A Union

Representatives
Guide to Accident
Investigation

By
Jim Howe
Assistant Director
UAW Health and Safety Department
JH:ckd
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INTRODUCTION

Acknowledgments
Most of the material in this manual is the result of personal experiences
investigating serious injuries and fatalities. Unfortunately most of this
experience was possible because of tragic events, most of which were completely
avoidable, which resulted in life long disability and or death for the victims. I owe
a great deal to the other accident investigators that I have had the opportunity to
work with.
Ludwig Benner, one of the most notable experts in the field of accident
investigation, has provided many important ideas and suggestions in this effort.

Introduction
***
Definition of Accident
***
Accident Investigation
Systems

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Introduction
The job of investigating accidents has typically been delegated to supervisors and other
management personnel that have little formal training if any. The result is incomplete
accident reports filled with inaccurate information. Hazardous remain, making future
injuries and illnesses a certainty.
To break this cycle and prevent workers from becoming sick and injured on the job,
union representatives will have to learn and practice the techniques of effective accident
investigation. In doing so, underlying causes of past injuries and illness can be
understood and corrected; preventing future tragedies from taking place.
Once an accident has occurred, for the victim(s), it's too late. As much as we regret the
incident and feel sorry for the victim(s) and their families nothing can be done that will
change what happened. It is a sad reality. The only way to give meaning and make
something positive from the tragedy is to investigate the incident, identify causes and
implement recommendations to prevent future suffering.
The term "accident" can be misleading. It is sometimes used to describe a tragic event
that could not be anticipated, that was the result of chance. Almost all industrial
"accidents" do not fall into this category. Almost every industrial "accident" has a
cause(s) and is predictable, avoidable and preventable.
When an accident occurs at a plant the individual(s) injured are not the only victim. Coworkers, first responders and many others are psychologically injured, some for a short
period of time and others for life. The Critical Incident Response program advocated in
this manual provides assistance to these victims.
This manual is intended to provide the user with a practical step by step approach to
accident investigation. It begins with planning and preparation and ends with report
development, writing recommendations and implementation.

Almost all accidents

- have causes
- are predictable
- are avoidable
- are preventable
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What is the purpose of accident investigation?

Why do we do accident investigation?
What are we trying to accomplish?
Do your objectives and mine coincide?
How will we know if we are successful?
What is the theory behind these answers?
What is the scope of the investigation?
When should the report start and stop?
When did the incident start and stop?
What method do you use to conduct accident investigation?
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Basic Elements of An Effective Accident Investigation

1.
2.
3.
4.
5.

Preparation
Initial Notification
On-site Investigation
Development of a Report
Implementation and Follow-up

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Preparation

Effective accident investigation begins long before arriving at the

incident site. It begins with preparation and planning.

Preparation
1.

Training and Communication

2.

Notification System

3.

Critical Incident Response

4.

Materials and Equipment

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The planning and preparation process must include the establishment of training
and communication, a notification system, identification of critical incident
response resources and the procurement of the necessary materials and
equipment.
1)

Training and Communication

a) Training for accident investigators
- methods and techniques of accident investigation
- interview methods
- photographing an accident site
- report writing and development
b) Training for Emergency Responders
- minimizing disturbance of the accident site
- knowledge of hazardous materials and processes
- plant layout--emergency routes
c) Training for Plant Security Personnel
- securing an accident site
- emergency first aid
- hazardous material training
d) Training for local union and management representatives
- familiarized with the accident investigation system
- importance of securing the accident site
- importance of investigations being conducted by qualified
personnel

Basic Required Skills of an Investigator

Observe
Listen
Empathize
Sequence
Reason
Question

- see objects, people, actions objectively, unbiased by experience.

- hear what people are communicating, not just what they say.
- put self in other persons shoes to understand what they are communicating.
- put a lot of disjointed data into its logical sequential order.
- putting data together to reach logical descriptions, and recommendations.
- define questions that when answered, provice understanding.

Ludwig Benner

2) Notification System
A communication system must be developed to insure the prompt
notification of appropriate union and management personnel in the event of
an accident. Often unions have found that it is helpful to negotiate contract
language that requires management to notify union representative(s) when
a serious accident occurs. The union and management should agree on the
criteria for a serious accident so that the language can be properly
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implemented. Prompt notification is critical to effective accident

investigation.
3)

Critical Incident Response Resources

The planning process should include the identification of internal and
external community resources that can assist in critical incident response
debriefing.

