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This material is for training purposes only.

Welcome
Course Overview
Part One

Accident investigation definitions

Characteristics of an effective program
Part Two: The six-step process

Step 1: Preserving and documenting the accident scene

Step 2: Collecting the facts through interviews

Step 3: Developing sequence

Step 4: Determining causes
Part Three

Step 5: Developing effective recommendations

Tools and techniques to measure costs/benefits

Step 6: Writing the report

Form Groups
 Introductions
 Elect a group leader
 Select a spokesperson
and recorder – or
alternate responsibilities
Discuss and report:
•Problems you have seen when thorough
accident investigation techniques are not
practiced, or
•Positive results when thorough accident
investigations are conducted.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Introduction to Accident Investigation

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This material is for training purposes only.

Objectives
After attending this workshop, the participants will be able to:
1.
2.
3.

Identify basic accident investigation concepts and describe the characteristics
of an effective accident investigation program.
Describe the six-step process for conducting accident investigations.
Conduct an accident investigation following the six-step procedure.

The basics
What is an accident?
_________________________________________________________
_________________________________________________________
________________________________________________________

What 2 key conditions must exist before an accident occurs?
_________________________________________________________

What causes most accidents?
According to the State of Oregon,

Hazardous conditions account for __% of all workplace accidents.

Unsafe/inappropriate behaviors account for __% of all workplace
accidents.

Uncontrollable acts account for ___% of all workplace accidents

Management is able to control factors that produce ____ % of all
workplace accidents.

What is the difference between accident investigation and
accident analysis?
_________________________________________________
_________________________________________________
_________________________________________________________

Does your organization conduct accident investigations for
the same reason as OSHA?
_____________________________________________

Introduction to Accident Investigation

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This material is for training purposes only.

What do accidents cost your company?
Direct Insured Costs
Unseen
costs can
sink the
ship!

1.Workers’ compensation premiums
2. Miscellaneous medical expenses. Medical expenses
include doctor fees, hospital charges, the cost of medicines,
future medical costs, and ambulance, helicopter, and other
emergency medical services.

Indirect - Uninsured, Hidden Costs - Out of Pocket

Indirect costs are those costs not covered
by insurance. They aren’t as obvious as
direct costs, but can add up.

Average direct and indirect
accident costs
Non-Lost-time injury:
Lost- time injury:
Fatality:

Examples:
1. Lost time by fellow employees/supervisor.
2. Investigation of accident.
3. Schedule delays.
4. Legal fees.
5. Training costs for new/replacement workers.
6. Damage to tools and equipment.
7. Lower morale.
8. Increased absenteeism.
9. Poorer customer relations.
10. Others?

Introduction to Accident Investigation

- Iceberg

3

$7,000
$28,000
$980,000

Using National Safety Council average
costs for 2000; includes both direct and
indirect costs; excludes property
damage.

Direct to Indirect Accident Cost
Ratios
Studies show that the ratio of indirect to direct
costs can vary widely, from a high of 20:1 to a
low of 1:1. Source: Business Roundtable,
1982.

This material is for training purposes only.

The basics
Are accidents always unplanned?
____________________________________________________________
____________________________________________________________
____________________________________________________________

What’s the difference between an incident and an accident?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Characteristics of an Effective Accident Investigation Program
An effective incident/accident analysis program includes:
1. Clearly stated and easy to follow written procedures.
2. Clearly assigned responsibility for conducting accident investigations.
3. All accident investigators will be formally trained on accident investigation
techniques and procedures.
4. Separation of the accident investigation from any potential disciplinary
procedures resulting from the accident. The purpose of the accident
investigation is to get at the facts, not find fault.
5. A written report, addressing the surface causes and root causes, with
recommendations to correct hazardous conditions and work practices, and
those underlying system weaknesses that "caused" them into existence.
6. Follow-up procedures to make sure short and long-term corrective actions
are completed.
7. An annual review of accident reports to make sure root causes are being
addressed and corrected, so that information about the types of accidents,
locations, trends, etc., can be gathered.

Introduction to Accident Investigation

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This material is for training purposes only.

The basics
Who should investigate?
____________________________________________________________
____________________________________________________________
____________________________________________________________

Group Exercise - Evaluate a Sample Program

Instructions:
Review the following sample accident investigation program. Edit the program as
you think it should be written.
 Does it meet the criteria you said was important?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
 What should be added/changed?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

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“Fix The System” Incident/Accident Analysis Plan
1.0 General Policy
____________________ considers employees to be our most valued asset and as such we will ensure that all
incident and accidents are analyzed to correct the hazardous conditions, unsafe practices, and improve related
system weaknesses that produced them. This incident/accident analysis plan has been developed to ensure our
policy is effectively implemented.
____________________ will ensure this plan is communicated, maintained and updated as appropriate.

2.0 Incident/Accident Reporting
2.1 Policy. All employees will report immediately to their supervisor, any unusual or out of the ordinary
condition or behavior at any level of the organization that has or could cause an injury or illness of any kind.
Supervisors will recognize employees immediately when an employee reports an injury or a hazard that could
cause serious physical harm or fatality, or could result in production downtime.
2.2 _____________________ will ensure effective reporting procedures are developed so that we can quickly
eliminate or reduce hazardous conditions, unsafe practices, and system weaknesses.

3.0 Preplanning.
Effective incident/accident analysis starts before the event occurs by establishing a well thought-out
incident/accident analysis process. Preplanning is crucial to ensure accurate information is obtained before it is lost
over time following the incident/accident as a result of cleanup efforts or possible blurring of people’s
recollections.

