Incident Investigation

This material was produced under a grant (SH-26282-SH4) from the

Occupational Safety and Health Administration, U.S. Department of Labor. It
does not necessarily reflect the views or policies of the U.S. Department of
Labor, nor does the mention of trade names, commercial products, or
organization imply endorsement by the U.S. Government.
 Learning Objectives

• Define the difference between an accident and near miss

• What to do at the scene of the incident

• How to interview the witnesses

• How to write the incident report

 Overview
• Definition of Terms • Interviewing Witnesses

• Purpose of Incident • Analyzing the Evidence

Investigation
• Writing the Report
• Incident Investigation
Preparation • Conclusion

• Visiting the Incident

Scene
 Definition of Terms
• Accident

Any unforeseen event, which causes injury or property

damage

• Near Miss

Any unforeseen event that causes a disruption in the

workflow, however it does not cause any injuries or property
damage.

★ For the purpose of this training an incident refers to both

an accident and a near miss
 Purpose of Incident
Investigation
The prevention of another future incident is the purpose of
incident investigation, not to lay blame or find who’s at fault.

The investigation should identify the causes of the incident

so that controls can be put in place to prevent the same /
similar incident from happening again.
 Purpose of Incident
Investigation
The findings from the investigation should be recorded and
kept on file, however these findings should not be used to
discipline anyone.

This encourages individuals to report all incidents and it also

encourages witnesses to tell investigators everything they
know about the incident.
 Incident Facts

• The majority of accidents are forecasted by near misses

in the workplace

• By investigating all incidents you can eliminate the

causes

• Unless causes are eliminated then the same / similar

incident will likely occur in the future
 Incident Facts
In 1931, Herbert 1
Heinrich stated in his Major
book that for every Injury

accident that causes

a major injury there 29
Minor Injuries
are 29 accidents that
cause a minor injury
and 300 accidents 300
Near Misses
that cause no injury.
Incident Investigation Should

• Determine what happened

• Determine the true cause of the accident

• Identify corrective actions

• Prevent future occurrence of the same / similar incident

 Incident Investigation
Preparation
When investigating an incident, time is your worst enemy.

There should be very little time between the occurrence of the

incident and the investigation.

The preparation before an incident is necessary to make sure that all

your resources are available at the time of the incident.

Preparation for incident investigation is just as important as the

investigation itself.
 Incident Investigation Team
• Upper Management

• Workers from the area not involved in the incident

(Hourly)

• Maintenance Supervisor

• Safety Supervisor

• Supervisor from affected area

• Safety Committee Members

 Essential Investigation
Equipment
• Writing Pad & Clipboard

• Tape Measure - • Pencils & Pens

preferably 100’
• Flashlight & extra
• Digital Camera batteries

• Graph Paper • High Visibility Plastic

Tape
• Straight-Edge Ruler
• Envelopes
 Visiting the Scene

When it comes to incident investigation, speed is crucial

Preserve evidence and record eyewitness accounts before

they are forgotten.
 Essential Tasks at Incident
Scene
1. Make sure the area is safe 5. Identify potential sources
for you and others of information such as
witnesses, injured
2. Ensure the injured personnel, and any
personnel are properly physical evidence
cared for
6. Sketch the scene
3. Ensure management is
notified of the situation 7. Take photographs

4. Secure the affected area 8. Collect any critical

evidence that will have to
be analyzed at a later date
 Sketching the Scene

• Place important information in the center and draw

relevant information around it

• Measure the area and draw the scene as close to scale

as possible

• Note the position of personnel and evidence

 Photographing The Scene
• Start by photographing the general area to get an idea of
where the incident took place

• After photographing the general area, photograph the

specific scene of the incident

• Take photos from all angles and viewpoints

• Use a straight edge ruler in some photos to give a better

idea of the size of the object you are photographing
Avoid jumping to
conclusions!!!!!
 Interviewing the Witnesses
• Once the witnesses have been identified you need to
separate them so that they don’t lose their individual
perceptions of the incident

• Have each witness write out what they saw happen

before, during and after the incident

• Interview witnesses as soon as possible while the

incident is still fresh in their minds
 Types of Witnesses
• Those who actually saw the incident happen or were
involved in the incident

• Personnel who came on the scene immediately after the

incident

• Personnel who witnessed events leading up to the

incident

• Personnel who have expertise in the work tasks that

were being performed when the incident happened
 Putting the Witness at Ease
• Let them know that your primary goal in conducting the
investigation is to prevent the recurrence of the same or
similar incident

• Inform the witness that you are not there to get anyone
in trouble or point finger at the guilty parties

• Choose a private location to conduct the interview

• Place yourself between the witness and the exit door.