During the course of the accident investigation, a Critical Incident Response Form
should be completed listing each individual that was involved/affected by the incident
and a short description of the nature of their involvement.
In some companies it has been a common practice to allow those involved in the
incident to leave the plant and go home. This is often not the best course of action
because it hampers the accident investigation process and is psychologically dangerous
to allow an employee that has been emotionally injured to leave the plant without the
assurance that proper emotional support systems are in place. Some of these
individuals may even feel that something that they did or did not do contributed to the
incident. In the vast majority of cases, it is best to keep those involved in the incident in
the plant, in a comfortable environment, separated from others that were involved,
available to investigators and offered/provided critical incident counseling.

10

CRITICAL INCIDENT PERSONNEL REPORT

Plant Allied Component Manufacturing
Local Union _4376____
Date 2/6/91
Incident
Don Thompson Press Incident_________________________________________________
The Health and Safety Investigation Team should complete the Name, Job Title, Shift and Involvement in Incident columns.
NAME

JOB TITLE

SHIFT

INVOLVEMENT IN INCIDENT

1)

Bill Evans

Press Operator

Working with Don

One of the first to respond to the
scene, friend of Don

2)

Tom Rolland

Inspector

3)

Ann Jones

Press Operator

Worked on adjacent press

4)

Kathy Oliver

Nurse

5)

Ron Spalding

Supervisor

DEBRIEF
YES

NO

YES

NO

YES

NO

Administered CPR at first aid

YES

NO

Gave Don work assignment

YES

NO

6)

YES

NO

7)

YES

NO

8)

YES

NO

9)

YES

NO

10)

YES

NO

** Provide a copy of this form to the EAP/Critical Incident Team.

** The EAP/Critical Incident Team will report progress to the investigation team.
** Do not forget the accident investigators.

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CRITICAL INCIDENT PERSONNEL REPORT

Plant

Date

Local Union ________

Incident

The Health and Safety Investigation Team should complete the name, job title, shift and involvement in Incident columns.
NAME

JOB TITLE

SHIFT

INVOLVEMENT IN INCIDENT

DEBRIEF

1)

YES

NO

2)

YES

NO

3)

YES

NO

4)

YES

NO

5)

YES

NO

6)

YES

NO

7)

YES

NO

8)

YES

NO

9)

YES

NO

10)

YES

NO

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11)

YES

NO

12)

YES

NO

13)

YES

NO

14)

YES

NO

** Provide a copy of this form to the EAP/Critical Incident Team.

** The EAP/Critical Incident Team will report progress to the investigation team.
** Do not forget the accident investigators.

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4)

Procurement of Materials, Equipment and Documents

Materials Needed
1. Photographic Equipment
2. Forms and Checklists
3. Personal Protective Equipment
4. Miscellaneous Supplies
5.
6.
7.
8.
9.
(add additional items)
Photographic Equipment
1. 35mm or Digital Camera
2. External Flash Unit (mandatory)
3. Tripod
4. Battery charger
5. Extra film, batteries, memory cards
6. Video Camera
7. Extra batteries, tape
8. Power supply
9.
10.
11.
(add additional items)
Forms, Checklists and Documents
1. Investigation form
2. Interview form
3. Document checklist
4. Phone listing
5. Photo log
6. Critical incident form
7. Relevant standards and regulations
8. Graph paper for sketches
9. Post-It pads
10.
11.
12.
(add additional items)
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Personal Protective Equipment

1. Safety Glasses
2. Safety Shoes
3. Hearing Protection
4. Gloves
5.
6.
7.
8.
(add additional items)
Miscellaneous Materials and Equipment
1. Flashlight
2. Masking tape
3. Chalk for marking areas
4. Plastic bags to store physical evidence
5. Permanent marking pens
6. Tape measure (25 foot)
7. Tags
8. Sound Level Meter
9. Air monitoring equipment
10. Caution tape
11.
12.
13.
14.
(add additional items)
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Initial Steps of an
Investigation
When a serious incident occurs, focus on the following three tasks in
this order.
1. Provide Medical Treatment for Victim(s)
2. Notification of family members if appropriate
3. Secure and preserve the accident site
After the above tasks have been completed investigators can begin the
investigation.
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Family Support
1. Initial communication
2. Support at the hospital
3. Assistance with travel and housing for out-of-town
family members
4. Counseling assistance
5. Medical treatment support
6. One union representative and one management
representative available to the family 24 hours a day
7. Arrange for family members to visit the accident site
when requested. This should be done when the plant
is not operating.
8. On-going support and benefit assistance

