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Chargeable Service Request ESSR Chargeback Procedures Regulated Waste Report to ESSR SciShield Training
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Incident Cause Analysis and Lessons Learned

Home Incident Cause Analysis and Lessons Learned

Effective incident investigations are essential to creating and maintaining a safe and healthy campus environment. By committing to identifying the root causes of workplace incidents, not simply assigning blame. Thoroughly investigating injuries, near misses, property damage, and other safety-related events, the university can identify contributing factors, implement effective corrective actions, and prevent similar incidents from occurring in the future. This webpage provides guidance, tools, and resources to support supervisors and departments in conducting timely, thorough, and consistent investigations that strengthen UMD's proactive safety culture and promote continuous improvement across campus.


Incident Investigation Form

Effective incident investigations are essential to identifying the underlying causes of workplace incidents and preventing similar events from occurring in the future. The ESSR Incident Investigation Form provides a standardized process for documenting incidents, identifying contributing factors, determining root causes, and developing corrective actions.

The form should be completed as soon as practical following any work-related injury, illness, near miss, property damage, or other safety-related event. A thorough investigation focuses on understanding why the incident occurred rather than assigning blame. The goal is to identify opportunities to improve processes, equipment, training, communication, and workplace conditions.

Incident Investigation Instructions

The accompanying Incident Investigation Instructions provide step-by-step guidance for completing each section of the form, including:

  • Gathering facts and evidence
  • Conducting employee and witness interviews
  • Identifying immediate and underlying causes
  • Performing root cause analysis
  • Developing corrective and preventive actions
  • Documenting findings and follow-up activities

What types of incidents should be investigated?

Incidents that result in injury, illness, property damage, or have the potential to cause serious harm (near misses) should be investigated. Investigating near misses is especially valuable because it provides an opportunity to prevent future incidents before someone is injured.

Who is responsible for completing an incident investigation?

Supervisors or department representatives are typically responsible for conducting the initial investigation, with assistance from ESSR Occupational Safety and Risk Resilience as needed. More complex or serious incidents may require additional involvement from ESSR.

When should an incident investigation be completed?

Investigations should begin as soon as possible after the incident occurs. Prompt investigations help preserve evidence, capture accurate witness statements, and identify corrective actions before similar hazards result in another incident.

What is the purpose of an incident investigation?

The purpose is to determine why an incident occurred and identify corrective actions to prevent recurrence. Investigations should focus on identifying contributing factors and root causes, not assigning blame.

What is a root cause?

A root cause is the underlying reason an incident occurred. While immediate causes explain what happened, root causes identify the system, process, or organizational issues that allowed the incident to occur.


Color-Coded Lessons

To quickly identify the primary focus of each lesson learned, ICALL uses a color-coded system based on the type of hazard or safety topic addressed. These categories help employees and supervisors easily locate information relevant to their work and promote awareness of common workplace risks. Each lesson may include one or more color-coded categories when multiple hazards or contributing factors are involved.

Blue Lesson

Blue: A lesson providing information that is not due to any UMD event; but will help our employees to benefit from increased awareness

UMD Lessons Learned Blue Heat Stress

Red Lesson

Red: Lesson from a negative event (e.g., injury, damage to property)

UMD Lessons Learned Red Needlestick

Yellow Lesson

Yellow: A lesson based on a near-miss, where an incident almost occurred, but timing and/or circumstance were such that an incident was averted.

UMD Lessons Learned Yellow Activated Machine Work

Green Lesson

Green: A lesson based on a safe work practice or innovative improvement in hazard mitigation

UMD Lessons Learned Green Safe Alternatives for Roof Work
Environmental Safety, Sustainability and Risk
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