Duty Holder Review information sheet

It is an expectation that you will review (investigate) an incident at your workplace as it allows you to examine what caused the incident and to identify and address the causes that contributed to that incident. It doesn’t aim to apportion blame for incidents, but rather for you to improve workplace safety. It is also a legal requirement to investigate an incident to ascertain if it arose from a significant hazard.

By reviewing your incidents you’ll be able to learn from them, make improvements and have better workplace health and safety systems.

The Duty Holder Review process is designed to enable you to improve your health and safety systems and for the regulator to gain a degree of assurance that systems associated with the incident have been improved.

This information sheet provides you with an outline of the steps involved in carrying out a self-review. 

Duty Holder review process

Follow these steps to do a thorough review (investigation).

  1. Identify all the people involved (victim, witnesses, etc).
  2. Get all the facts (who, where, when, what, how, why).
  3. Describe the sequence of activities leading up to the incident.
  4. Include the Health and Safety Representative in your review.
  5. Talk to the victim(s) and their families (if appropriate).
  6. Identify and analyse the immediate, underlying and root causes of the incident.

Note: Identifying underlying causes involves asking a series of ‘why’ questions about the causes you have identified. Each question may have several answers which may lead to further ‘why’ questions. By understanding the reasons for immediate and underlying causes you can make changes that are more likely to be sustainable and effective.

While root causes may be harder to identify, they are more important as they reveal key areas for improvement in your health and safety and/or management systems.

  1. Develop and implement actions to prevent a similar incident. Include any actions you’ve already taken and any planned follow-up actions.
  2. Review your existing health and safety system, particularly the part of the area related most to the workplace involved in the incident. Specify your system in the report and identify changes needed.

Note: The analysis of the cause(s) captured at step 6 should make it clear what corrective actions need to be implemented. These might include improving your existing health and safety management systems.

Note: The reporting template we provide shows all the information you need. You are not required to use the template but you will need all the information it asks for to undertake a thorough and effective review.

  1. Sign the report off.

Once your review has been completed, submit the completed report and supporting documents to the Duty Holder Review Officer, as detailed in our letter to you. Please note the information you provide is subject to the Official Information Act 1982.

It is important that someone in your organisation who holds a leadership or management position signs the report. 

For further information about the Duty Holder Review Process, please contact WorkSafe.