4.0 Incident/Accident Analysis.
4.1 All supervisors are assigned the responsibility for analyzing incidents and accidents in their departments. All
supervisors will be familiar with this plan and properly trained in analysis procedures.
4.2 Each department supervisor will immediately analyze all incidents that might have resulted in serious injury or
fatality. Supervisors will analyze incidents that might have resulted in minor injury or property damage within 4
hours from notification.
4.3 The supervisor will complete and submit a written incident/minor injury report through management levels to
the plant superintendent. If within the capability/authority of the supervisor, corrective actions will begin
immediately to eliminate or reduce the hazardous condition or unsafe work practice that might result in injury or
illness.

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4.4 In cases of an incident/accident such as a fire, release, or explosion emergency, the supervisor will:
1. Secure or barricade the scene;
2. Immediately collect transient information;
3. Interview personnel.

5.0 Incident/Accident Analysis Team
5.1 Incident/Accident Analysis Team Makeup
If the supervisor determines that additional assistance is needed for investigation, a team will be compiled and may
include:
1. A third-line or higher supervisor from the section where the event occurred;
2. Personnel from an area not involved in the incident;
3. An engineering and/or maintenance supervisor;
4. The safety supervisor;
5. A first-line supervisor from the affected area;
6. Occupational health/environmental personnel;
7. Appropriate wage personnel (i.e., operators, mechanics, technicians); and,
8. Research and/or technical personnel.

Team member

Department

Shift

Phone

_____________________________ ___________________________

____

____________

_____________________________ ___________________________

____

____________

_____________________________ ___________________________

____

____________

_____________________________ ___________________________

____

____________

_____________________________ ___________________________

____

____________

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5.2 The Incident/Accident Analysis Team Leader (Supervisor)
The Incident/Accident Analysis team leader will:
1. Control the scope of team activities by identifying which lines of analysis should be pursued, referred to
another group for study, or deferred;
2. Call and preside over meetings;
3. Assign tasks and establish timetables;
4. Ensure that no potentially useful data source is overlooked; and,
5. Keep site management advised of the progress of the analysis process.

6.0 Determining the Facts
A thorough search for the facts is an important step in incident/accident analysis. During the fact-finding phase of
the process, the supervisor or the team members will:
1. Visit the scene before the physical evidence is disturbed;
2. Sample unknown spills, vapors, residues, etc., noting conditions which may have affected the sample; (Be
sure you sample using proper safety and health procedures.)
3. Prepare visual aids, such as photographs, field sketches, maps, and other graphical representations with the
objective of providing data for the analysis.
4. Obtain on-the-spot information from eyewitnesses, if possible. Interviews with those directly involved and
others whose input might be useful should be scheduled soon thereafter. The interviews should be
conducted privately and individually so that the comments of one witness will not influence the responses
of others.
5. Observe key mechanical equipment as it is disassembled. Include as-built drawings, operating logs, recorder
charts, previous reports, procedures, equipment manuals, oral instruction, change of design records, design
data, records indicating the previous training and performance of the employees involved, computer
simulations, laboratory tests, etc.
6. Determine which incident-related items should be preserved. When a preliminary analysis reveals that an
item may have failed to operate correctly, was damaged, etc., arrangements should be made to either
preserve the item or carefully document any subsequent repairs or modifications.
7. Carefully document the sources of information contained in the incident report. This will be valuable
should it subsequently be determined that further study of the incident or potential incident is necessary.

7.0 Determining the Cause
It is critical to determine the cause(s) of the accident. Therefore, the investigation will uncover:
1. Direct causes
2. Hazardous conditions
3. Unsafe behaviors
The supervisor or team will use appropriate methods to sort out the facts, inferences, and judgments. Even when
the cause of an incident appears obvious, the investigation team will still conduct a formal analysis to make sure
any oversight, or a premature/erroneous judgment, is not made.

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This material is for training purposes only.

8.0 Recommending Corrective Actions and System Improvements
A recommendation for corrective action and system improvement will contain three parts:
1. The recommendation itself, which describes the actions and improvements to be taken to prevent a
recurrence of the incident.
2. The name of the person(s) or position(s) responsible for accomplishing actions and improvements.
3. The correction date(s).

9.0 Communicating Results
9.1 To prevent recurring incidents we will take two additional steps:
1. Document findings; and
2. Review the results of the analysis with appropriate personnel.
9.2 Incident documentation will address the following topics:
1. Description of the incident (date, time, location, etc.);
2. Facts determined during the analysis (including chronology as appropriate);
3. Statement of causes; and
4. Recommendations for corrective and preventive action (including who is responsible and correction date).

10.0 Review and approval
Appropriate operating, maintenance and other personnel will review all incident/accident analysis reports.
Personnel at other facilities will also review the report to preclude a similar occurrence of the incident.

Plan reviewed by __________________________________________ Date _______________________
__________________________________________ Date _______________________
__________________________________________ Date _______________________
Plan approved by __________________________________________ Date _______________________

Introduction to Accident Investigation

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This material is for training purposes only.

The basics

Review
Let’s review some of the important points about initiating the
accident investigation.

1. What two key conditions must exist before an accident occurs?

2. Are accidents always unplanned?

3. What are the characteristics of an effective incident/accident analysis program?

Introduction to Accident Investigation

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This material is for training purposes only.

The Six-Step Process

Investigating Accidents
The three primary tasks of the accident investigator are to:


Gather useful information,
Analyze the facts surrounding the accident, and
Write the accident report.

