ACCIDENT INVESTIGATION & REPORTING

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  The primary reason for investigating an accident is
not to blame someone but to determine the cause
of the accident.

 The investigation concentrates on gathering

accurate information about the details that led to
the accident.

 This information benefits the ongoing effort of

reducing the probability of accidents.

 As problems are revealed during the investigation,

action items and improvements that can prevent
similar accidents from happening in the future will
be easier to identify than at any time.
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 TYPES OF ACCIDENT INVESTIGATIONS

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  An accident-analysis report is completed when the accident in
question is serious. This level of report should answer the same
questions as the regular accident report plus one more – why.
Therefore it involves a formal accident analysis. The analysis is
undertaken for the purpose of determining the root cause of the
accident.

 Accident analysis requires special skills and should be undertaken

only by an individual with those skills. There are two reasons for
this.

 First, the accident analysis must identify the actual root cause or
the company will expend resources treating only symptoms or
even worse, solving the wrong problem.

 Second, serious accidents are always accompanied by the

potential for court case if there might be legal action as a result
of an accident, it is important to have a professional conduct the
investigation even if it means bringing in an outside consultant.

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  Accident reports are called for when the accident in
question is a minor incident that did not result in any of
the following circumstances:
 death,

 loss of consciousness,

 medical treatment beyond first aid,

 more than one additional day of lost work beyond

the day of the accident, or
 Any modifications to the injured employee’s work
duties beyond those that might occur on the day
of the accident.

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  Accident–analysis reports are called for when any of
the following circumstances result from the accident
in question:

 death,

 loss of consciousness,

 professional medical treatment beyond first aid,

 one or more days of lost work over and above

any time lost the day of the accident, or
 any modifications to the injured employee’s
work duties beyond those that might occur on
the day of the injury.

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  There are several reasons why it is important to
conduct investigations immediately.

 First, immediate investigations are more likely to

produce accurate information. On the other hand,
the longer the time between an accident and an
investigation, the greater the probability of important
facts becoming distorted as memories weaken.
 Second, it is important to collect information before
the accident scene is changed and before witnesses
begin comparing notes.

 Finally, immediate Investigation is evidence of

management’s commitment to preventing future
accidents. An immediate response shows that
management cares.

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 The Society of Manufacturing Engineers recommends using
the following questions when conducting accident
investigations:

 What type of work was the injured person doing?

 Exactly what was the injured person doing or trying to do

at the time of the accident?

 Was the injured person skillful in the task being performed

at the time of the accident? Had the worker received
proper training?

 Was the Injured person authorized to use the equipment or

perform the process involved in the accident?

 Were there other workers present at the time of the

accident? If so, who are they, and what were they doing?

 Was the task in question being performed according to

properly approved procedures?

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  Was the proper equipment being used, including personal protective
equipment?

 Was the injured employee new to the job?

 Was the process, equipment, or system involved new?

 Was the injured person being supervised at the time of the accident?

 Are there any established safety rules or procedures that were clearly
not being followed?

 Where did the accident take place?

 What was the condition of the accident site at the time of the
accident?

 Has a similar accident occurred before? If so, were corrective

measures recommended? Were they implemented?

 Are there obvious solutions that would have prevented the accident?

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 COMMON CAUSES OF ACCIDENTS

 Many common causes of accidents are in the following

categories:

 personal beliefs and feelings,

 decision to work unsafely,

 mismatch or overload,

 systems failures,

 traps,

 unsafe conditions, and

 unsafe acts.

 The common causes in each of these categories can

help investigators determine the root cause of an
accident.
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 Personal beliefs and feelings

Causes in this category include the following:

 individual did not believe the accident would happen to him ;
 individual was working too fast showing off or being a know-
it-all;
 individual ignored the rules out of dislike for authority and
rules in general;
 individual gave in to peer pressure; and
 individual had personal problems that clouded his judgment.

Decision to work unsafely

Some people for a variety of reasons feel it is in their best
interests or to their benefit to work unsafely. Hence, they make a
conscious decision to do so.

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 Mismatch or overload

Causes in this category include the following:

 individual is in poor physical condition;
 individual is fatigued;
 individual has a high stress level;
 individual is mentally unfocused or distracted;
 the task required is too complex or difficult;
 the task required is boring;
 the physical environment is stressful (e.g., excessive
noise, heat, dust, or other factors).
 the work in question is very demanding – even for an
individual in good physical condition; and
 Individual has a negative attitude (e.g., hostile,
uncooperative, etc.)

