP-012 does not require securing scaffold components progressively during erection.
Now the critical distinction:
- Correction (immediate): Inspect all scaffold platforms for unsecured planks; secure all loose components today
- Corrective action (systemic): Revise SWP-012 to require progressive securing of all components; implement buddy-check verification at each lift level; update scaffold inspection checklist
And the mandatory feedback loop — this finding updates the hazard register:
- Hazard register update (6.1.2): Hazard HAZ-007 “Falling objects” — add “unsecured scaffold components during progressive erection” as a specific scenario; reassess risk rating
Shall I build the full procedure and CAPA register using this as the worked example?
You: Yes, and include fields for effectiveness review — we want to make sure corrective actions actually work.
Agent: Absolutely. The register will track each corrective action through to effectiveness verification. For CA-047 (the scaffold procedure revision), I’ll set the effectiveness review for 90 days after implementation — enough time to observe whether the new buddy-check system is working across multiple scaffold builds.
[Agent drafts both documents…]
Running
validate_incident_procedure_ohs…Result: PASS — Procedure covers 6 incident types, 5-Why and Fishbone methodologies defined, correction vs corrective action distinguished, hazard feedback loop to Clause 6.1.2 present, legal reporting aligned to SafeWork NSW requirements, continual improvement addressed. All mandatory checks passed.
Sample Output Excerpt
Below is a representative excerpt from the Corrective Action Register showing the CAPA tracking structure with the scaffold near-miss as a worked example.
Corrective Action Register — SafeBuild Construction
Register Structure
| Field | Description |
|---|---|
| Incident ID | Unique identifier (INC-NNN) |
| Date | Date of incident |
| Site | Location where incident occurred |
| Category | Fatality / Serious injury / Dangerous incident / LTI / Medical treatment / Near-miss / Property damage |
| Description | Brief factual description of what happened |
| Root Cause | Outcome of 5-Why or Fishbone analysis |
| Correction | Immediate action taken to address consequences |
| Corrective Action ID | Unique identifier (CA-NNN) |
| Corrective Action | Systemic action to eliminate root cause |
| Owner | Person responsible for implementing corrective action |
| Target Date | Due date for completion |
| Status | Open / In progress / Closed / Overdue |
| Effectiveness Review Date | Date to verify corrective action effectiveness (minimum 90 days post-implementation) |
| Effectiveness Result | Effective / Not effective / Partially effective |
| Hazard Register Updated | Yes/No — confirms 6.1.2 feedback completed |
Register Entries
| INC ID | Date | Site | Category | Description | Root Cause | Correction | CA ID | Corrective Action | Owner | Target | Status | Effectiveness Review |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| INC-047 | 2026-03-24 | Site 1 | Dangerous incident | Scaffold plank fell from Level 6 to ground; no injury due to exclusion zone | SWP-012 does not require progressive securing during erection | Inspected all scaffolds; secured all loose components | CA-047 | Revise SWP-012 for progressive securing; implement buddy-check at each lift level; update inspection checklist | Safety Officer | 2026-04-14 | In progress | 2026-07-14 |
| INC-046 | 2026-03-18 | Site 2 | Near-miss | Excavator swung boom over workers in trench without spotter | No spotter procedure for excavator operations near open excavations | Stopped excavator operations; established temporary exclusion zone | CA-046 | Create SWP for excavator operations near excavations; mandatory spotter when working within 5m of personnel | Site Manager (Site 2) | 2026-04-07 | Open | 2026-07-07 |
| INC-043 | 2026-02-28 | Site 3 | LTI | Worker lacerated hand on exposed rebar; 3 days off work | Rebar caps removed during concrete inspection and not replaced; no re-capping procedure after inspection | First aid administered; worker transported to hospital; rebar capped | CA-043a | Add “rebar re-capping verification” step to concrete inspection checklist | Safety Officer | 2026-03-15 | Closed | 2026-06-15 |
| INC-043 | 2026-02-28 | Site 3 | LTI | (same incident) | (same root cause) | (same correction) | CA-043b | Procure high-visibility rebar caps (fluorescent orange) for all sites | Procurement Officer | 2026-03-21 | Closed | 2026-06-21 |
Hazard Register Feedback Log
| INC ID | Hazard Ref | Update Made | Date Updated |
|---|---|---|---|
| INC-047 | HAZ-007 | Added “unsecured scaffold components during progressive erection” scenario; risk rating increased from Medium to High | 2026-03-25 |
| INC-046 | HAZ-012 | Added “excavator swing radius near open excavations” scenario; new control: mandatory spotter procedure | 2026-03-19 |
| INC-043 | HAZ-009 | Added “exposed rebar after concrete inspection” scenario; new control: re-capping verification step | 2026-03-01 |
Extension Tools
validate_incident_procedure_ohs
Validates the incident investigation procedure and corrective action register for completeness against ISO 45001 Clauses 10.1, 10.2, and 10.3.
Inputs:
| Parameter | Description |
|---|---|
procedure_path | Path to the incident investigation procedure (Markdown) |
register_path | Path to the corrective action register (Markdown) |
Checks performed:
| Area | Check | Severity |
|---|---|---|
| Incident Types | At least 3 incident types covered (fatalities, serious injuries, occupational diseases, near-misses, property damage, environmental releases) | ERROR |
| Investigation Methodology | Root cause analysis methodology defined (5-Why, Fishbone/Ishikawa, TapRoot, ICAM, Fault Tree, or equivalent) | ERROR |
| Correction vs Corrective Action | Procedure distinguishes between correction (immediate) and corrective action (systemic) | WARNING |
| Hazard Feedback Loop | Investigation findings feed back into hazard identification (Clause 6.1.2) — mandatory ISO 45001 requirement | ERROR |
| CAPA Register | Required fields present: incident ID, description, root cause, correction, corrective action, owner, target date, effectiveness review date | ERROR |
| CAPA Register | Structured format (table or list) used | WARNING |
| Legal Reporting | Reporting timelines aligned with legal requirements (OSHA, RIDDOR, WorkSafe, etc.) | WARNING |
| Continual Improvement | Clause 10.3 mechanisms described (trend analysis, benchmarking, lessons learned, safety culture) | WARNING |
The tool produces a finding-level report with ERROR, WARNING, and INFO severity. The hazard feedback loop (6.1.2) check is a strict requirement — without it, the OHSMS cannot demonstrate that investigations drive hazard re-assessment.
Getting Started
Activate the ISO 45001 Incident Investigation & Corrective Action skill. For best results, complete these prerequisite skills first:
- Organization Profile — provides organizational context and workforce details
- Hazard Identification & Legal Register — provides the hazard register that investigation findings must feed back into
- OH&S Policy & Leadership — provides roles and responsibilities for investigation authority
- Operational Controls — provides the controls that may need updating based on investigation findings
- Monitoring & Measurement — provides incident data and KPIs that drive trend analysis
Have this information ready:
- Your applicable legal reporting requirements and thresholds (e.g., OSHA, RIDDOR, SafeWork, WorkSafe)
- Any recent incidents or near-misses to use as worked examples
- Current incident reporting process (if any) — how incidents are reported, by whom, and to whom
- Preferred root cause analysis methodology (or let the agent recommend one)
- Existing corrective action tracking system or spreadsheet format
- Any patterns or trends you have noticed in past incidents (repeat hazards, common root causes)
The agent guides you through a 6-step workflow: define incident categories and legal reporting triggers, develop the investigation procedure with root cause analysis methodology, create the corrective action register with correction vs corrective action tracking, establish the mandatory hazard identification feedback loop, define continual improvement mechanisms, and validate both documents for Clause 10 completeness.