UNIT-04

ACCIDENT REPORTING &

INVESTIGATION PROCEDURE
OBJECTIVES
 Explain the meaning and impact of accidents

 Identify different types of accident causes

 Know the purpose of accident investigation

 Explain how to conduct an accident investigation

 Know how to document accident investigations.

PURPOSE OF ACCIDENT INVESTIGATION
 Determine the sequences of events leading to failure.

 Identify the cause of the accident.

 Find methods to prevent accident from recurring.

WHAT TO DO IF ACCIDENT HAPPENS?
The most important things in an accident are:

⦁ When an accident happens, the most important thing is taking care of

the victim or victims.

⦁ After that, the most important thing is finding the causes of the accident.

⦁ All of us, including employers,

need help and advice to identify the causes of
accidents.
CONSEQUENCES OF ACCIDENTS

Direct Consequences Indirect Consequences

1. Personal injury 1. Lost income

2. Property loss 2. Medical expenses
3. Time to retrain another person
4. Decreased employee moral
LOSS
 Accidents also cause great economic losses

 Lost efficiency due to break-up of crew.

 Damage to tools and equipment.

 Damage from accident due to fire, water, chemicals, spills, crashes, etc.

 Loss of customers because products and services are not provided.

 Training costs for replacement worker.

IMPORTANT TERMS
What is an accident ?
An unwanted, unplanned event that causes injuries, illnesses, or
property damage.

What is an incident ?
An unwanted, unplanned event that almost causes injuries, illnesses, or
property damage.
 BASIC SAFETY MANAGEMENT.

What is Accident ???………

 BASIC SAFETY MANAGEMENT.

Accident:
It is unwanted and unexpected event which may or may not cause injury to the
person and damage to the property is called as Accident.

Why?
Over Confidence
Ignorance Not Wearing PPE

Carelessness
Not following the safety Rules
Negligence Accident
Illness

Urgency
Worries
Fatigue
Lack of concentration
 BASIC SAFETY MANAGEMENT.

Types of Industrial Accidents

R NLWD LWD R

Fatal / amputation

Serious/Death
 BASIC SAFETY MANAGEMENT.

What is Accident ???………

“It is unplanned & Unintended OCCURANCE which resulted in
1. Injury,
2. Property Damage
3. Or Both(1 & 2)
During the course of Employment.

No Permanent
Solution

• Human Factor/ Unsafe Act Area of Focus

•Eqpt. Factor/ Unsafe Condition

Permanent Solution
 BASIC SAFETY MANAGEMENT.
Why Accident Occurs : Unsafe
Human Related
-Over Confidence Action
- Urgency,
- Negligence
- Lack of concentration
Equipment
- Fatigue, Related Unsafe
- Less skill Condition
- No proper training
- Hazardous Arrangement /Layout
- Ignorance
- Not following safety Rules - Improper Guarding
- Not Wearing PPE - Use of Defective equipment
-Operating Eqpt. Without Authority
- Improper illumination
- Unsafe Loading/ Placing
- Making safety device inoperative - Improper ventilation
- Taking unsafe position
- Lack of PPE
- Using unsafe equipment
- Working at unsafe speed
- Poor 4S
 BASIC SAFETY MANAGEMENT.

Our Strong Belief…..

Heinrich’s Principle

“ For each major industrial

accident, there are 29 other
accidents derived from the
same cause that result in
minor injuries, and 300
near-accidents.”

Near Misses are

caution call/ warning
to some thing BIG
which is going to
come……..
 BASIC SAFETY MANAGEMENT.

Hierarchy of Incident/ Accident

An accident is an unexpected or unplanned incident or
circumstance, which may or may not cause injury to the
member or damage to the facilities

Fatalities
Accidents
Severe Injuries

Minor injuries
Incidents
Near Miss

Unsafe conditions/Act
Definitions as per IS 3786
Definitions as per IS 3786
Definitions as per IS 3786
Definitions as per IS 3786
Definitions as per IS 3786

Incidence Rate:
CAUSES OF ACCIDENTS
Unsafe Conditions:

 Poorly maintained machinery or equipment.

 Defective or missing personal protective equipment.
 Unguarded machinery or equipment.
 Missing or inadequate Guard
 warnings or safety and health signs.
 Lack of housekeeping.
CAUSES OF ACCIDENTS
Unsafe Acts:

 Conduct work operations without prior training.

 Block or remove safety devices.

 Clean, lubricate, or repair equipment while its in operation.

 Working without protection in hazardous places.

