8 October 2026 by ASC Team
Open the incident register on most South African sites and the column headed “cause” says the same thing in different handwriting: operator did not follow procedure, operator error, negligence, failed to wear PPE. Every one of those is a description of the last act before the injury. None of them is a cause, because none of them answers the only question an investigation exists to answer: what made that act likely, and what will we change so that the next person, on the next shift, does not do the same thing? General Administrative Regulation 9 under the Occupational Health and Safety Act 85 of 1993 requires the employer to investigate within seven days and to record the suspected cause and the recommended steps to prevent a recurrence. An investigation that stops at the operator has recorded a symptom and recommended a reminder. This guide is about getting past that line, with a forklift incident as the worked example.
What does the law actually ask the investigation to find?
Section 24 requires the employer to report certain incidents to an inspector: a death, unconsciousness, the loss of a limb or part of one, an injury or illness likely to cause death, a permanent physical defect or at least 14 days away from the person’s usual work, a major incident, and incidents in which health or safety was endangered. General Administrative Regulation 8 sets the clock, within seven days on WCL 1 or WCL 2 for the 14 day class and forthwith for the most serious. Section 24(2) freezes the scene only after a death, a likely death or the loss of a limb or part of one: nobody disturbs it without an inspector’s consent, except to prevent a further incident, remove the injured or dead, or rescue people. Other reportable incidents do not freeze the scene; preserve it anyway, as evidence.
Regulation 9 is the investigation. The employer must keep a record in the form of Annexure 1 of every reportable incident and every incident that needed medical treatment beyond first aid, for at least three years. Under 9(2), each must be investigated within seven days of the incident by the employer, a person the employer appoints, a health and safety representative or a committee member, and finalised as soon as reasonably practicable. Under 9(3) the findings go into Annexure 1 immediately after completion. Under 9(4) the committee examines every record at its next meeting, and the employer ensures that reasonably practicable steps are implemented and followed up to prevent a recurrence.
Annexure 1 itself asks for a short description, the suspected cause, and the recommended steps to prevent a recurrence, and then for the action the employer took and the committee’s remarks. It does not prescribe a method. The five whys, the cause and effect diagram and the rest are good practice, not law. But the form’s own logic defeats “operator error”: if the suspected cause is the operator, the recommended step to prevent a recurrence is a different operator, and nobody writes that down because everyone knows it is not true.
What happened in the forklift aisle at Mzansi?
Mzansi Fresh Meals is the case site in ASC’s courses: a chilled ready meals plant in Kempton Park with 400 people on two shifts and 60 agency workers, a training scenario built from real audit, inspection and incident patterns. No real company is named. Six electric forklifts and three pallet jacks share an aisle with the pickers, separated by painted lines and a speed rule. In 2025 a forklift struck a picker. He was off for 14 days. The incident was reported under section 24 within seven days, recorded in Annexure 1, and investigated. The suspected cause was recorded as “operator did not follow procedure”: the picker had stepped over the line to reach a pallet, and the driver had not sounded the horn at the crossing.
Both statements were true. Neither was a cause. Here is the same incident taken one step further at each turn.
| The investigation asked | The answer | What it points to |
|---|---|---|
| Why did the picker step over the line? | The pallet he needed was on the forklift side, because the night shift stacks returns there when the racking is full | A work organisation condition: the line is crossed every shift by design, not by one person’s choice |
| Why did the driver not sound the horn? | The horn on that forklift had not worked for a month. It was on the pre-start checklist, ticked every day | A maintenance condition and a checking condition: the control existed on paper and was known not to work |
| Why was the forklift still in service with no horn? | Two of the thirteen operator licences had expired and there was pressure to keep every working truck moving; the defect had been reported once, to a supervisor who had since left | A supervision and resourcing condition, and a reporting route that ended with one person |
| Why do forklifts and pickers share an aisle at all? | The 2021 baseline risk assessment rated the aisle as medium with “painted demarcation and speed limit” as the controls, and had never been reviewed | A risk assessment condition: the hazard was rated with controls that cannot physically keep a truck from a person |
| How often had this nearly happened? | Once or twice a week, for years. Three near misses were recorded for the whole site in 2025 | A reporting condition: the site had no way of hearing about the hazard until it caused an injury |
The immediate causes were the step over the line and the silent horn. The underlying causes were a layout that forces crossings, a defect reporting route that fails when one person leaves, a pre-start check that is ticked rather than done, a baseline risk assessment that rated a struck-by hazard as controlled by paint, and a near miss system that did not exist. Section 8(2)(b) requires the employer to eliminate or reduce a hazard before resorting to personal protective equipment, and the control that the hierarchy puts first here is a barrier rail with gated crossing points. That is the recommended step that prevents a recurrence. “Retrain the picker on the walkway rule” is not; the site had already done it.
Why does blame stop an investigation?
Three reasons, and they compound. Blame is cheap: a warning costs nothing and a barrier rail needs a budget. Blame is comfortable for the people who sign the report, because every cause beyond the operator is a condition somebody above the operator created or left in place. And blame does the real damage afterwards: once a site is known to find operators at fault, the operators stop talking. The picker gives short answers. The driver who reported the horn once does not report the next defect. The near misses stay in people’s heads. Section 26 of the Act forbids the employer from disadvantaging an employee for giving information required under the Act, but no section can make a worker volunteer what they have learned will be used against them.