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Securing the Scene

Once evidence is disturbed it may be
destroyed forever
Early in the investigation it is difficult to
know what evidence is most important
Carefully document evidence before it is
changed. Discuss how it will be changed.
Test the process on similar equipment not
related to the incident.
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Criteria for Releasing an Incident Site

1. The physical site/evidence has been
completely documented.
2. Appropriate corrective measures have
been implemented.
3. Other investigators have completed their
investigation of the site. (coroner, OSHA,
etc.)
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Mentally Preparing
for an Accident
Investigation

Before you arrive at the accident site, think about the accident investigation process.
You may want to review this manual. It is important to remember that as a trained
accident investigator you have the ability to:
1)
transform the chaos of the investigation to an orderly effective
investigation
2)
keep an open mind, control your biases and not jump to conclusions.
3)
recognize that the first step is to document;
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a) the accident site on photographs and video tape

b) and the witness data on interview notes.
Remember there will be plenty of time after the initial investigation to determine the
cause(s) and develop recommendations.
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Communication of Accident Information to the Plant

Workforce
As soon as possible and no later than the day following a serious accident, a written
communication should be posted and/or handed out. Joint Union/Management
communications have the greatest credibility. The communication should be limited to a
brief summary of the facts of the incident.
This communication should include:
1)
Date and time of the incident
2)
Name, department and job classification of the victim(s)
3)
Brief (a few paragraphs) summary of incident
4)
Medical condition of the victim(s)
5)
Status of the accident investigation process
who is involved (International Union, Local Union, corporation, group,
division, etc.)
6)
Name of the medical facility where the victim(s) is being treated

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On Site
Investigation

On Site Investigation
conduct interviews
photograph/video scene
collect documents

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On Site Investigation

photograph/video scene
collect documents
conduct interviews

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There are only two sources of information

during an accident investigation - people and
things.

Accident Investigation Tasks

(not in order of performance)
1. Make the accident site safe - lockout machinery and use necessary personal protective
equipment.
2. Convene opening meeting of all involved in the investigation (not witnesses) to: a)
assess the current status of the investigation b) and delegate tasks.
3. Select a conference room near the accident site to conduct the investigation
4. Identify all witnesses to be interviewed
5. Create an event matrix
6. Collect related documents (see list)
7. Contact OSHA and other appropriate individuals
8. Create a shot list for photographs and video taping
9. Complete the Critical Incident Form
10. Contact Critical Incident Team
11. Maintain contact with medical personnel
12. Conduct interviews
13. Transfer interview notes to, post-it building blocks and place on event matrix
14. Shoot photographs and video tape

Opening Meeting To Begin The

Accident Investigation Process
Locate a conference room near the site of the accident that can be used to coordinated the
accident investigation. The room or adjacent area should have available;
- telephones (both inside and outside lines)
- adequate meeting space to accommodate the investigation team as well as
additional local union and management personnel
- chart boards
- copy machine
Make the following points;
1)
we are here to conduct an unbiased investigation of the incident so that appropriate
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2)

corrective action can be taken a this facility and at other facilities within the
company.

2)

Make sure that;

- the victim(s) are receiving quality medical care
- the victim(s)family has been notified
- and the accident site has been secured.

3)

Explain that the investigation will be most effective and efficient if it is conducted
jointly.

4)

Review the accident investigation process.

a)

Review the four laws of accident investigation and the mental movie concept.

b)

Review interview guidelines

- one or two interviewers, never have a large group present during an
interview
- conduct interviews in a quiet private area (those interview may be
quite emotional and need support) At times it is helpful to interview
people at the site of the accident, it is important to make sure that this
does not create an emotional hardship for the interviewees
- basically the objective of the interview process is to transfer the
mental movie from the interviewee to the written record of the
interviewer. Begin asking about the earliest events that the
interviewee saw, heard or did and keep asking, "and then what
happened?" Try to document the events in the order that they
occurred.
select interviews that will be able to relate to the interviewee and not
be threatened. Members of plant security and labor relations are often
viewed by hourly workers as adversarial and thus do not make very
good interviewers.
- prioritized the interview schedule according to;
- the significance of the interview information
- availability of interviewees (It may make sense to interview a
person that may not appear to be significantly involved in the
accident but will be leaving the plant in an hour at the end of the
shift before an individual that was directly involved.)

Do not ask witnesses or those involved to write out and sign a statement. This method of
collecting information is ineffective and inadequate because many people will be inhibited
by having to write a statement because they; have poor handwriting, spelling or grammar.
5)

During the investigation process complete the Critical Incident Response Form.
(see attached) Provide a copy of the competed form to the Critical Incident
Response Team or the local EAP (Employee Assistance Program) Committee.