Ask 5 QUESTION(5W & 1H)
 WHO
 WHAT
 WHEN
 WHERE
 HOW

1. Who
• was injured?
• saw the incident?
• was working with him/her?
• had instructed, trained, assigned the affected person/
• else was involved?
• Can help prevent the re-occurrence?
 2. what • PPE was used or should have been used?•

• problems or questions was encountered?•

 was the injury/illness?•
• did the employee and others do after the
 was being done at time of injury or incident?•
incident?•
 were they told to do so?• • did witnesses see?•
 tools were being used?•
• will be done to prevent re-occurrences.•
 machinery was involved?•
 operation was being performed?• • safety rules or procedures were violated?•
 instruction had been given?• • safety rules or procedures were lacking?•
 precautions were given?•
 precautions were necessary?• • safety rules or procedures were needed?•

• additional training should be included?

3. When
 did the injury or incident occur?
 did the employee begin the task?
 the employee assigned to the task?
 were the hazard or risk pointed out to the employee?
 did the supervisor last check on the employee's progress?
 did the employee last notice that something is wrong?
 was appropriate training provided?
 was a risk assessment done? Three more questions you need to
answer for your accident investigation report to be valid
4.Why
 was the employee injured?
 did the employee behave that way?
 did other persons behave that way?
 was PPE not used?
 were specific instructions not given to the employee?
 was the employee in that position/place?
 did the employee continue working under the circumstance?
 was the employee allowed to continue working?
 wasn't the supervisor there at the time?
5. Where
 did the injury or incident occur?
 was the employee at the time of the incident?
 was the supervisor at the time of the incident?
 were co-workers at the time of the incident?
 were the witnesses when the incident occurred?
6. How
 was the employee injured?•
 could the injury/illness have been avoided?•
 could co-workers avoid similar injury/illness?•
 could the supervisor have prevented the injury/illness?

Make sure you answer all of the above when investigating any major or
minor accident at your workplace.
3 STEPS OF EFFECTIVE INVESTIGATION
1. Investigate

2. Analyze

3. Report
1. INVESTIGATE
 Seal the accident area.

 Interview witnesses.

 Draw and take measurements of the accident area.

 Take samples.
2. ANALYZE

 Say what happened step-by-step.

 Analyze the events with the 6 key questions:

 Who?
 What?
 When?
 Where?
 Why?
 How?
3. REPORT
 Say what happened.

 Say which were the surface causes.

 Say which were the root causes.

 Say what needs to be done so the accident doesn’t happen again.

INVESTIGATE AND ANALYSIS

Accidents must be investigated and analyzed from three different

points of view:
1 . Direct cause of injury

2. Surface causes of accident

3. Root causes of the accident

1. DIRECT CAUSE OF INJURY
 A harmful transfer of energy that produces injury or illness.

EX. The worker suffered two broken legs when the truck crashed into
the wall.
2. SURFACE CAUSES OF ACCIDENT
 Specific unsafe conditions or unsafe behaviors that result in an accident.

EX. The truck crashed into the wall because the brakes failed.
3. ROOT CAUSES OF THE ACCIDENT
 Common conditions and behaviors that ultimately result in an accident.

EX. The company did not have a maintenance program for its vehicles.
Weed out the causes of injuries and illnesses
Strains
Burns
Direct Causes of
Cuts Injury/Illness

Surface
Causes of the
Accident

Conditions Behaviors
Lack of time Fails to enforce

Inadequate training

No discipline procedures Inadequate labeling procedures

No orientation process Outdated Procedures

Inadequate training plan

No accountability policy No inspection policy

Root Causes of the

- Accident Weed Accident
RISK ANALYSIS
Importance of Risk Analysis
 Almost all of the things that we do involve risk of some kind, but it can
sometimes be challenging to identify risk, let alone to prepare for it.

 Risk Analysis helps you understand risk, so that you can manage it,
and minimize disruption to your events.

 Risk Analysis also helps you control risk in a effective way.

 Risk Analysis helps you identify and manage potential problems that
could undermine your activity.

 Risk is made up of two things: the probability of something going wrong, and
the negative consequences that will happen if it does.

 You carry out a Risk Analysis by first identifying the possible threats that you
face, and by then estimating the likelihood that these threats will materialize.
PROBABILITY
PROBABILITY THAT SOMETHING WILLGOWRONG
A- Likely to occur immediately or in a short period of time,
expected to occur frequently.
B- Probably will occur in time.
C - May occur in time
D - Unlikely to occur.
SERIOUSNESS
SERIOUSNESS OF RISK
I May result in death.
II May cause severe injury major
property damage, significant financial loss, and/or
result in negative publicity for the organization and/or institution.
III Maycause minor injury, illness, property damage, financial loss and/or
could result in negative publicity for the organization
and/or institution.
IV Hazard presents a minimal threat to safety, health and well-being of participants.
Five Steps of RiskAnalysis
RisksAssessment Steps.
2
Assess
Risks
3
1 Identify Methods to
Identify Manage Risks
Risks

5 4
Manage & Implement
Evaluate Methods

 Step 1 – Identify Risks.