The fix is in how the interview is run. The person leading it says at the start that the purpose is to find what to change, not who to blame, and then behaves that way. Questions are about the work, not the person: what normally happens here, what was different that night, what would have made this easier to do safely. The representative takes part, which section 18(1) allows, examining the causes of incidents together with the employer, and regulation 9(2) names a representative as one of the people who may investigate. A site where the representative sits in on every investigation gets different answers from the floor.
How far back is far enough?
Stop when the next why would leave the site’s control, and when the cause you have reached is something you can change and verify. “The driver did not sound the horn” is not it; the change it implies is a reminder. “The pre-start check is ticked without the horn being tested, because the sheet is signed in the office” is it; the change is to do the check at the truck, and the verification is a defect count that goes up before it goes down. “Forklifts and pedestrians share a route with no physical separation” is it; the change is a rail, and the verification is that nobody can cross except at a gate.
Write the causes in that form, as conditions, with the control that addresses each one labelled by its level on the hierarchy, an owner and a date. Then do the thing regulation 9(4) and ISO 45001 clause 10.2 both ask for and most sites skip: go back and check that the action was taken and that it worked. Clause 10.2 also requires the risk assessment to be reviewed after an incident, and that is where the 2021 baseline finally gets its medium rating corrected. If a near miss in the same aisle is reported after the rail is installed, the system is working, in both senses.
What goes on the form?
Annexure 1, section 2, asks the investigator for a short description, the suspected cause and the recommended steps. Write the description as a sequence of events with times. Write the suspected cause as the underlying conditions, in one sentence each, with the immediate causes named as such. Write the recommended steps against each condition, with the hierarchy level. Section 3 is the employer’s action, signed and dated; section 4 is the committee’s remarks under regulation 9(4). Under the COID Act, section 39 separately requires the employer to report the accident to the Compensation Commissioner within seven days of receiving notice, and since 1 April 2026 law firms report an administrative penalty of 10 percent of the employee’s annual earnings for a late report. That report is about compensation; the investigation is about prevention. Keep them apart.
Frequently asked questions
Does the law require a root cause method?
No. General Administrative Regulation 9 requires an investigation within seven days and Annexure 1 asks for the suspected cause and the recommended steps. The five whys, the cause and effect diagram and similar methods are good practice and ISO 45001 clause 10.2 territory, not law.
Who may investigate an incident?
Regulation 9(2): the employer, a person the employer appoints, a health and safety representative or a committee member. Section 18(1) separately lets a representative examine the causes of incidents together with the employer.
Is operator error ever the cause?
An act by a person is always part of the sequence, and a deliberate breach may have to be dealt with under the site’s own rules. But as the recorded cause it ends the investigation where the useful questions begin. Record the act as an immediate cause and keep going.
Can we move the forklift after an injury?
Section 24(2) applies only after a death, a likely death or the loss of a limb, and even then you may make safe, remove the injured and rescue people. A 14 day injury like the 2025 forklift strike is reportable under 24(1)(a) but outside 24(2), so the forklift may lawfully be moved. Photograph it first; photographs are irreplaceable afterwards.
How quickly must we investigate?
Regulation 9(2): within seven days of the incident, finalised as soon as reasonably practicable. Reporting to an inspector under regulation 8 runs on its own clock: within seven days for the 14 day class, forthwith for a death and the most serious injuries.
What if the person at fault was a contractor’s worker?
The incident is still investigated and recorded, and regulation 8(3) requires an incident involving a person other than an employee to be reported forthwith to the provincial director. Section 37(2) and a written agreement affect the presumption of liability between the site and the contractor; they do not change what the investigation has to find.
Which ASC course teaches investigation that finds causes?
This guide is drawn from Hazard Identification, Risk Assessment and Incident Investigation, FS67, a course for supervisors, representatives, SHEQ officers, engineers and consultants: anyone who writes a risk assessment or investigates an incident. Module 2 is the investigation, and lesson 2.6 closes the forklift incident in the Incident Investigation and Corrective Action tool.
R1 495, prices in rand with no VAT added. About 5 hours, self paced, lifetime access.
- Section 24, General Administrative Regulations 8 and 9, Annexure 1, COIDA reporting and the 2026 penalties.
- The first hour, gathering evidence, interviewing without blame, the sequence of events, immediate and underlying causes, the five whys and the cause and effect diagram.
- Corrective action with clause 10.2 as the structure, the hierarchy again, and verification of effectiveness.
- Three knowledge checks, three games, eight scenario checks, three case study assessments and a final, all at 70 percent.
Enrol now and find the causes. All eight courses and the free guides sit at ISO 45001 and health and safety training. For a team, ask about a group arrangement on WhatsApp ASC.
Related guides: Baseline, issue based and task based: which risk assessment do you owe and Why the near miss you did not report matters.
Sources
- Occupational Health and Safety Act 85 of 1993, sections 8, 18, 24, 26 and 37, SAFLII consolidated text, saflii.org
- General Administrative Regulations, 2003, regulations 8 and 9 and Annexure 1, saflii.org
- Compensation for Occupational Injuries and Diseases Act 130 of 1993, section 39, SAFLII consolidated text; administrative penalties from 1 April 2026 as reported by Bowmans and CMS
- ISO 45001:2018, Occupational health and safety management systems: Requirements with guidance for use (ISO), clause 10.2
This guide is training, not legal advice. ISO 45001 is copyright and is not reproduced here. ASC is not affiliated with ISO. Last updated 8 October 2026.