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Initial goal is to document the

accident scene and interview
those who were immediately
involved.
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STEP WORKSHEET MATRIX

TIME
A
B
C

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27

28

Information and Documents to be Collected

Needed

Received

________

________

1)

Photographs

________

________

2)

Witness Statements

________

________

3)

Personnel, work history and demographics

________

________

4)

Blueprints of equipment and plant layouts

________

________

5)

Equipment operating manuals

________

________

6)

Maintenance records

________

________

7)

Results of past inspections

________

________

8)

Results of inspections after accident

________

________

9)

Results of Industrial Hygiene Sampling (in-plant and

governmental)

________

________

10)

Training records: technical and health and safety

________

________

11)

Records of past injuries and illnesses of the victim

________

________

12)

Records of past injuries and illnesses of other workers

who perform tasks that are the same or similar to the one
being performed by the victim

________

________

13)

Death Certificate

________

________

14)

Results of analysis of physical evidence: finger prints,

chemical analysis, metallurgical tests, weld integrity,
electrical components, etc.

________

________

15)

Autopsy Results

________

________

16)

Contractor Contracts

________

________

17)

Contractor Pre-bid Documents

________

________

18)

Plant Security Reports

________

________

19)

Sketch of accident scene (before and after)

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Mental
Movie
Concept

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The first law of accident investigation states

that everyone and everything is always
someplace doing something during the
accident.

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The second law of accident investigation states

that time advances steadily during the accident.

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The third law of accident investigation states that the

witness has it, you need it and the witness does not
have to give it to you.

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The fourth law of accident investigation states that you

should always expect everyone to do what they perceive
to be in their best interests, and you will never be
disappointed.

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Interview
*
*
*
*
*
*
*
*
*
*
*

Victim(s)
Co-workers
Supervisors
Workers that perform similar jobs in other
departments or on different shifts
Engineers
Maintenance Personnel
Witnesses
Emergency Personnel
Medical Personnel
Equipment Suppliers
Coroner

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Interview Reminders
1. Prioritize interviews based upon importance of information, emotional
condition and availability.
2. Select a comfortable, private, non-threatening place
3. Explain who you are and what you are doing
4. Explain that you need his/her help to understand, as accurately as possible,
what happened
5. Ask for help
6. Be sensitive to the emotional state of the individual
7. Ask the individual to tell you what he/she saw, heard or did - start at the
beginning
8. The most important question "and then what happened?"
9. Remember the mental movie
10. When possible "walk through" the actions of the individual (people recall
things best in order of occurrence)
11. Take your time

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DO NOT
1.
2.

Conduct group interviews (inquisitions)

Ask the individual to write out a statement

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INTERVIEW FORM
Interviewee:
Accident:
Accident Location:
Interviewed by:
_______________________________________ on _____/_____/_____
Direction: Write out a description of what the interviewee saw, hear, or did. Ask the
interviewee to describe the accident setting and what they saw, heard, or did, or
what they observed other people or things doing during the incident. The objective
is to transfer the mental movie of the incident as seen through the eyes of the
interviewee in chronological order. You should ask questions to fill in the missing
frames of the mental movie.

Note: Attach additional sheets if needed

36

LEGAL
ISSUES

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Photographing and video taping the accident scene.

Remember that the objective is to document the setting at
the end of the accident.

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Video Taping and Photographing of the Accident Site

Remember the Mental Movie Concept

Most of these suggestions, apply to both shooting video tape as well as still photographs.
Video Shots
1.

Do not expose yourself to hazards during the video taping.

For example,
y
Make sure the equipment is locked out.
y
Use proper fall protection equipment.
y
Wear proper personal protective equipment.

2.

Begin the video tape with a wide outside shot of the plant complex, including the
plant sign. Next, shoot a wide shot of the area where the accident occurred.

3.

Using the widest angle adjustment on the zoom lens, video tape the operation from
the place where the victim was located immediately prior to the accident.

4.

Do not video tape witness statements or interviews.

5.

Remove spectators from the video taping scenes.

6.

Remember, when in doubt about taping a certain scene - tape it. Sometimes,
elements that may not seem relevant at the time, prove to be significant later. It is
better to have extra video tape than not enough.

7.

Video tape the route or movements that the victim followed prior to the accident.
Video tape scenes the victim would have seen (such as the view from a fork lift
driver).

8.

Often, it is useful to include rulers and tape measures laid out in the scene, so that
later precise measurements can be determined.

9.