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 Systems failure

Causes in this category consist of the various errors

management makes that are serious. Common causes
in this category include

 lack of a clear policy:

 lack of rules, regulations, and procedures;
 poor hiring procedures;
 inadequate monitoring and inspections;
 failure to correct known hazards;
 insufficient training for employees;
 rules that are in place are not enforced;
 inadequate tools and equipment provided;
 poor safety management;
 no or insufficient job safety analysis; and
 insufficient management support for safety.

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 Traps

Poor design of workstations and processes can create traps

that, in turn, lead to unsafe behavior. Causes in this category
include
 defective equipment;
 failure to provide, maintain, and replace proper personal
protective equipment;
 failure to train employees in the proper use of their
personal protective equipment;
 mechanical lifting equipment that is inadequate for the
jobs required of it;
 uncontrolled hazards that might lead to slips and falls;
 excessive reaching, bending, bending down, and twisting;
 awkward positions that result from poor workstation or tool
design;
 excessive temperature extremes;
 insufficient lighting; insufficient ventilation,

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 Unsafe conditions

Common causes in this category include the following:

 unsafe condition created by the person injured in

the accident;
 unsafe condition created by a fellow employee;

 unsafe condition created by management;

 unsafe condition knowingly unnoticed by

management; and
 unsafe condition created by the elements (e.g.,
rain, sun, snow, ice, wind, darkness, etc.).

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 Unsafe acts

Common causes in this category include the following:

 individual chooses to ignore the rules;
 people are involved in horseplay or fighting;
 individual uses drugs or alcohol;
 individual uses unauthorized tools or equipment;
 individual chooses an improper work method;
 individual fails to ask for information or other
resources needed to do the job safely;
 individual forgets a rule, regulation, or
procedure;
 individual does not pay proper attention;

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 WHO SHOULD INVESTIGATE

 Who should conduct the accident investigation?

 Should it be the responsible supervisor?

 The safety and health professional?
 A higher-level manager?
 Outside specialist?

 In some companies, the supervisor of the injured

worker conducts the investigation. In others, a safety
and health professional performs the job.

 Some companies form an investigative team; others

bring in outside specialists.

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  The are several reasons for the various approaches used in
accident investigations. Factors considered in deciding how
to approach include:

 Size of the company

 Structure of the company’s safety and health

program
 Type of accident

 Seriousness of the accident

 Technical complexity

 Number of times that similar accidents have occurred

 Company’s management philosophy

 Company’s commitment to safety and health

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 7. Allowing politics to enter into an investigation.

 The goal of an investigation is and must be to identify the

root cause so that appropriate corrective action can be taken.

 Personal likes, dislikes, favoritism, and office politics will

corrupt an investigation from the beginning.

8. Failing to conduct an in-depth investigation.

 Everyone is in a hurry and investigating an accident was not

on your agenda for the day.

 In addition there is sometimes pressure from higher

management to “get this thing behind us.” Such pressures
and circumstances can lead to a rushed investigation in which
the goal is to get it over with not to find the root cause of the
accident.

 Surface-level investigations almost ensure that the same type

of accident will happen again.
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 9. Allowing conflicting goals to enter into an investigation.

 The ultimate goal of an accident investigation is to

prevent future accidents and injuries. However, even
when that is your goal there may be other people who
have different goals.

 Some may see the investigation as an opportunity to

redirect blame, others may see it as an opportunity to
protect the organization from court case.

 Safety and health professionals should be aware that

other agendas may be in play every time an accident
investigation is conducted.

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 10. Failing to account (report) for the effects of uncooperative
people.

 One would think that employees and management personnel

would automatically want to cooperate in accident investigation
to ensure that similar accidents are prevented in the future.

 Further, the lack of cooperation will not always be obvious. In

fact often it will be hidden (e.g., a person you need to interview
keeps putting you off or canceling meetings).

 Safety and health professionals need to understand that self-

interest is one of the most powerful motivators of human
beings and influence this into their planning for accident
investigations.

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  These 10 mistakes will probably never be completely
eliminated from every accident investigation.

 However, if safety and health professionals are aware of

them, they can at least ensure that such mistakes are
minimized.

 The fewer of these mistakes that are made during an

accident investigation, the better the quality of the
investigation and the more likely that it will lead to
effective corrective action.

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 ACCIDENT CAUSATION MODELS

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 Figure 1: Accident Causation

 When this model is used, possible causes in each

category should be investigated.

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 Task
 Here the actual work procedure being used at the
time of the accident is examined. Members of the
accident investigation team will look for answers to
questions such as:

 Was a safe work procedure used?

