Investigation is more than reporting
Reporting an accident and examining its causes are different actions. The resolution requires all incidents and accidents to be investigated within fifteen days of occurrence. That deadline does not replace other care or reporting duties.
Organise the response to preserve information from the outset without delaying assistance or creating additional exposure. Investigation should not wait for someone to complete an administrative form. Agree who initiates the process and who ensures the necessary participation.
Who forms the investigation team
Decree 1072 provides for, at minimum, the immediate manager or supervisor, a representative of the joint committee or OSH monitor, and the person responsible for the SG-SST. Resolution 1401 adds specialist participation when the accident is serious or fatal.
In those cases, a licensed professional and personnel involved in designing rules or processes or in maintenance participate as required by Article 7. This composition cannot be replaced by someone drafting a report without knowing the task. Experts may support specific technical issues.
Reconstructing events and analysing causes
The report must describe what happened and distinguish the causes identified. The resolution allows a methodology suited to the activity to be selected, provided it meets the minimum content requirements.
As an investigation practice, separate verified facts, witness accounts and unresolved questions. Examine the sequence, conditions, equipment and organisation. A conclusion limited to distraction may leave maintenance, design, instructions or operational pressure unexplored. The aim is to explain what allowed the event and which barriers must change.
Reporting, submission and coordination
The resolution specifies report content and requires investigations of serious and fatal accidents to be submitted to the relevant administrator within the deadline in Article 14. The 2007 text uses institutional terminology from that time; it must be interpreted within the current occupational risk framework.
Where different companies are involved, clarify their participation and the corrective actions belonging to each. Keep a traceable version of the case file, avoiding incompatible documents about the same event or unsupported conclusions.
Turning conclusions into improvements
Decree 1072 connects investigation with identifying SG-SST deficiencies and preventive, corrective and improvement actions. The resolution requires resources, owners, follow-up and verification of effectiveness.
Each measure must address a cause and allow a change to be checked. Do not close an investigation merely because a circular was issued. Observe the task after intervention, review equivalent situations and communicate useful learning without disclosing unnecessary personal data. If the control does not work, adjust the measure.
Hypothetical example: a near fall without injury
A person avoids falling while walking through an area with a spill. The workplace initiates an incident investigation. The team discovers that the leak recurs after an operation and that cleaning only temporarily removes its effects.
The source is corrected, the working method reviewed and the area checked during several operations. The file explains causes, owners and follow-up. The absence of injury is not used as a reason to disregard the learning.