Basic Steps for Conducting An
Accident Investigation/Analysis
Step 1 – Preserve and document the scene
Step 2 – Collect the facts through interviews
Step 3 – Develop sequence of events
Step 4 – Determine causes
Step 5 – Recommend improvements
Step 6 – Write the report

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This material is for training purposes only.

The first two steps in the procedure help you gather accurate information about the accident.

Step 1: Preserve and Document the Accident Scene

In this session, we take a look at strategies for preserving and documenting the
accident scene. We’ll learn why it is important to begin the investigation early-on,
when it’s “safe” to investigate. Next, we’ll cover how to secure the accident scene
once the investigation has been initiated. Finally, you’ll learn what the law says about
reporting accidents to OSHA.

Why is it appropriate to begin the investigation immediately?
____________________________________________________
____________________________________________________

What are effective methods to secure an accident scene?
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

.

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This material is for training purposes only.

Step 1: Preserve and Document the Accident Scene
SAMPLE ACCIDENT INVESTIGATOR’S KIT
Essential
Camera*
Tape recorder and spare cassette tapes
Tape measure - preferably 100 foot
Clipboard and writing pad
Graph paper
Straight-edge ruler (Can be used as a scale reference in photos)
Pens, pencils
Accident investigation forms
Flashlight
Strings, stakes, warning tap
* Digital cameras are not generally recommended is there is a possibility of
legal action, as digital images can be easily altered.
Helpful
Accident investigator’s checklist
Magnifying glass
Sturdy gloves
High visibility plastic tapes to mark off area
First aid kit
Identification tags
Scotch tape and masking tape
Specimen containers; plastic bags with ties
Compass
Ten 4-inch spikes
Hammer
Paint stick (yellow/black)
Chalk (yellow/white)
Protractor
Video camera

Have a ready-and-waiting accident investigator's kit. You won't be able to fulfill
this purpose unless you come prepared so make sure an accident investigation
kit is available for use.

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This material is for training purposes only.

SKETCHING TECHNIQUES
1.

Make sketches large; preferably 8" x 10".

2. Makes sketches clear. Include information pertinent to the investigation.
3. Include measurements.
4. Print legibly. All printing should be on the same plane.
5. Indicate directions, i.e., N, S, E, W.
6. Always tie measurements to a permanent point, e.g., telephone pole, building.
7. Use sketches when interviewing people. You can mark where they were standing. Also,
the sketch can be used to pinpoint where photos were taken.
Example Sketch for a Fatality
Lumber Storage Area, ZYX Sawmill, Ltd.
N

Lumber Piles

Accident-Details
Time: 6.45 p.m.
Lighting: Dusk
Deceased: 6’1” Tall

Height

Height

Height

8 Ft.

8 Ft.

8 Ft.

Eye Level of Operator: 7’
Top of Load: 9’4”
Traveling Speed of Load:
Approx. 5 mph

Location of deceased (face down)
Photo
Location
PointEast

Very Poor Operator
Visibility

Direction of travel of deceased
Mr. J. Operator
Height

Height

Height

Height

Height

8 Ft.

8 Ft.

8 Ft.

8 Ft.

8 Ft.

22” Space
Introduction to Accident Investigation

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This material is for training purposes only.

Step 1: Preserve and Document the Accident Scene
Accident Scenario – Sketch Exercise

An employee of PC Pallet was fatally crushed by a falling stack of bundled
lumber while picking up building material (2x4 lumber that was 16-feet long)
at a material-handling facility of another company (RRC). The victim was
identifying the bundles of lumber that were going to be purchased by PC
Pallet, while an employee of RRC was operating a powered industrial truck
(forklift) to move bundled lumber in the stacks. Bundles of lumber were
arranged in a row with four stacks. The front stack was four bundles high
(approximately 11 feet). The second and third stacks were each 6 bundles
high (approximately 16.5 feet). The fourth stack was 4 bundles high
(approximately 11 feet). The top (fourth) bundle of the first/front stack had
been moved by a RRC forklift operator and placed on the PC Pallet truck,
which was parked approximately 36 feet from the stacked lumber bundles.
As the third bundle of the first stack was being moved by the forklift, the top
four bundles of the second stack shifted and three of these bundles fell over
the remaining two bundles of the first stack and fatally struck the victim, who
was standing approximately 14 feet from the front stack of lumber. The
stacked lumber was placed on an earthen surface that was damp and had
been exposed to snow and fluctuating temperatures during the past week. It
was reported that the stacks had been leaning forward prior to the accident.

Group Exercise: On a blank piece of paper, sketch the accident scene
for this scenario.

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Step 1: Preserve and Document the Accident Scene
Group Exercise:
What “documents” will you be interested in interviewing?
That's right...you don't just review records, you "interview" them by
asking questions. If you ask . . . they will answer.

Record
_________

Why - What do you expect to find?
_______________________________________________________

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________

_______________________________________________________

_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________

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DOCUMENT ANALYSIS
This document covers the four areas that should be reviewed in determining the
root cause of hazards, accidents and incidents. It is not uncommon to find factors
in each of the four areas: Management, Employee, Equipment and Environment.

Yes

No

Management Checklist

____ ____

1. Did supervisors detect, anticipate, or report an unsafe or hazardous condition?

____ ____

2. Did supervisors recognize deviations from the normal job procedure?

____ ____

3. Did supervisors and employees participate in job review sessions, especially for
those jobs performed on an infrequent basis?

____ ____

4. Were supervisors made aware of their responsibilities for the safety of their
work areas and employees?

____ ____

5. Were supervisors properly trained in the principles of accident prevention?

____ ____

6. Was there any history of personnel problems or any conflicts with or between
supervisors and employees or between employees themselves?