 Step 2— Assess event to determine levels of risk
 Step 3—Id entify Methods to Manage Risks
 Step 4—Implement Methods
 Step 5—Manage and Evaluate
1. Identify
Step 1: Identify the existing and possible threats that you might face.
Look for and identify threats by thoroughly dissecting the
activity; consulting with members of the organization
Reservation and Event Planning Services.
2. Assess Risk
Step 2: Decide who might be harmed and how - consider
everyone at the event, not just students. Once you've
identified the threats you're facing, you need to work out
both the likelihood of these threats being realized, and
their possible impact.
Tip:
 Don't rush this step. Gather as much information as you can
so that you c a n estimate the probability of a threat occurring.
 Probabilities are particularly hard to assess: where you c a n,
base these on past data.
3. Identify Methods to Manage Risks

Step 3: Evaluate the risks arising from threats, and decide whether
the existing precautions are adequate, or if more should
be done. If something needs to be done, take steps to
eliminate or control the risks.
3. Identify Methods to Manage Risks
 Using existing assets - this may involve existing equipment,
improving existing methods and systems, changing people's
responsibilities, improving accountability and internal
controls, and so on.
 You can also manage risks by adding or changing things. For
instance, you could do this by choosing different activities, by
improving safety procedures or safety gear, or by adding a
layer of security to your activity.
 Developing a contingency plan - this is where you a ccept a
risk, but develop a plan to minimize its effectsif it happens.
4. Implement Methods
Step 4: Record the findings and state how they can be
controlled to prevent harm. Most importantly,
organizational members and advisor must be informed
about the outcome of the risk assessment, as they will be
the ones who will need to take action.
5. Manage & Evaluate
Step 5: Risk evaluation allows you to determine the
significance of risks to the event and decide to
accept the specific risk or take action to prevent
or minimize it.
Key Points.
 You do a Risk Analysis by identify threats, and by then
estimating the likelihood of those threats being realized.
 Once you've identified the risks you face, you can start
looking at ways to manage them effectively. This may
include using existing assets, developing a contingency
plan, or investing in new resources.
 Risk Assessment
Review the:
 Risk Management Questionnaire
 Pre-Event Planning
 Event Planning Guide Worksheet
 Risk Assessment Worksheet examples
 UWM Matrix

Complete the:
 Event Planning Guide
 Risk Assessment Worksheet
INCIDENT INVESTIGATION
What isIncident?
An Incident is Any event That could have or Did
Result in…

Injury or illness
Property damage
Environmental release
Adverse community reaction
Business interruption
Why Investigation
 Prevent recurrence
 Demonstrate our commitment to safety
 Spot deficiencies in safety mgmt
Who should Investigate ?

 “Line management” is responsible for investigating all incidents.

 Safety Person will co-ordinate in Root Cause Analysis.

 Ultimate ownership of Investigation & Countermeasure

implementation & Recurrence prevention will with the Line
Managers.
Investigation process
 Make initial response & report- FIR
 Form investigation team
 Determine the facts
 Determine the key factors
 Determine the systems to be strengthened
 Recommend corrective & preventive action
 Document & communicate the findings
 Follow up
1.Initial response plan
 Co-ordinate emergency
 Preserve incident scene
 Preserve potentially relevant evidence
Report incident (Preliminary) Brief,
Facts, Incident classification
3.Determine the facts
Chronological description of the incident
Description of injury, exposure, property damage, etc.,
Relevant background technical info on the process
Normal operating procedure
Hazard analysis of the process
2.Investigation team
 Select the team
 Define responsibility
 Define scope of investigation
3.Determine the facts contd …
Performing walkthrough
Identify key human, physical & documentary evidence
Events that precedes the incidents
Identify changes made to the scene to mitigate the incident
3.Determine the facts contd …

Topics / Questions
Plan on topics to be covered

Prepare checklist of questions

Open ended, Specific & Closed type questions

Reflecting the meaning

4.Determine the key factors (root causes)

Many key factors (root causes) are found in our operating

systems and are not easily visible
5. Determine systems to be strengthened
 Operating procedure

 Management of change

 Training / performance

 Process hazard analysis

 Process technology
6.Corrective & Preventive actions
7. Document & communicate the findings

 Details of incident –5W, 1H

 Immediate & root causes

 Recommendations
8. Follow up
Root Cause Analysis (RCA)
RCA
 The highest level cause of a problem is called “Root Cause”.

