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ACCIDENT INVESTIGATION

The immediate aim of an accident investigation is to obtain accurate and full information
about the circumstances and causes of the accident.
The incident should be investigated as promptly as possible while the circumstances are
fresh in the memory of all parties, and before any evidence is removed or destroyed.
The ultimate objective is to prevent the occurrence of similar accidents in the future, to
uncover new hazards where such exist and to devise adequate measure to control them.
Accident investigations frequently identify one or more of the following underlying causes:
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failure of employer to provide an adequate safe system of work.


failure of employer to provide adequate information, instruction, training or supervision.
failure of employer to provide adequate personal protective equipment.

For the accident investigation to be successful in identifying all of the causes it will be
necessary to establish:
(a)

Events leading up to the incident1.


2.
3.
4.
5.
6.
7.
8.
9.

(b)

Facts of the incident itself1.


2.
3.
4.

(c)

the system of work being carried on;


the instructions given for the work;
variations from instructions or safe work systems;
workplace conditions such as lighting, floor surfaces, stair treads and handrails,
warning signs, temperature, weather if the incident occurred outside, etc.;
the exact location of the incident (with sufficient detail for the spot to be readily
identified by somebody else reading the report);
the materials in use or being handled;
the type of transport or equipment in use.

the state of the system and the actions that occurred at that moment;
the persons directly involved, and those involved at a distance, if any;
the tools, equipment, materials and fixtures directly concerned;
the time.

Relevant facts of what occurred immediately after the incident1.


2.
3.
4.

the injuries or damage directly resulting;


the events leading to consequential injury or damage;
the persons involved, including those rendering aid;
any problems in dealing with the injuries or damage such as no method for
releasing a trapped person, a faulty extinguisher, isolation switch difficult to
locate, and similar specifics.
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Persons who have knowledge of the work in hand or conditions at the scene, whether or not
they were there at the actual event or saw it occur, can also contribute to establishing the
chain of events and will have to be interviewed.
A checklist can be made to help establish the facts.
Checklist questions to help establish the facts.
WHO
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was injured?
saw the accident?
was working with the injured?
had instructed and/or assigned the job to the injured?
else was involved?
has information on events prior to the accident?

WHAT
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is the injury?
is the damage or loss?
was the injured doing?
had the injured been instructed to do?
tools were being used?
machinery/plant/equipment was in use?
previous similar accidents or near misses (incidents) have occurred?
action had been taken to prevent recurrence?
did the injured and any witnesses see?
safety rules were violated?
safe systems of work, permits to work, isolation procedures were there?
training had been given?
were the contributory causes of the accident?
communication system was in use?

WHEN
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did the accident occur?


did the damage become evident?
did the injured start the job?
was an explanation of the hazards given?
did the supervisor last see the injured?
was something observed to be wrong?

WHY
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did the injury occur?


did communication fail?
was training not given?
were the unsafe conditions permitted?
was the hazard not evaluated?
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was personal protective equipment not provided?


was protective equipment not used?
was there no safe system of work, permit to work or isolation procedure operating?
were specific safety instructions not given?
was the injured where he/she was?
was the supervisor not consulted when things started to go wrong?
was the supervisor not there at the time?

WHERE
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did the accident occur?


did the damage occur?
was the supervisor at the time?
were the witnesses at the time?

HOW
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did the injury occur?


could the accident have been avoided?
could the injury have been avoided?
could the supervisor have prevented the accident?
could better design help?

INCIDENT INVESTIGATION
Those to be involved will require adequate training.
The following are considered as essential tools in the competent investigation of incidents
and should be held by the SHO:


Report form and Checklist as a routine prompt for basic questions

Notebook or pad of paper

Camera

Measuring tape, which should be long enough and robust, like a surveyors tape

Special equipment in relation to the particular investigation.

RESPONSIBILITIES
The Line manager is in the best position to investigate the accident or near-miss due to their
familiarity with the people concerned, the work area, methods of work and equipment or
chemicals involved. The supervisor is usually on the spot and can begin the investigation
soon after the time of the incident, an important factor in good investigation procedures.
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For any serious incident or accident, the SHO must lead the team and he/she should sign the
report and oversee all accident investigations.
The workplace procedures for accident investigation should identify the responsibilities of
management following the accident.

When an incident happens Line managers should:


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take any action required to deal with the immediate risks, e.g. first aid, put out the fire,
isolate any danger, fence off the area

assess the amount and kind of investigation needed and inform the SHO

investigate - find out what happened and why and report

take steps to stop something similar happening again

Those carrying out the investigation should be aware of the time allowed for completion of the
investigation; e.g. the report must be presented to the SHO on the first working day following
the day of the incident. If by this time investigations are incomplete and a written report is not
available, a verbal progress report on the investigation should be made.

INTERVIEWING WITNESSES
There are two types of witness:



eye witnesses, persons who actually see the accident happen;


circumstantial witnesses, those who did not actually see the accident but who can
contribute valuable information.

Witnesses and others should be interviewed as soon as possible and individually so that the
comments of one do not influence the others.
Witnesses must be convinced that investigators want to find all the factors that contributed to
the accident and not to allocate blame.
There are certain proven techniques for a successful interview. The following elements form
the basic approach to investigation interviewing1.
2.
3.
4.
5.
6.

Conduct the interview in private at the workplace.


Put the interviewee at ease; dont hurry things.
Ask for the interviewees version of what happened.
Only ask necessary questions. Dont ask leading questions.
Repeat the interviews story as you (the interviewer) understand it.
Close the interview on a positive note. Thank the witness.
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Remember that the accident victim or witness may be emotional. The best way to put the
interviewee at ease is to remind him or her of the purpose of the interview(a) You are solely interested in prevention, not in affixing blame.
(b) You can only achieve prevention with his or her help in identifying all the factors.
(c) You are interested in fact NOT theory.
Be polite and reassuring, NOT aggressive and rude. Ensure the interviewee understands
that all statements are confidential.

PRINCIPLES OF ACCIDENT PREVENTION


The two main principles are:
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The identification of hazards, risk assessment and risk control.

OSH Promotion and communication to influence behaviour and encourage safe


attitudes.

RECORD AND REPORT FORMS


A record form of the incident should be completed to assist recording of those details for
statistical analysis.
An incident report should contain the following:










A summary of what happened


An introductory summary of events prior to the accident
Information gained during investigation
Details of witnesses
Information about injury or loss sustained
Conclusions
Recommendations
Supporting material (photographs, diagrams to clarify)
The date, and be signed by the person or persons carrying out the investigation.

The full details of every accident or near-miss, having been investigated, must be
consolidated into a single file which should include the supervisors investigation report,
witness statements, plans/diagrams/photographs, copies of medical certificates and
insurance claim forms, copies of any notification made to the relevant statutory body.
All accidents or incidents should be reported by employees and recorded in the accident
book.
All accidents and near misses must be recorded, however minor. Unless the company is
informed of these incidents, it will be unable to take remedial action.
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If an injury, damage incident or near miss is reported to a member of management, that


manager should ensure that the SHO is informed.
The SHO must ensure that OSH Act requirements are met. The OSH Act 1994 places a duty
on the employer to report to the nearest DOSH office any accident, dangerous occurrence,
occupational poisoning or occupational disease which has occurred or is likely to occur at the
place of work. The OSH Act 1994 also places a duty on every registered medical practitioner
or medical officer to report certain diseases as in accordance with legislative requirements
and occupational poisonings.
Managers are responsible for assisting contractors and visitors in complying with company
policy regarding accident reporting whilst on company premises.