____ ____

7. Did supervisors conduct regular safety meetings with their employees?

____ ____

8. Were the topics discussed and actions taken during the safety meetings
recorded in the minutes?

____ ____

9. Were the proper resources (e.g., equipment, tools, materials, etc.) required to
perform the job or task readily available and in proper condition?

____ ____

10. Did supervisors ensure employees were trained and proficient before
assigning them to their jobs?

____ ____

11. Did management properly research the background and experience level of
employees before extending an offer of employment?

Question #

Comments:

_________

_______________________________________________________________________

_________

_______________________________________________________________________

_________

_______________________________________________________________________

_________

_______________________________________________________________________

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DOCUMENT ANALYSIS
Employee Checklist
Yes

No

____ ____

1. Did a written or well-established procedure exist for employees to follow?

____ ____

2. Did job procedures or standards properly identify the potential hazards of job
performance?

____ ____

3. Were employees familiar with job procedures?

____ ____

4. Was there any deviation from the established job procedures?

____ ____

5. Did any mental or physical conditions prevent the employee(s) from properly
performing their jobs?

____ ____

6. Were there any tasks in the job considered more demanding or difficult than
usual (e.g., strenuous activities, excessive concentration required, etc.)?

____ ____

7. Was the proper personal protective equipment specified for the job or task?

____ ____

8. Were employees trained in the proper use of any personal protective
equipment?

___ _____

9. Did the employees use the prescribed personal protective equipment?

____ ____

10. Were employees trained and familiar with the proper emergency procedures,
including the use of any special emergency equipment?

____ ____

11. Was there any indication of misuse or abuse of equipment and/or materials
at the accident site?

____ ____

12. Is there any history or record of misconduct or poor performance for any
employee involved in this accident?

____ ____

13. If applicable, are all employee certification and training records current and
up-to-date?

____ ____

14. Was there any shortage of personnel on the day of the accident?

Question # Comments:
_________

_______________________________________________________________________

_________

_______________________________________________________________________

_________

_______________________________________________________________________

_________

_______________________________________________________________________

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This material is for training purposes only.

DOCUMENT ANALYSIS
Equipment Checklist
Yes

No

____ ____

1. Were there any defects in equipment (including materials and tools) that
contributed to a hazard or created an unsafe condition?

____ ____

2. Were the hazardous or unsafe conditions recognized by management,
employees, or both?

____ ____

3. Were the recognized hazardous conditions properly reported?

____ ____

4. Are existing equipment inspection procedures adequately detecting hazardous
or unsafe conditions?

____ ____

5. Were the proper equipment and tools being used for the job?

____ ____
____ ____

6. Were the correct/prescribed tools and equipment readily available at the job
site?

____ ____

7. Did employees know how to obtain the proper equipment and tools?

____ ____

8. Did equipment design contribute to operator error?

____ ____

9. Was all necessary emergency equipment readily available?

____ ____

10. Did emergency equipment function properly?

____ ____

11. Is there any history of equipment failure for the same or similar reasons?

____ ____

12. Has the manufacturer issued warnings, Safe-Alerts, or other such
information pertaining to this equipment?

____ ____

13. Were all equipment guards and warnings functioning properly at the time of
the accident?

Question #

Comments:

_________

_______________________________________________________________________

_________

_______________________________________________________________________

_________

_______________________________________________________________________

_________

_______________________________________________________________________

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This material is for training purposes only.

DOCUMENT ANALYSIS
Environment Checklist
Yes

No

____ ____

1. Did the location of the employees, equipment, and/or materials contribute to
the accident?

____ ____

2. Were there any hazardous environmental conditions that may have contributed
to the accident?

____ ____

3. Were the hazardous environmental conditions in the work area recognized by
employees or supervision?

____ ____

4. Were any actions taken by employees, supervisors, or both to eliminate or
control environmental hazards?

____ ____

5. Were employees trained to deal with any hazardous environmental conditions
that could arise?

____ ____

6. Were employees not assigned to a work area present at the time of the
accident?

____ ____

7. Was sufficient space provided to accomplish the job?

____ ____

8. Was there adequate lighting to properly perform all the assigned tasks
associated with the job?

____ ____

9. Did unacceptable noise levels exist at the time of the accident?

____ ____

10. Was there any known leak of hazardous materials such as chemicals,
solvents or air contaminants?

____ ____

11. Were there any physical environmental hazards, such as excessive vibration,
temperature extremes, inadequate air circulation, or ventilation problems?

____ ____

12. If applicable, were there any hazardous environmental conditions, such as
inclement weather, that may have contributed to the accident?

____ ____

13. Is the layout of the work area sufficient to preclude or minimize the possibility
of distractions from a passerby or from other workers in the area?

____ ____

14. Is there a history of environmental problems in this area?

Question #

Comments:

_________

______________________________________________________________________

_________

_______________________________________________________________________

_________

_______________________________________________________________________

_________

_______________________________________________________________________

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This material is for training purposes only.

Step 1: Preserve and Document the Accident Scene
Quiz
Let’s review some of the important points about preserving and
documenting the accident scene.

1.

What's the most practical way to secure an accident scene?

2.

What might be the result if the investigation is not initiated as soon
as possible?

3.

If a workplace fatality or hospitalization of three or more employees
occurs, the affected employer must notify OSHA within _____.
a.
twenty-four hours c. eight hours
b.
sixteen hours
d. four hours

4.

