ACCIDENT/INCIDENT INVESTIGATION

by

OLATUNDE, OLUWASEUN ADEOLA

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This is to certify that OLATUNDE, OLUWASEUN ADEOLA submitted this literature study to the Nigeria Institute of Safety Professional in partial fulfillment of Membership of the Institute.

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AUTHORIZED SIGNATORY

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AUTHORIZED SIGNATORY

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SUMMARY A successful accident investigation determines not only what happened, but also finds how and why the accident occurred. Investigations are crucial as an effort to prevent a similar or perhaps more disastrous sequence of events. Research has shown that a typical accident is the result of many related and unrelated factors that somehow all come together at the same time. It is estimated that there are usually more than ten factors that contribute to a serious accident. Although, this combination of factors normally makes an investigation very time consuming and resource intensive, the good news is that the accident can normally be prevented by removing only a few of the contributing factors.

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OUTLINE CHAPTER 1 What is an accident and why should it be investigated? CHAPTER 2 Developing an Accident Plan • Who should do the accident investigating? • Should the immediate supervisor be on the team? CHAPTER 3 What are the steps involved in investigating an accident? • Eye-Witnesses account • Interviewing the witness CHAPTER 4 What caused the accident? • Accident Causation Model • Why look for the "root cause"? CHAPTER 5 Reporting the Investigation • What should be done if the investigation reveals "human error"? • How should follow-up be handled? -4- .

Accident/Incident investigation and analysis are a critical element of safety management. Furthermore. It involves the transfer of an excessive amount of energy due usually to the motion of people. reputation and the environment. one should be careful when using the word ‘INVESTIGATION’ which often implies that the primary purpose of the activity is to establish blame which would ultimately defeat its purpose. However. The express purpose of the -5- . and that may (or may not) include injury or property damage. damage to assets. or substances.CHAPTER 1 WHAT IS AN INCIDENT/ACCIDENT AND WHY SHOULD IT BE INVESTIGATED? An incident usually refers to an unexpected event that cause or have the potential to cause harm to people. incident which does not cause harm or injury is referred to as a Near miss. It is an action carried out in order to determine the cause or causes of an accident or series of accidents so as to prevent further incidents. objects. An accident can be defined as an unplanned event that interrupts the completion of an activity. The term "accident" can also be referred to as an incident that results in the actual injury or damage.

Reasons to investigate a workplace accident include: • most importantly. Although accident investigation is a valuable and necessary tool to help reduce accident losses. to find out the cause of accidents and to prevent similar accidents in the future • to fulfill any legal requirements • to determine the cost of an accident • to determine compliance with applicable safety regulations • to process workers' compensation claims • Maintain worker morale • Expose deficiencies in process and/or equipment. it is always considerably more expensive to rely on accident investigation than hazard investigation as a strategy to reduce losses and eliminate hazards in -6- . The same principles apply to a quick inquiry of a minor incident and to the more formal investigation of a serious event.investigation is improving the organization’s safety management system and the only way to receive any long-term benefit from the investigation is to make sure system weaknesses are uncovered and permanently corrected. Incidents that involve no injury or property damage should still be investigated to determine the hazards that should be corrected.

DECREASED OUTPUT OF INJURED WORKER UPON RETURN .LEGAL EXPENSES .LOSS OF BUSINESS & GOODWILL Figure 1: Accident Cost Iceberg -7- .EXTRA SUPERVISORY TIME .INVESTIGATION TIME .OVERTIME . when the accident happens it's important to minimize accident costs to the company. In some cases it may cost hundreds of thousands of dollars more as a result of direct.INTERRUPTIONS .CLERICAL TIME . But.WAGES PAID FOR LOST TIME . .BUILDING DAMAGE TOOL & .PRODUCTION DELAYS & . indirect.EXPENDITURE OF EMERGENCY SUPPLIES & .COST OF HIRING OR TRAINING REPLACEMENTS . This can be done if effective accident investigation procedures are used.the workplace.EQUIPMENT DAMAGE PRODUCT & MATERIAL DAMAGE . and unknown accident costs as indicated in the Figure 1 below.

