QUALITY DOCUMENT
Name of Form: Investigation Procedure

Investigation Procedure

1.0  PURPOSE

The purpose of this procedure is to set the framework for the undertaking of investigations.  

2.0  SCOPE

This procedure applies to Kelsian Group Limited ("Kelsian") businesses within:

• Australian Public Transport (APT)
• Kelsian Corporate
• SeaLink Marine and Tourism (M&T)
• Tower Transit Singapore

3.0  RESPONSIBILITIES

General Managers / Managing Directors are responsible for:

• Ensuring investigators are competent in the ICAM process
• Implementing this procedure within their Business Unit
• Obtaining legal professional privilege as required
• Ensuring workers understand the criticality of preserving site security post-incident.
• Ensuring timeframes are maintained in accordance with this procedure.

Business Unit HSEQ representative is responsible for:

• Supporting the Business Unit during an investigation
• Communicating key learnings in accordance with this procedure.

Workers are responsible for:

• Assisting with any requests from investigators as required.
• Ensuring site preservation if first on-site at an incident.

Divisional Heads of HSEQ are responsible for:

• Providing advice and support to Business Units on investigation processes. 

4.0  INVESTIGATION

The purpose of investigating is to establish underlying root causes to prevent a re-occurrence.

An internal investigation must be conducted for:

• Notifiable incidents (i) to Regulatory Authorities  
• High potential incidents
• Systematic trends – multiple incidents occurring with a similar nature  
• Any other incidents required by Kelsian or Divisional management  

Investigators are to be competent and have the independence to ensure an impartial analysis is undertaken.

Investigations can be undertaken by internal investigators and external regulatory authorities. Workers must assist with any requests from investigators when requested. 

5.0  LEGAL PROFESSIONAL PRIVILEGE

Legal Professional Privilege protects information collected and communications during an investigation from compulsory production in the context of court and legal proceedings. To obtain Legal Professional Privilege the General Manager/Managing Director of the Division/Business Unit must request legal advice from Internal Legal via email prior to the investigation commencing. 

6.0  MAINTAINING EVIDENCE

Securing the Site

The site where the incident has occurred is not to be disturbed until an Investigator / Inspector arrives or any earlier time that an Inspector may direct.

The worker responsible for the site at the time of the incident is responsible for securing the incident site and:

• Taking appropriate action to make the area safe and prevent escalation of the situation
• Preserving the incident scene whilst ensuring actions are implemented to prevent further incidents
• Photographing or recording the scene as soon as possible • Ensuring perishable evidence is preserved
• Carrying out a preliminary assessment of the incident
• Documenting the emergency response actions for later analysis

The above requirement does not prevent any action:  

• To assist an injured person
• To remove a deceased person
• That is essential to make the site safe or to minimise the risk of further incidents.
• That is associated with a police investigation
• For which an Inspector or Regulator has given permission 

Securing other Evidence

The preservation of evidence outside of the incident site may be required for investigation purposes. This includes securing and protecting CCTV footage and/or audio records, that may shed light on the nature and quality of the incident. 

7.0  UNDERTAKING THE INVESTIGATION

The purpose of an investigation is to determine: 

• What happened
• Why it happened
• What is going to be done about it
• What was learned, and
• What can be shared 

It is important to identify all people who might have relevant information to obtain statements as soon as practicable after the incident. Where interviews are required, these must be held in a no-blame environment, collaboratively and respectively.

During the investigation, it is important to consider:

• If similar incidents have occurred, or if any trend is identified
• Review of risk registers to understand control effectiveness
• Consultation with relevant parties

Recommendations are to be identified to eliminate the root cause of the incident, or if not practicable, to reduce the likelihood of a recurrence. Recommendations must be appropriate to the effect or the potential effect of the incident.

Depending on the severity of the incident the investigation can be scalable in approach, utilising the SafeConnect (ii) reporting system or the Significant Investigation Report form. 

8.0  INVESTIGATION TIMEFRAMES AND APPROVALS

Investigating within an appropriate timeframe is essential to allow for sufficient time for a thorough and detailed investigation. When establishing a timeframe for an investigation, the following should be considered:

• Scope of the investigation
• Complexity of the investigation
• Timeframe to gather required information
• Availability of resources
• Timeframe for review and approval of the investigation

Once established, the investigation shall be classified, delivered and approved within the following timeframes: 

The initial review meeting is to be held with the relevant Divisional Executive, General Manager/Managing Director of the Business Unit, Divisional Head of HSEQ and other stakeholders.

Where it has been identified that the originally agreed timeframe cannot be achieved, an extension of investigation can be requested by the lead investigator. Requests for extensions must be approved through the Divisional Head of HSEQ. 

9.0  CORRECTIVE ACTIONS

Once approved, corrective actions must be recorded, assigned and actioned in accordance with the Actions Management procedure.

Where management rejects a recommendation put forward by the investigating team, the details of the reasoning must be recorded within the investigation report. 

10.0  COMMUNICATE KEY LEARNINGS

Where identified as part of the investigation, learnings should be shared broadly throughout the business. This can be communicated through toolbox talks, team meetings, internal business media posts or formally documented safety communications (e.g., Safety Alert). Details should cover the following information:

• Incident summary
• Incident cause (if known and available at the time of issue)
• Action/s that were taken and required
• Where to go for further information and assistance

Key learnings are to be presented through relevant safety governance committees. 

11.0  RELATED DOCUMENTS

11.0  REFERENCES

• ISO 45001:2018 Occupational health and safety management systems – Requirements with guidance for use

12.0  DEFINITIONS

13.0  VARIATION

Where a Business Unit identifies an impediment in its ability to comply with this document or part thereof, a Variation Form must be completed. 

14.0  VERSION CONTROL

To ensure the HSEQ Management System remains relevant and maintains a focus on continuous improvement, this document must be reviewed at least every 2 years and where appropriate amended by the Document Control Procedure. 

i.  There may be instances where a marine incident is notifiable to Australian Maritime Safety Authority but is minor and therefore an ICAM incident investigation is not necessary.  

ii.  Local systems/processes to be used where SafeConnect has not been deployed.