When documenting the scene, one of the biggest challenges facing
the investigator is to:
a. determine who is to blame
b. determine what is relevant
c. determine who is in charge
d. determine who is liable

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Step 2: Collect Facts through Interviews

Introduction
Once you have initially preserved and documented the accident scene, it becomes
important to start digging for details through the interview process. Conducting an
interview is perhaps the most difficult part of an investigation. This section will help
you understand how to organize the interview and obtain accurate information.

When is it best to interview? Why?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Whom should we interview? Why?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Where should we conduct the interview?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
When should we NOT interview?
________________________________________________________
________________________________________________________

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Step 2: Collect Facts through Interviews
Group Exercise: Cooperation is the Key

Purpose. Gaining as much information as possible about
an accident is extremely important. Interviewing witnesses
is both a science and an art, and can make the difference
between a failed or a successful accident investigation.
This exercise will help you gain a greater awareness of those
interviewing questions you need to prepare for the
interview and help ensure your success as an investigator. Remember,
you must communicate a message of cooperation, not intimidation.
Instructions. Read the accident scenario provided. Your group is located at the
scene of the accident (classroom) and your job now is to ask follow-up questions to
gather information about the accident. Identify the person you are interviewing and
the questions you will ask.

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Did You Get the Facts?
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Mary Alice Conlin - Application Case Study (Page 1)

The accident occurred on a Walsh 55-ton full-revolution mechanical power
press. Mary Alice Conlin lost three fingers and part of her thumb on the
right hand when she reached into the press to extract a part.
The maintenance man did not secure the shield a week before the injury
event as he was in a hurry to get to another machine breakdown. Besides,
he needed a part to fix this press and had to wait for the part to be ordered.
The press was foot pedal operated with a point of operation guard. The foot
pedal was not guarded. The guard had a flip-up plexi-glass shield on the
front that was hinged, not fixed in place (secured). The employee (Mary
Alice) was removing a piece of metal that was stuck in the die. The guard
was flipped open. While removing the scrap part, she accidentally stepped
on the foot pedal. The employee lost 3 fingers and part of her thumb on the
right hand. She had been a press operator for 3 days. At approximately
9:00 a.m., employee #2 heard Mary Alice scream and ran to her while
shouting for help.
Employee #3, the designated first aider, heard the scream. He grabbed his
first aid kit and ran to Mary Alice to render first aid treatment. At
approximately 9:05 a.m., employee #2 ran to the supervisor’s office and the
rescue squad was called. Approximately 10 minutes later, the rescue squad
arrived and rendered treatment to stabilize Mary Alice who appeared to be
in shock. The rescue squad transported Mary Alice to the emergency room
at 9:30 a.m.

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INTERVIEWING QUESTIONS
WHO?

WHERE?

Who was injured
Who saw the accident
Who was working with the employee
Who had instructed/assigned the employee
Who else was involved
Who else can help prevent recurrence

Where did the accident occur
Where was the employee at the time
Where was the supervisor at the time
Where were fellow workers at the time
Where were other people who were involved at
the time
Where were witnesses when accident occurred

WHAT?

WHY?

What was the accident
What was the injury
What was the employee doing
What had the employee been told to do
What tools was the employee using
What machine was involved
What operation was the employee performing
What instructions had the employee been given
What specific precautions were necessary
What specific precautions was the employee
given
What protective equipment should have been
used
What protective equipment was the employee
using
What had other persons done that contributed to
the accident
What problem or questions did the employee
encounter
What did the employee or witnesses do when the
accident occurred
What extenuating circumstances were involved
What did the employee or witnesses see
What will be done to prevent recurrence
What safety rules were violated
What new rules are needed

Why was the employee injured
Why and what did the employee do
Why and what did the other person do
Why wasn’t protective equipment used
Why weren’t specific instructions given to the
employee
Why was the employee in the position
Why was the employee using the tools or
machine
Why didn’t the employee check with the
supervisor when the employee noted
things weren’t as they should be
Why did the employee continue working under
the circumstances

WHEN?

HOW?

When did the accident occur
When did the employee start on that job
When was the employee assigned on the job
When were the hazards pointed out to the
employee
When had the employee’s supervisor last
checked on job progress
When did the employee first sense something
was wrong

How did the employee get injured
How could the employee have avoided it
How could fellow workers have avoided it
How could supervisor have prevented it - could it
be prevented

Why wasn’t the supervisor there at the time

Introduction to Accident Investigation

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This material is for training purposes only.

Step 2: Collect Facts through Interviews

Quiz
Let’s review some of the important points about collecting
information on the accident.

1.

What relevant information might be obtained by reviewing the
OSHA Injury and Illness records?

2.

What is the purpose of the interview process. How do you best
achieve that purpose?

3.

Which of the following is an effective interview techniques?
a. Ask "why-you" questions
b. Ask open-ended questions
c. Interview in a crowd
d. Encourage fault-finding

4.

Why is it important to repeat the facts and sequence of events back
to the interviewee?

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This material is for training purposes only.

Step 3: Develop the Sequence of Events
Group Exercise: Develop the Sequence
Use the information gathered about the accident described in
the interview exercise to construct a sequence of events
listing the events prior to, during, and after the accident.
Instructions. Determine the injury event and list the events that led up to the
injury. Once you start the sequence, ask "What happened next?“ to determine the next
event.
Event __

____________________________________________________________

Event __

__________________________________________________________________

Event __

__________________________________________________________________

Event __

__________________________________________________________________

Event __

____________________________________________________________

Event __

__________________________________________________________________

Event __

__________________________________________________________________

Event __

__________________________________________________

Event __

____________________________________________________________

Event __

____________________________________________________________

Event __

____________________________________________________________

Event __

____________________________________________________________

Event __

____________________________________________________________

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This material is for training purposes only.