 Identifying the root cause for the particular problem.

 Ex: 5 - Why Root Cause Analysis, Fishbone diagram, Pareto

diagram.
5 - WHYs
When are the 5 Whys most useful?

 When problems involve human factors or interactions.

 In all types of health, safety and environmental

situations whether investigating a personal injury or
solving the reasons behind an environmental incident.
Steps
1. Organize your 5 why meeting
2. Define the problem statement
3. Ask the 1st “WHY”
4. Ask “why” 4 more times.
5. Determine your countermeasure.
6. Assign responsibilities.
7. Monitor progress.
8. Close the meeting
 Step 1: Invite anyone affected by the issue
As soon as the problem or situation is identified (and all immediate
concerns are dealt with), invite anyone at all on the team who
was affected or noticed the issue to be involved in a 5 Whys
meeting. As a remote team, we hold ours via Zoom.
 Step 2: Select a 5 Whys master for the meeting

The 5 Whys master will lead the discussion, ask the 5 whys, and
assign responsibility for the solutions the group comes up with. The
rest of those involved will answer those questions and discuss.

In our experience, anyone can be a 5 Whys master — there are no

special qualifications, and it doesn’t have to be the leader of the
project or the originator of the issue. We’ve also found that it’s a
good idea for the 5 Whys master to take notes for the meeting,
unless he or she would like to assign someone else to this.
 Step 3: Ask “why” five times
Dig at least five levels deep into the issue with five levels of “whys.” This seems
like the simplest part but can in fact get a bit tricky! Getting the right question to
start with, the first why, seems to be the key.

When we conduct our 5 Whys, it can feel natural and almost beneficial to go
down all potential paths and be really comprehensive. However, this can widen
the scope of how much learning and corrective actions need to occur. This is
meant to be a ‘lean’ process in which picking one path allows us to perform just
the amount of corrective actions needed to solve a problem.

We often have to tell ourselves we just need to pick one and go with it. If the
same problem seems to occur again, then we can do another choosing the
other route.

Together, we work through each of those five whys and discover actionable
steps that have been or will be taken.
 Step 5: Email the whole team the results
After each 5 Whys process, someone involved in the meeting will write
down what was discussed in the clearest, plainest language as
possible. Then we add it to a Paper folder and—in one of the most
important steps of the whole process—email the whole team with the
results.

This makes sense to do, and not just for a company like Buffer that
focuses on transparency. It’s super useful for everyone on your team to
stay in the loop and understand any steps you’re taking as the result of
a 5 Whys.
 Step 4: Assign responsibility for solutions
At the end of the exercise, we go through each why
question-and-answer pairing and come up with five
related “corrective actions” that we all agree on. The
master assigns responsibility for the solutions to various
participants in the discussion.
Benefits of the 5 Whys:
 It helps to quickly identify the root cause of a problem.
 It helps to differentiate between the contributing factors
of a problem and its root cause(s).
 It helps determine the relationship between different root
causes of a
problem.
 It can be learned quickly and doesn't require statistical
analysis to be used.
Advantage
1. Allow you to identify cause of your problem, not its symptoms
2. Simple and easy to use
3. Help you avoid taking immediate action without considering the real root
cause of the problem.

Disadvantage
1. Different people may get different answer as to the cause of the same
problem
2. It is only as good as the knowledge and experiences of the people using it.
3. You may not dive deep enough to uncover the root cause of the problem
entirely.
 Car Corrective
Root Cause
won’t action
start
Schedule
Maintenance
Battery preventive
not performed
Dead maintenance
Why?
Alternator
not
working
Why?
Why?
Belt
broken
Why?
Belt
beyond
life
Why?
Example of a 5 Why Analysis. ...
1. Why was the worker's finger crushed?
His finger was caught between a moving pulley and belt.

2. Why was the finger caught between the pulley and the belt?
The guard on the pulley was missing.

3. Why was the guard missing?

A mechanic had overlooked replacing it.

4. Why was it overlooked?

There is no written equipment servicing checklist.

5. Why is there no checklist?

No hazard assessment was completed.
PARETO ANALYSIS.
PARETO ANALYSIS.
 It is a technique used for the selection of a limited number of
tasks that produce signific ant overall effect.

 It uses the Pareto Principle (also known as the 80/20 rule).