NB: The term incident is used in some situations and jurisdictions to cover both an "accident" and "incident". -8- . it is usually found that many events were predictable and could have been prevented if the right actions were taken -. For simplicity.making the event not one of fate or chance (thus. the word incident is used). we will use the term accident to mean all of the above events. It is argued that the word "accident" implies that the event was related to fate or chance. When the root cause is determined.

etc. (fire. Some expansion questions could be. everyone will be too busy dealing with the emergency at hand to worry about putting together an investigation plan. police.) • Who should do the accident investigation? • Training required for accident investigators • Timetables for conducting hazard correction.CHAPTER 2 DEVELOPING AN INVESTIGATION PLAN When a serious accident occurs in the workplace. You might wish to develop a flow chart to quickly show the major components of your program The plan should include as a minimum procedures that determine: • Who should be notified of accident? (Designated person within the organization) • Who is authorized to notify outside agencies. forms. need to be listed out as step-by-step procedures. reducing the chance for evidence to be lost and witnesses to forget. All procedures. etc. Who is responsible for the finished report and what is the time frame? Who receives copies of the report? -9- . Preplanning will also help you address situations timely. so the best time to develop effective accident investigation procedures is before the accident occurs. notifications.

and industrial relations environment of a particular situation. persons. Other members of the team can include: • employees with knowledge of the work • safety officer • health and safety committee • union representative.10 - . Some jurisdictions provide guidance such as requiring that it must be conducted jointly. with both management and labour represented. In most cases. the supervisor should help investigate the event.Who determines which of the recommendations will be implemented? Who is responsible for implementing the recommendations? Who goes back and assures that fixes are in place? Who assures that fixes are effective? Who should do the accident investigation? Ideally. or that the investigators must be knowledgeable about the work processes involved. if applicable • employees with experience in investigations • "outside" expert . procedures. experienced in investigative techniques. fully knowledgeable of the work processes. an investigation would be conducted by someone experienced in accident causation.

• representative from local government Should the immediate supervisor be on the team? The advantage is that this person is likely to know most about the work and persons involved and the current conditions. The counter argument is that there may be an attempt to gloss over the supervisors shortcomings in the accident.11 - . and if the worker representative(s) and the members review all accident investigation reports thoroughly. This situation should not arise if the accident is investigated by a team of people. Furthermore. . the supervisor can usually take immediate remedial action.

. Always check for still-present dangerous situations.CHAPTER 3 WHAT ARE THE STEPS INVOLVED IN INVESTIGATING AN ACCIDENT? Accident Scenario: Ekenne hurts bad. Step One Check for Danger This is the first thing to do when you arrive at an accident site as people might be busy scrambling to help out the injured oblivious of the dangers around. Make sure you and others don’t become victims. .12 - . Step Two Help the Injured Ensure First Aid procedures are carried out on the injured and moved as soon as possible to the hospital.. fell off a scaffold over at the worksite! You've just been notified of an injury in the workplace and immediately swing into action. You grab your investigator's kit and hurry to the accident scene.

equipment being used materials or chemicals being used. therefore. The easiest way to do this is to place yellow warning tape around the area. housekeeping of area. or police. noise levels. lighting levels. and identify all witnesses. Based on your knowledge of the work process. weather conditions. In some jurisdictions. Physical evidence is probably the most non-controversial information available. Step Four Study Evidence Before attempting to gather information. safety devices in use. you may want to check items such as: Positions of injured workers. an accident site must not be disturbed without prior approval from appropriate government officials such as the coroner. damage to equipment. both of the general area and specific items.Step Three Secure the accident site Ensure to secure the accident scene. It is also subject to rapid change or obliteration. Later careful study of these may reveal conditions or observations . examine the site for a quick overview. warning signs or guards may be required.13 - . position of controls of machinery. If tape is not available. position of appropriate guards. it should be the first to be recorded. inspector. time of day. take steps to preserve evidence. You may want to take photographs before anything is moved.