Step 3: Develop the Sequence of Events
Quiz
Let’s review some of the important points about developing a
sequence of events on the accident.

1.

An “event” occurs when one _______ performs an _______.

2.

Name the actor(s)/action(s) for the following: “Robert used a wrench to pound
a nail.”

3.

Developing the sequence of events is critical in the accident “analysis” process
to:
a. Find out who to interview
b. Fix the system
c. Place the blame
d. Document the scene

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This material is for training purposes only.

Step 4: Determine the Causes

Multiple Causation and the Accident Weed
Injury Analysis
or
1. Direct Causes ofInjury
the Injury
• Always the harmfulIllness
transfer of energy.
• Kinetic, thermal, chemical, etc.
• Contact with, exposure too, etc.

Strains
Burns
Cuts

Conditions
Un

gu

Acts
ar
de

d

2. Indirect (Surface) Causes of Accident
m

ac

hi
ne

Ho

Bro

ken

te
Crea

too
ls

C h em
ical s

Ignore

pill

Defe

ctive

Untrained

No accountability policy

rt in

jury

Contributing Indirect Causes
• Contributes to the accident
• Unique hazardous condition
• Inappropriate/unsafe behavior
• Exists/occurs more distant from the accident
• Exists/occurs anytime, anywhere by anyone

ain

Lack of vision No mission statement

Inadequate training plan

rd

Fails to tr

Too much
work
work
To much

No orientation process

a haza

Fails to enforce

Lack of time

No discipline procedures

ard

Fails to inspect

worker

Inadequate training

a h az

rep o
s to
Fail

PPE

Event Analysis
Primary Surface Causes
• Produces the accident
• Unique hazardous condition/unsafe behavior
• Exists/Occurs close to the injury event
• Involves the victim, possibly others

play
rse

3. Basic (Root) Causes of the Accident
No recognition

System Analysis
Inadequate system implementation
• Failure to carry out safety policies, programs,
plans, processes, procedures, practices
• Pre-exist indirect causes
• Under control of management
• Failure can occur anytime, anywhere
• Produces common indirect causes

Inadequate labeling

Outdated hazcom program
No recognition plan

No inspection policy

Inadequate system design
• Poorly written or missing policies, programs,
plans, processes, procedures, practices
• Pre-exist indirect causes
• Under top management control
• Produces inadequate implementation

Any way you look at it, design is the key to
an effective safety management system.
If design is flawed, yet perfectly implemented, the
system fails. If design is perfect, yet
implementation is flawed, the system fails as a
result of design flaws in other related processes.

Introduction to Accident Investigation

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This material is for training purposes only.

Steps in Root Cause Analysis: Three Levels of Cause Analysis
1. Injury Cause Analysis. Analyze the injury event to identify and describe the nature of the
harmful transfer of energy that caused the injury or illness.
Examples:

Laceration to right forearm resulting from contact with rotating saw blade.

Contusion from head striking against/impacting concrete floor.
2. Indirect (Surface) Cause Analysis. Analyze events to determine specific hazardous
conditions and unsafe or inappropriate behaviors.
a.

For primary indirect causes. Analyze events occurring just prior to the injury
event to identify those specific conditions and behaviors that directly caused the
accident.
Examples:

Event x. Unguarded saw blade. (condition or behavior?)

Event x. Working at elevation without proper fall protection. (condition or
behavior?)
b.

For contributing indirect causes. Analyze conditions and behaviors to determine
other specific conditions and behaviors (contributing causes) that contributed to the
accident.
Examples:

Supervisor not performing weekly area safety inspection. (condition or
behavior?)

Fall protection equipment missing. (condition or behavior?)
3. Root Cause Analysis. Analyze system weaknesses contributing to indirect causes.
a.

For inadequate implementation. Analyze each contributing condition and
behavior to determine if weaknesses in carrying out safety policies, programs, plan,
processes, procedures and practices (inadequate implementation) exist.
Examples:

Safety inspections are being conducted inconsistently.

Safety is not being adequately addressed during new employee orientation.
b.

For inadequate design. Analyze implementation flaws to determine the underlying
inadequate formal (written) programs, policies, plans, processes, procedures and
practices.
Examples:

Inspection policy does not clearly specify responsibility by name or position.

No fall protection training plan or process in place.

Introduction to Accident Investigation

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This material is for training purposes only.

Step 4: Determine the Causes

Class Exercise
List some of the possible causes of the accident according to the multiple
cause theory. Don’t spend a lot of time on this exercise. There will be
additional exercises to determine direct, indirect and root causes of the
accident.
What may be the cause of causes of the accident according to the
multiple cause theory?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Direct Cause
Provide the information below for the accident scenario.
Injury Result

Caused by (transfer)