This eases the witnesses feelings of being trapped
 Interviewing the Witness

When interviewing the witness, review their written statement

with them and clear up any discrepancies.

If possible, show them photographs that you took of the scene

to help them remember any pertinent information.
 Interviewing Questions
• WHAT happened

• WHO witnessed or was involved in the incident

• WHERE did the incident occur and where was the witness
in relation to where the incident occurred

• WHEN did the incident happen

• By answering the previous questions you are able to

answer WHY and HOW the incident happened
 Use Open Ended Questions Such
As
• Tell me what you saw?

• Tell me about…

• Explain how this job is done?

• Where were you at the time of the incident?

• Who else saw the incident?

 Common Mistakes to Avoid
• Do not ask leading questions (e.g. “Do you think that…)

• Do not intimidate the witness (e.g. “That was a stupid thing to

do”)

• Do not introduce your own personal opinions of the incident

• Note taking should not interfere with the interview process

• Do not interrupt the witness while they are talking

• Do not use a tape recorder during the interview. This usually

makes the witness uncomfortable.
 Analyzing the Evidence
• Review the standard operating witnesses
procedures (SOP) for the task
that was being performed when • Review photographs that were
the incident happened taken at the scene

• Require that maintenance • Review training records of

analyze any equipment involved personnel involved in the
and review equipment manuals incident

• Review Witness statements and • Review Environmental factors

cross reference each of them to
point out any discrepancies. If • Review whether management
discrepancies are found then you had enforced the policies and
will have to re-interview rules
 Reviewing the SOP

• Was the safe work procedure used?

• Were the appropriate tools used?

• Was the required PPE used?

• Were safety devices in place and functioning?

 Analyzing Equipment

• Was there an equipment malfunction?

• What was the cause of the equipment failure?

• Was the equipment being used according to the

manufacturer’s recommendations?

• Was the equipment modified in any way?

 Reviewing Training Records
• Was the individuals involved in the incident properly
trained?

• When did the individuals last receive training?

• Who provided them with the training?

• How much experience did the trainer have?

• How much experience did the worker have?

• What was the training content?

 Environmental Factors

• What was the weather at the time of the incident?

• What was the temperature at the time of the incident?

• What time of day did the incident occur?

• Any other distractions in the area of the incident?

 Writing the Incident Report

The intent of the incident report is to effect change so that the

same or similar incident does not happen again in the future.

The report should not place blame and it should be filed away
for future reference.

The written incident report can also be used as a training tool.

Writing the Incident Report
Six Sections of an Incident Report

1. Who, Where, When

2. Description of the Incident – What Happened

3. Findings

4. Corrective Actions and Improvements

5. Conclusion

6. Appendix
 Section I
• Who
✴ Injured party • When
✴ Witnesses ✴ Date

• Where ✴ Time

✴ Location of Incident ✴ Shift

 Section II

• Description of The Incident

✴ What happened prior to the incident

✴ What happened during the incident

✴ What happened after the incident

 Section III

• Findings
✴ Direct Cause - The act that directly caused the incident (e.g.
the grinding wheel on the bench grinder exploded)

✴ Indirect Cause - The root cause of the incident (e.g. improper

training on using a bench grinder)
 Section IV
• Corrective Actions
✴ How the hazardous conditions that directly caused the incident
will be eliminated and the target date these actions will be
completed

• System Improvements
✴ Improvements to procedures and policies that indirectly caused
the incident and the target date for these improvements to be
implemented
 Section V
• Conclusion
✴ Estimated cost of incident (
https://www.osha.gov/dcsp/smallbusiness/safetypays/)

✴ Name of personnel responsible for implementing the corrective actions

and system improvements

✴ Description of the intended results and positive impact of the suggested

changes

✴ Date that corrective actions and system improvements have been

implemented and the results of those actions. This is also the date that
the report is closed.
 Section VI

• Appendix
✴ Printouts of all the photographs taken

✴ Sketch of the scene

✴ Witness statements

✴ Investigation notes
 Conclusion
For the incident investigation process to be effective,
management must have a plan in place for implementing the
corrective actions and making system improvements.