debris. to place blame but just to gather the facts. In some situations witnesses may be your primary source of information because you may be called upon to investigate an accident without being able to examine the scene immediately after the event. Eyewitness Accounts This is a very important part of an investigation. Broken equipment. Sketches of the accident scene based on measurements taken may also help in subsequent analysis and will clarify any written reports. It is not your job.14 - . individual perceptions may be lost in the normal . and samples of materials involved may be removed for further analysis by appropriate experts. You are ultimately trying to determine surface and root causes for the accident. interviewing witnesses is probably the hardest task facing an investigator. written notes about the location of these items at the accident scene should be prepared. Witnesses should be kept apart and interviewed as soon as possible after the accident.missed previously. If witnesses have an opportunity to discuss the event among themselves. Even if photographs are taken. Because witnesses may be under severe emotional stress or afraid to be completely open for fear of recrimination. as an accident investigator. It is important to remember that you are gathering information to use in developing a sequence of steps that led up to the accident.

You may decide to interview a witness at the scene of the accident where it is easier to establish the positions of each person involved and to obtain a description of the events.process of accepting a consensus view where doubt exists about the facts. at ease • emphasize the real reason for the investigation.15 - . On the other hand.. Interviewing a witness Interviewing is an art that cannot be given justice in a brief document such as this. • put the witness. but a few do's and don'ts can be mentioned. The purpose of the interview is to establish an understanding with the witness and to obtain his or her own words describing the event: DO. who is probably upset.. rather than in a group. Witnesses should be interviewed alone. The decision may depend in part on the nature of the accident and the mental state of the witnesses. listen • confirm that you have the statement correct • try to sense any underlying feelings of the witness . to determine what happened and why • let the witness talk. it may be preferable to carry out interviews in a quiet office where there will be fewer distractions.

• make short notes or ask someone else on the team to take them during the interview • ask if it is okay to record the interview. etc. what caused the accident? .. but there are some general questions that should be asked each time • Where were you at the time of the accident? • What were you doing at the time? • What did you see.) at the time? • What was (were) the injured worker(s) doing at the time? • In your opinion. • intimidate the witness • interrupt • prompt • ask leading questions • show your own emotions • jump to conclusions Ask open-ended questions that cannot be answered by simply "yes" or "no". hear? • What were the environmental conditions (weather.16 - . if you are doing so • close on a positive note DO NOT. light.. The actual questions you ask the witness will naturally vary with each accident. noise.

They can give you much information about the circumstances surrounding the accident.• How might similar accidents be prevented in the future? Step Five Background information Gathering background information about the accident may be accomplished in many ways. co-workers.17 - . Interview other interested persons such as supervisors. etc. including: • Training records • Disciplinary records • Medical records (as allowed) • Maintenance records • EMT reports • Police reports (rare) • Coroner's report (fatalities) • Past similar injuries • Safety Committee records . Of course you’ve gotten initial statements through interviews with eyewitnesses. You should tell those who you initially interview that you may conduct follow-up interviews if more questions surface. You should also review any records associated with the accident.

analysis is in-depth and the question of liability does not surface until after system weaknesses have been determined. the question of discipline may be discussed. . If safety management system weaknesses did not in any way contribute to the accident. to note that one of the symptoms of conducting accident investigations to determine liability is that not much analysis is conducted once liability can be established. It's important. here.18 - .After gathering all the needed information about the accident. It's important that you read through the information initially to develop an accurate sequence of events that led up to and included the actual injury event. in a fix-the-system culture. On the other hand.

ranging from Heinrich's domino theory to the sophisticated Management Oversight and Risk Tree (MORT).CHAPTER 4 WHAT CAUSED THE ACCIDENT? Accident Causation Models Many models of accident causation have been proposed. When this model is used. environment.task.19 - . material. Each category is examined more closely below. and management. Figure 2 attempts to illustrate that the causes of any accident can be grouped into five categories . possible causes in each category should be investigated. personnel. Figure 2: Accident Causation .