Object/Energy Source

_________________________________________________________

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ACCIDENT TYPES THAT DESCRIBE TRANSFER OF ENERGY
STRUCK-BY. A person is forcefully struck by an object. The force of contact is
provided by the object. Example -- a pedestrian is truck by a moving vehicle.
STRUCK-AGAINST. A person forcefully strikes an object. The person provides the
force. Example -- a person strikes a leg on a protruding beam.
CONTACT-BY. Contact by a substance or material that by its very nature is harmful
and causes injury. Example -- a person is contacted by steam escaping from a pipe.
CONTACT-WITH. A person comes in contact with a harmful material. The person
initiates the contact. Example -- a person touches the hot surface of a boiler.
CAUGHT-ON. A person or part of his/her clothing or equipment is caught on an
object that is either moving or stationary. This may cause the person to lose his/her
balance and fall, be pulled into a machine, or suffer some other harm. Example – a
person snags a sleeve on the end of a hand rail.
CAUGHT-IN. A person or part of him/her is trapped, stuck, or otherwise caught in
an opening or enclosure. Example -- a person’s foot is caught in a hole in the floor.
CAUGHT-BETWEEN. A person is crushed, pinched or otherwise caught between
either a moving object and stationary object or between two moving objects.
Example -- a person’s finger is caught between a door and its frame.
FALL TO SURFACE. A person slips or trips and falls to the surface he/she is
standing or walking on. Example -- a person trips on debris in the walkway and falls.
FALL-TO-BELOW. A person slips or trips and falls to a surface level below the one
he/she was walking or standing on. Example -- a person trips on a stairway and falls
to the floor level below.
EXERTION. Someone over-exerts or strains him or herself while doing a job.
Examples -- a person lifts a heavy object or a person repeatedly twists the torso to
place materials on a table. Interaction with objects, materials, etc., is involved.
BODILY REACTION. Caused solely from stress imposed by free movement of the
body or assumption of a strained or unnatural body position.. Example - a person
bends or twists to reach a valve and strains back.
EXPOSURE. Over a period of time, someone is exposed to harmful conditions.
Example -- a person is exposed to levels of noise in excess of 90 dBa for 8 hours.

Introduction to Accident Investigation

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This material is for training purposes only.

Step 4: Determine the Causes
Group Exercise: Event Analysis (Indirect cause)

Determine the primary indirect causes for the accident scenario.
Look for specific employee acts/behaviors and hazardous conditions
that caused the injury.
Examples
 Event x. Unguarded saw blade. (act or condition?)
 Event x. Working at elevation without proper fall protection. (act or condition?)

Event
Act(s)_____________________________________________________
Condition(s)________________________________________________
Event
Act(s)_____________________________________________________
Condition(s)________________________________________________
Event
Act(s)_____________________________________________________
Condition(s)________________________________________________

The contributing indirect causes are also specific acts/behaviors and
conditions.
Examples:
 Supervisor not performing weekly area safety inspection. (act or condition?)
 Fall protection equipment missing. (act or condition?)
 Responsible person not trained on how to hook up harness. (act or condition?)

Event
Act(s)_____________________________________________________
Condition(s)________________________________________________
Event
Act(s)_____________________________________________________
Condition(s)________________________________________________

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This material is for training purposes only.

Step 4: Determine the Causes
Group Exercise: System Analysis (Root Cause)
– Get to the roots by asking Why? Why? Why?
Instructions. Analyze each indirect cause to identify
potential root cause(s) that contributed to or produced the
accident.

Determine system implementation weaknesses. Look for the common
behaviors that represent inadequate implementation of safety programs and
processes. It’s important to understand that poor implementation of one program area
may be the result of poor implementation in another safety management program area:
 Management commitment and accountability
 Employee involvement
 Worksite analysis
 Hazard identification & control
 Education & training
 Safety system evaluation
System Implementation Root Causes
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

Introduction to Accident Investigation

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This material is for training purposes only.

Step 4: Determine the Causes

Group Exercise:
Determine system design weaknesses. Then ask “why” to determine the
inadequate/missing policies and plans that caused them. These are common
conditions.
• Inspection policy does not clearly specify responsibility by name or position
• No fall protection training plan or process in place
• Procedures for administering corrective actions absent from the
accountability plan
System Design Root Causes
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

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This material is for training purposes only.

Step 4: Determine the Causes
Team Exercise: Digging up the roots
1.
2.
3.
4.

Enter the direct cause of injury within the box below.
List hazardous condition and unsafe behavior from the sequence of events.
Determine contributing causes for the hazardous
condition and unsafe act/behavior.
Determine implementation and design root causes for contributing causes.
Direct Cause of Injury
________________________________
________________________________

Hazardous Conditions

Unsafe Behaviors

__________________________________

_________________________________

__________________________________

_________________________________

Contributing conditions/behaviors
__________________________________
_________________________________
__________________________________

_________________________________

__________________________________

_________________________________

Implementation root causes
__________________________________

_________________________________

__________________________________

_________________________________

__________________________________

_________________________________

__________________________________

_________________________________

Design Root Causes
__________________________________
_________________________________
__________________________________

_________________________________

__________________________________

_________________________________

__________________________________

_________________________________

Introduction to Accident Investigation

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This material is for training purposes only.

Here is another way to put the information together.
1. Injury Event (injury, illness, other losses). Pinpoint the problem and enter within 1st rectangle.
2. Sequence. Develop sequence of events from start to finish, based on interviews and physical evidence. Describe each
event as an occurrence with one noun/verb. Describe the events precisely as they happen. Enter into the 2nd rectangle.
3. Injury Analysis (direct cause). Analyze the injury event to identify and describe the direct cause of the injury and enter
within the 3rd rectangle.
4. Event Analysis (indirect cause-acts/conditions). After the sequence of events is established, the causes of each event
can be described. This involves asking why, why, why, why, why. You may decide not to ask questions for all events in the
sequence, just the ones critical for understanding the causes. Determine indirect causes (hazardous condition and unsafe
behavior) from the sequence of events. Enter within the 4th rectangle.
5. System Analysis (root cause). The last step is to find the root causes, the procedures, standards, controls that
management did not design or failed to implement. Continue asking “why” in order to develop the information needed to
establish the root causes. Root causes are usually not physical things. They are program and/or related behavioral
inadequacies. Determine system design and system implementation causes for each of the indirect causes. Enter in 5th
rectangle.