 Doing 20% of the work can generate 80% of the benefit of doing
the entire job.

 It also states that about 80% of the problems are created by

20% of the causes.
FISH BONE DIAGRAM
FISH- BONE DIAGRAM:
 The fishbone diagram or Ishikawa diagram is a cause-and-
effect diagram that helps managers to track down the reasons
for imperfections, variations, defects, or failures. The diagram
looks just like a fish's skeleton with the problem at its head and
the causes for the problem feeding into the spine.

 The Fishbone Diagram identifies many possible causes for an

effect or problem. It can be used to structure a brainstorming
session.
 It immediately sorts ideas into useful categories.
 It is also known as, Ishikawa Diagram, Herringbone Diagram
and Cause- and-Effect Diagram.
The 5 (or 8) M's For Identifying Causes of Variation in Manufacturing
• Choosing the categories that are most likely to affect your quality
can be done in more ways than one. Toyota developed the 5Ms as
a list of categories and later thought leaders added a further 3 Ms
to that for a total of 8. These are:

 Material

 Machine

 Man power

 Method

 Money

 Measurement

 Management and Maintenance

WHEN TO USEA FISHBONE DIAGRAM
 When identifying possible causes for a problem
 When a team’s thinking tends to fall into ruts

FISH-BONE DIAGRAM PROCEDURE

How to create a fishbone diagram
Fishbone diagrams are typically made during a team meeting and drawn
on a flipchart or whiteboard. Once a problem that needs to be studied
further is identified, teams can take the following steps to create the
diagram:

 The head of the fish is created by listing the problem in a statement

format and drawing a box around it. A horizontal arrow is then drawn
across the page with an arrow pointing to the head, this acts as the
backbone of the fish.
 Then at least four over-arching “causes” are identified that might
contribute to the problem. Some generic categories to start with may
include methods, skills, equipment, people, materials, environment or
measurements. These causes are then drawn to branch off from the
spine with arrows, making the first bones of the fish.
 For each over-arching cause, team members should brainstorm any
supporting information that may contribute to it. This typically involves
some sort of questioning method, such as the 5 Whys or the 4P’s (Policies,
Procedures, People and Plant) to keep the conversation focused. These
contributing factors are written down to branch off their corresponding
cause.

 This process of breaking down each cause is c ontinued until the root
causes to the problem have been identified. The team then analyzes the
diagram until an outcome and next steps are agreed upon.
When to use a fishbone diagram
A few reasons a team might want to consider using a fishbone
diagram are:

 To identify the possible causes of a problem.

 To help develop a product that addresses issues within current
market offerings.
 To reveal bottlenecks or areas of weakness in a business process.
 To avoid reoccurring issues or employee burnout.
 To ensure that any corrective actions put into place will resolve the issue.
 How Did It Happen ?

CASE # 1

Member was Carrying out excavation for Member Using sharp crowbar
New Cable laying near Dormitory STP for excavation

Cable only 100mm below ground in the During excavation,Crowbar which was too
excavation area and its depth below sharp damaged the cable resulted in
ground not known to Member heavy spark
Cause & Effect Diagram (4M)
MAN MACHINE

Crow bar used was Crow bar not insulated

sharpened not good for
Not experienced properly
electrical works
person for
electrical work

Cable damage
during excavation
Cable at 100mm
Depth only Information to client
was not clear from
Cable laying was contractor
not done as per
Person name was
standard
missing in permit
Cable laying
Night shift permit
standard not taken for one month
clear to all
Excavation permit not
taken as excavation was
less than 1.5 mtr deep
MATERIAL METHOD
 COUNTERMEASURE PLAN
Immediate Action :

Sl. No Action Description Target date Status

Stopped the work immediately & excavation carried out in 12.01.20XX Completed
1
Power off condition
Informed all the workers about the cause & result for the
2 accident

Permanent C/M :

4M Problem C/M Target Date Status

Establish, Identify and train the Job 17th Jan’XX

Man No Job leader to guide Leader

1. Use of insulated crowbar 17th Jan’XX

Crow bar used non insulated
Machine 2. Tool Check of all Contractors
& has sharp edge

Cable not laid as per Preparation of standards for cable 30th Jan’XX
Method
standards laying

Reoccurrence prevention

 Confirmation of depth of underground Cable at all places using cable detecting instrument
 Fixing of utility service line route markers in all places
 4.1.Fire Incident - Garage :

4M Analysis:

Probable Causes:
1. Smoking near work area (Many BUDS found nearby area.)
2. Poor 4S Condition near hot work area
BASIC SAFETY MANAGEMENT.

Q&A
Thank you