Task Here the actual work procedure being used at the time of the accident is explored. investigators might ask: Was there an equipment failure? What caused it to fail? Was the machinery poorly designed? Were hazardous substances involved? Were they clearly identified? Was a less hazardous alternative substance possible and available? . an important follow-up question is "If not. 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? For most of these questions.20 - . why not?" Material To seek out possible causes resulting from the equipment and materials used.

each time the answer reveals an unsafe condition. Environment The physical environment. The purpose for investigating the accident is not to establish blame against . or fumes present? Personnel The physical and mental condition of those individuals directly involved in the event must be explored. is another factor that need to be identified.21 - . The situation at the time of the accident is what is important. dusts. not what the "usual" conditions were. the investigator must ask why this situation was allowed to exist. For example. and especially sudden changes to that environment. 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.Was the raw material substandard in some way? Should personal protective equipment (PPE) have been used? Was the PPE used? Were users of PPE properly trained? Again.

Some factors will remain essentially constant while others may vary 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)? Management Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management and the role or presence of management systems must always be considered in an accident investigation.someone but the inquiry will not be complete unless personal characteristics are considered.22 - . Failures of management systems are often found to be direct or indirect factors in accidents. Ask questions such as: Were safety rules communicated to and understood by all employees? Were written procedures and orientation available? Were they being enforced? Was there adequate supervision? Were workers trained to do the work? Had hazards been previously identified? .

Obviously there is considerable overlap between categories. It is a readily apparent reason for an accident that usually appears early in an accident investigation. It must however be noted that these accident causation model helps to ultimately determine the SURFACE AND ROOT CAUSES of an accident. Some investigators may prefer to place some of the sample questions in different categories. however. Surface causes. A long-lasting corrective action does not come from a surface cause. as long as each pertinent question is asked.23 - . the categories are not important. Secondary surface causes are unique conditions or behaviors that indirectly contribute to the accident. by any person in the . Primary surface causes directly cause the accident and usually involve the victim and some object or behavior.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. A surface cause leads to a root cause. this reflects the situation in real life. Secondary surface causes can occur anytime.

Conditions are objects or "states of being. . A root cause may be referred to as a "basic" cause in any accident investigation reports. Examples: a. d.organization. Inadequate purchasing policy. b. policies. Unguarded saw (condition) Horseplay (behavior) Not using hearing protection when required (behavior) Slippery floor (condition) Inadequately trained employee (condition) Root causes. They are the programs. and at any location. activity. This are underlying system weaknesses that indirectly produce the primary and secondary surface causes leading to an accident. and procedures in any of the seven elements or activity areas in a safety management system. No clearly stated supervision. • • • • • Inadequate or missing safety training plan.24 - . plans. It takes more in-depth investigation and results in long-lasting corrective action that can prevent repetition of the accident. e." Behaviors describe some sort of action. processes. No inspection procedures. c. Inadequate hazard reporting process. The system weaknesses always exist prior to the surface causes that produced the accident.

25 - . why not? An inquiry that answers these and related questions will probably reveal conditions that are more open to correction than attempts to prevent "carelessness". it is necessary to examine some underlying factors in a chain of events that ends in an accident. why was the worker distracted? • Was a safe work procedure being followed? If not. why not? • Were safety devices in order? If not. . For example. an "investigation" which concludes that an accident was due to worker carelessness. if ever. why not? • Was the worker trained? If not.• No progressive discipline process. and goes no further. Therefore. is there only a single cause. On the other hand. Why look for the "root cause"? An investigator who believes that accidents are caused by unsafe conditions will likely try to uncover conditions as causes. one who believes they are caused by unsafe acts will attempt to find the human errors that are causes. The important point is that even in the most seemingly straightforward accidents. fails to seek answers to several important questions such as: • Was the worker distracted? If yes. seldom.