Take shots from above the accident scene whenever possible to get a broad view of
the accident scene.

10.

Video tape similar operations to the one that the victim was performing when the
accident occurred.

Audio Track
1.

There should be no audio track editorializing or describing potential causes for the
accident.
39

2.

The audio track should include descriptions of the angle of the shot, machine
number, date, time, location, name of a part or operation, things moved or changed
since the accident occurred, direction of the shot (i.e. "facing North"), etc.

Video Taping Tips

1.

Whenever possible, use a tripod and additional lighting on the camera to improve
video quality.

2.

Most of the time it is probably better not to use the auto focus feature on the
camera. Instead, use the manual focus feature.

3.

When you are planning the video taping, think about explaining what you have found
and the circumstances that took place, then shoot the scenes accordingly. In other
words, tell a story with the video tape.

4.

Use the date and time feature on the video camera.

5.

The purpose of the video tape is to gather visual information to be used during the
investigation.

Photographs
1.

Apply the above suggestions.

2.

Create a log of all photographs taken listing the shot number, roll number,
description of shot, who took it, date, etc.

40

PHOTOGRAPHIC SHOT LIST

Date ______________________________
Name of
Victim(s)____________________________________________________
Plant Name ________________________________ Local Union #_______
1.

_______________________________________________________

2.

_______________________________________________________

3.

_______________________________________________________

4.

_______________________________________________________

5.

_______________________________________________________

6.

_______________________________________________________

7.

_______________________________________________________

8.

_______________________________________________________

9.

_______________________________________________________

10.

_______________________________________________________

11.

_______________________________________________________

12.

_______________________________________________________

13.

_______________________________________________________

14.

_______________________________________________________

15.

_______________________________________________________

41

Developing a
Report

42

Recommendations
1. Specific Situation
2. Similar Situations, Conditions, Equipment
3. Management System Deficiencies
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43

Hierarchy of Health and Safety Controls

Most Effective

1) Elimination or Substitution
2) Engineering Controls
3) Warnings
4) Training and Procedures
Administrative Controls

Least Effective

5) Personal Protective Equipment

HS ID # 166C:\FILES\HIERARCH\HIERCHT.DOC

44

substitute for hazardous material

change process to eliminate noise
perform task at ground level
automated material handling

ventilation systems
machine guarding
sound enclosures
circuit breakers
platforms and guard railing
interlocks
lift tables, conveyors, balancers
computer warnings
odor in natural gas
signs
backup alarms
beepers
horns
labels
safe job procedures
rotation of workers
safety equipment inspections
Hazard Communication Training
Lockout
Confined Space Entry
safety glasses
ear plugs
face shields
safety harnesses and lanyards
back belts

In the end, the only thing that will be

remembered is your report.

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IMPLEMENTATION
AND
FOLLOW UP
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Accident Investigation
BIBLIOGRAPHY

Benner, Ludwig, and Kingsley Hendrick. Investigating Accidents With STEP, Marcel Dekker1
Inc., New York and Basel, 1987.
Ferry, Ted S. Modern Accident Investigation and Analysls - Second Edition, John Wiley and
Sons, Inc., New York, 1988.
Kuhlman, Raymond. Professional Accident Investigation, Institute Press, Loganville,
1977.

47

GETTING THE FACTS

1.

The right questions

a.

Who questions
1)
Who was injured
2)
Who saw the mishap?
3)
Who first responded?
4)
Who talked with the victim?
5)
Who has done the same job before?
6)
Who has trained the victim?
7)
Who supervised the victim?
8)
Who told the victim to do this work
9)
Who maintained this equipment
10)
Who inspected this equipment
11)
Who modified this equipment?
12)
Who installed this equipment?

b.

What questions
1)
What did the victim do prior to the accident?
2)
What was the victim doing at the time of the accident?
3)
What equipment was involved (serial number, model number, company
number, manufacturer's name)?
4)
What is the normal process?
5)
What was different this time?
6)
What were the instruction
7)
What was the training?

c.

Where questions
1)
Where was the victim at the time of the accident?
2)
Where was the equipment?
3)
Where was the witness?
4)
Where was the first aid/emergency equipment?
5)
Where was the supervisor?

d.

When questions
1)
What time did the accident take place? Was it at the end of the shift
2)
Was it at the end of the week?
3)
How long had the victim been working that day? That week?

e.

How questions
1)
How does the equipment normally operate?
2)
How did the equipment operate on this day?
3)
How does the victim normally perform this job?
4)
How did the victim perform this job this day?
5)
How did the mishap occur?

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