Management must also periodically evaluate the quality of the

incident investigation process to make sure that it is still an
effective tool.

Retraining after an incident is necessary for all parties

involved
Employee Rights and
Responsibilities
 Employee Rights & Responsibilities
Occupational Safety and Health Act of 1970
• To assure safe and healthful working conditions for
working men and women

• By authorizing enforcement of the standards developed

under the Act

• By assisting and encouraging the States in their efforts

to assure safe and healthful working conditions

• By providing for research, information, education, and

training in the field of occupational safety and health…
 Employee Rights &
Responsibilities
•
You have the right to:
File a confidential complaint with OSHA to have their workplace
inspected.

• Receive information and training about hazards, methods to

prevent harm, and the OSHA standards that apply to their
workplace. The training must be done in a language and
vocabulary workers can understand.

• Get copies of their workplace medical records.

• Participate in an OSHA inspection and speak in private with the

inspector.
 Employee Rights & Responsibilities Continued:

• File a complaint with OSHA if they have been retaliated

or discriminated against by their employer as the result
of requesting an inspection or using any of their other
rights under the OSH Act.

• File a complaint if punished or discriminated against for

acting as a “whistleblower” under the additional 21
federal statutes for which OSHA has jurisdiction.
 Whistleblower Protection
• OSHA's Whistleblower Protection Program enforces the
whistleblower provisions of more than twenty whistleblower
statutes protecting employees who report violations of
various workplace safety, airline, commercial motor carrier,
consumer product, environmental, financial reform, food
safety, health insurance reform, motor vehicle safety,
nuclear, pipeline, public transportation agency, railroad,
maritime, and securities laws. Rights afforded by these
whistleblower acts include, but are not limited to, worker
participation in safety and health activities, reporting a work
related injury, illness or fatality, or reporting a violation of the
statutes.
 Whistleblower Protection
• The Whistleblower Protection Advisory Committee (WPAC) was
established to advise, consult with, and make recommendations to the
Secretary of Labor and the Assistant Secretary of Labor for
Occupational Safety and Health on ways to improve the fairness,
efficiency, effectiveness, and transparency of OSHA's administration
of whistleblower protections. In particular, the committee advises
OSHA on the development and implementation of improved customer
service models, enhancements in the investigative and enforcement
process, training, and regulations governing OSHA investigations. In
addition, WPAC advises OSHA in cooperative activities with other
federal agencies that are responsible for areas covered by the
whistleblower protection statutes enforced by OSHA.
 Whistleblower Protection
• Protection from discrimination means that an employer cannot
retaliate by taking "adverse action" against workers, such as:
• Firing or laying off
• Blacklisting
• Demoting
• Denying overtime or promotion
• Disciplining
• Denial of benefits
• Failure to hire or rehire
• Intimidation
• Making threats
• Reassignment affecting prospects for promotion
• Reducing pay or hours
 Employee Rights &
Responsibilities
 OSHA website: http://www.osha.gov and OSHA offices: Call (800-
321-OSHA)
• Workers Rights: http://www.osha.gov/Publications/osha3021.pdf
 Compliance Assistance Specialists in the area offices
 National Institute for Occupational Safety and Health (NIOSH) –
OSHA’s sister agency
 OSHA Training Institute Education Centers
 Doctors, nurses, other health care providers
 Other local, community-based resources
 Review
• Definition of Terms • Interviewing Witnesses

• Purpose of Incident • Analyzing the Evidence

Investigation
• Writing the Report
• Incident Investigation
Preparation • Conclusion

• Visiting the Incident

Scene
 What We Learned

• Defined the difference between an accident and near miss

• What to do at the scene of the incident

• How to interview the witnesses

• How to write the incident report