why. Findings These ask the questions. when. your investigation is to determine cause. it’s just a fill-in the blank portion. This section includes the sequence of events you developed to determine cause. It's virtually impossible to blame any one individual for a workplace accident. Don't let anyone pressure you into placing blame. Photographs and diagrams may save many words of description. where. and then their associated root causes. This is the who. the investigators must find all possible answers to this question.26 - . Remember. It merely tells who conducted the inspection. or your assumptions.CHAPTER 5 REPORTING THE INVESTIGATION Background Information. . Identify clearly where evidence is based on certain facts. You have kept an open mind to all possibilities and looked for all pertinent facts. why did it happen? To prevent recurrences of similar accidents. when it was done. etc. Refer to appendix for an example of an accident investigation form. Ensure to list the surface causes first. not blame. eyewitness accounts. what. who the victim was. Description of the Accident. Remember that readers of your report do not have the intimate knowledge of the accident that you have so include all pertinent detail.

but it would jeopardize the chances for a free flow of information in future accident investigations. Once you are knowledgeable about the work processes involved and the overall situation in your organization. This would not only be counter to the real purpose of the investigation. you have determined that a blind corner contributed to an accident. it should not be too difficult to come up with realistic recommendations.Recommendations It is important to come up with a set of wellconsidered recommendations designed to prevent recurrences of similar accidents. For example.27 - . . Rather than just recommending "eliminate blind corners" it would be better to suggest: • install mirrors at the northwest corner of building X (specific to this accident) • install mirrors at blind corners where required throughout the worksite (general) Never make recommendations about disciplining a person or persons who may have been at fault. Recommendations should: • be specific • be constructive • get at root causes • identify contributing factors Resist the temptation to make only general recommendations to save time and effort.

In the unlikely event that you have not been able to determine the causes of an accident with any certainty. you use the same procedure to recommend actions to correct the root causes. Compare this figure with the costs associated with taking corrective action. It is quite likely that similar accidents will continue to occur. after making recommendations to eliminate or reduce the surface causes. . An action plan must be prepared with target dates and names of people (or department) in charge of the actions. Summary. The recommendation should also include an action plan. In this final section.28 - . it's important to present a costbenefit analysis. You may want to address return on investment also. you probably still have uncovered safety weaknesses in the operation. It's crucial that. If you fail to do this. Following up on the action plan up to its completion is essential. What are the estimated direct and indirect costs of the accident being investigated? These represent potential future costs if a similar accident were to occur. It is appropriate that recommendations be made to correct these deficiencies.

Furthermore. How should follow-up be handled? Management is responsible for acting on the recommendations in the accident investigation report. Follow-up actions include: • Respond to the recommendations in the report by explaining what can and cannot be done (and why or why not). when a thorough worksite accident investigation reveals that some person or persons among management. However. not to discipline an individual. supervisor. The intention here is to remedy the situation. and the workers were apparently at fault. • Develop a timetable for corrective actions.29 - . then this fact should be pointed out. if you have one.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 lay blame. Failing to point out human failings that contributed to an accident will not only downgrade the quality of the investigation. it will also allow future accidents to happen from similar causes because they have not been addressed. The health and safety committee. . can monitor the progress of these actions. Any disciplinary steps should be done within the normal personnel procedures. However never make recommendations about disciplining anyone who may be at fault.

30 - . • Check the condition of injured worker(s). • Re-orient worker(s) on their return to work. • Inform and train other workers at risk.• Monitor that the scheduled actions have been completed. Table 1: Example of an action plan table Causes/Issues Action Responsibility Completion date .

Washington State Department of Labour & Industries. AIGA013/05 Asia Industrial Gases Association . Nigeria Institute of Safety Professionals Incident/Accident Investigation and analysis (2005). Contractor Employee HSE training Manual.31 - . Division of Occupational Safety & Health (DOSH). Occupational Health and Safety Academy Accident investigation basics (How to do a workplace accident investigation) (2009). Canadian Centre for Occupational Health and Safety Accident/Incident Investigation (Introduction to Safety Management) (2008).REFERENCES Accident Investigation (2006).

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