 Had conditions changed to make the normal
procedure unsafe?

 Were the appropriate tools and materials available?

Were they used?
 Were safety devices working properly?

 Was lockout used when necessary?

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 Environment
 The physical environments, and especially sudden changes
to that environment are factors that need to be identified.

 The situation at the time of the accident is what is

important, not what the "usual" conditions were. For
example, accident investigators may want to know:

 What were the weather conditions?

 Was poor housekeeping a problem?

 Was it too hot or too cold?

 Was noise a problem?

 Was there adequate light?

 Were toxic or hazardous gases, dusts, or fumes

present?
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 Personnel
 The physical and mental condition of those individuals
directly involved in the event must be examined.
 The purpose for investigating the accident is not to
establish blame against someone but the investigation
will not be complete unless personal characteristics are
considered.
 Some factors will remain essentially constant while
others may differ from day to day:

 Were workers experienced in the work being done?

 Had they been adequately trained?
 Can they physically do the work?
 What was the status of their health?
 Were they tired?
 Were they under stress (work or personal)?

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 Management

 Management holds the legal responsibility for the safety of

the workplace and therefore the role of supervisors and
higher management must always be considered in an
accident investigation.

 Answers to any of the previous types of questions logically

lead to further questions such as:
 Was safety rules communicated to and understood by
all employees?
 Were written procedures available?

 Were they being enforced?

 Was there adequate supervision?

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 Management continue.......

 Were workers trained to do the work?

 Had hazards been previously identified? Had

procedures been developed to overcome them?
 Were unsafe conditions corrected?

 Was regular maintenance of equipment carried out?

 Were regular safety inspections carried out?

 This model of accident investigations provides a guide

for uncovering all possible causes and reduces the
likelihood of looking at facts in isolation.

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 Injured workers(s)

 The most important immediate tasks

 rescue operations,

 medical treatment of the injured,

 prevention of further injuries

 Injured workers have priority and others must not

interfere with these activities. When these matters are
under control, the investigators can start their work.

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  We may take photographs before anything is moved both of
the general area and specific items.

 Later careful study of these may reveal conditions or

observations missed previously.

 Sketches of the accident scene based on measurements

taken may also help in following analysis and will clarify any
written reports.

 Broken equipment, remains, and samples of materials

involved may be removed for further analysis by appropriate
experts.

 Even if photographs are taken, written notes about the

location of these items at the accident scene should be
prepared.
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 DO NOT...
 threaten the witness

 interrupt

 ask leading questions

 show your own emotions

 make lengthy notes while the witness is talking

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  If we were not at the scene at the time, asking questions is
a straightforward approach to establishing what happened.

 Answers to a first few questions will generally show how

well the witness could actually observe what happened.

 Another technique sometimes used to determine the

sequence of events is to replay them as they happened.
Obviously, great care must be taken so that further injury
or damage does not occur.

 A witness (usually the injured worker) is asked to rebuild in

slow motion the actions that came first before the
accident.

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 Background Information

 A third, and often an unnoticed source of information can

be found in documents such as technical data sheets,
maintenance reports, past accident reports, formalized
safe-work procedures, and training reports.

 Any relevant information should be studied to see what

might have happened, and what changes might be
recommended to prevent recurrence of similar accidents.

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 What should I know when making the analysis and
conclusions?

 At this stage of the investigation most of the facts about

what happened and how it happened should be known.

 This has taken considerable effort to accomplish but it

represents only the first half of the objective.

 Now comes the key question--why did it happen?

 To prevent recurrences of similar accidents the

investigators must find all possible answers to this
question.

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  When our analysis is complete ….

 write down briefly a step-by-step account of what

happened (our conclusions) working back from the
moment of the accident, listing all possible causes at
each step.

 This is not extra work: it is a draft for part of the final report.
Each conclusion should be checked to see if:
 it is supported by evidence

 the evidence is direct (physical or documentary) or based

on eyewitness accounts, or the evidence is based on
assumption.

 This list serves as a final check on differences that should

be explained or eliminated.

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 What should be done if the investigation reveals "human
error"?

 A difficulty that has bothered many investigators is the idea that

one does not want to put down blame.

 However, when a detailed worksite accident investigation

reveals that some person or persons among management,
supervisor, and the workers were apparently at fault, then this
fact should be pointed out.

 The intention here is to remedy the situation not to discipline an

individual.

 Failing to point out human failings that contributed to an

accident will not only downgrade the quality of the
investigation.

 Furthermore, it will also allow future accidents to happen from

similar causes because they have not been addressed.
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