Fix the System . . Not the Blame!
The Situation
(injury, illness, other
losses)

1. Injury Event

2. Sequence of Events

Brakes failed and Ike
drove off the dock

 Ike in hospital

1. Brake fluid leaked from master cylinder overnight

 Forklift a total loss

2. Ike assigned to operate forklift, 2nd day on job; no training

 Lost production

3. Brakes not checked before using forklift
4. Barrier guard removed from dock to install new conveyors

 EPA involvement

5. Barrier guard not replac ed

 Lawsuits
6. Brakes on forklift failed
7. Ike drove off the dock
8. Rescue squad transported Ike to hospital
9. Cleanup of hazardous materials started
10. EPA contacted

3. Injury Analysis–
Direct Cause
Impact following a 12 foot fall
from dock to concrete floor,
causing a broken back

4. Event AnalysisIndirect Cause
(act or condition)
 Not inspecting vehicle (act)
 Ike not trained (condition)
 Vehicle driven without
sufficient brake fluid
(condition)

5. System Analysis-Root
Cause (procedures,
standards, controls)
 Operator not trained (implementation)

 Protective barrier removed
from dock, presenting
exposure (condition)
 Supervisor failed to inspect for
barrier (act)

Introduction to Accident Investigation

37

 Selection criteria less than adequate (design)
 Maintenance procedures not adequate
(implementation/design)
 No inspection policy (design)

This material is for training purposes only.

Step 4: Determine the Causes
Quiz
Let’s review some of the important points about cause analysis.

1.

Which theory below states, “An accident is the result of a series of related events:
Eliminate any one event and you prevent a future accident?”
a. Single event theory
b. Domino theory
c. Multiple cause theory
d. System weakness theory

2.

The three phases of cause analysis are:

3.

The underlying safety system weakness are called the:

Introduction to Accident Investigation

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This material is for training purposes only.

Step 5: Develop Recommendations
Group Exercise: Recommending Corrective Actions
Instructions: In this exercise you’ll develop and recommend immediate
actions to correct the surface causes of an accident. Using the control
strategies as a guide, determine corrective actions that will eliminate or
reduce one of the hazardous conditions or unsafe behaviors identified in the
previous exercise.
Recommendation: ________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Group Exercise: Recommendations for System Improvements
Fix the system…not the blame
Instructions. Develop and write a recommendation to improve one or
more policies, plans, programs, processes, procedures, and
practices related to the accident scenario.

Recommendation:

_____________________________________________________

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

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This material is for training purposes only.

Answer the following six questions to help develop and justify recommendations.
1.
2.
3.
4.
5.
6.

Pinpoint the problem
What is the history of the problem?
Pinpoint the specific solution.
Who is the decision-maker?
What motivates the decision-maker?
What will be the cost/benefits if the recommendation is
approved and the predictable cost/benefits if not?

Determine the costs
To calculate direct cost, enter the following:
Most likely injury:
Total value of the insurance claim for injury or illness

$

To calculate indirect cost, multiply direct cost by a cost multiplier.
The cost multiplier that you use will depend on the size of the direct cost.

If your direct
cost is:

Use this cost
multiplier:

$0 - $2,999
$3,000 - $4,999
$5,000 - $9,999
$10,000 or more
Direct Cost
$

x

Cost Multiplier

4.5
1.6
1.2
1.1
=

Indirect Cost

=

$

What are the total direct and indirect accident costs?
Direct Costs $ ________ + Indirect Costs $ __________ = $_________
Return on Investment (ROI): Benefits = Costs minus investment
ROI = Benefits
=
Investment
Introduction to Accident Investigation

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This material is for training purposes only.

Step 5: Develop Recommendations
Quiz
Let’s review some of the important points about developing
recommendations.

1.

(Fill in the blank) When making recommendations, we need to propose
corrective actions ____ system improvements.
a. instead of
b. or
c. rather than
d. and

2.

Engineering controls include all of the following except:
a. Substitution
b. Enclosure
c. Rescheduling
d. Redesign

3.

Which control strategy is most effective in eliminating hazards?
a. Engineering Controls
b. Management Controls
c. PPE Control
d. Personnel Controls

4.

All of the following are safety management system improvements except:
a. Writing a new safety policy.
b. Establishing a proactive incentive program.
c. Placing a guard on a table saw.
d. Revising an accident investigation form.

Introduction to Accident Investigation

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This material is for training purposes only.

ACCIDENT INVESTIGATION REPORT
Date:___________________
Accident Investigator(s) ___________________ Dept. ______________ Tel #____________________

____________________________________________________________________
Section I. BACKGROUND
WHO was involved or injured?
Employee:
Address:
Job Title:
Department:
Phone: Home: Work:
Date of birth: Date hired:
Male/Female
Name of physician or other health care professional:
Name/Location of Treatment Center:
Was employee treated in an emergency room: Yes/No
Was employee hospitalized overnight? Yes/No

Length of Service:

WHEN did accident/incident occur?
Date of Injury or Illness:
Time of Accident: ___ AM/PM
Date Accident Reported:

Time Employee began work: ___ AM/PM

WHERE did the accident/incident occur?
Department:

Location:

Equipment:

WHAT happened?
What was employee doing just before accident occurred:
What happened:
What was the injury or illness:
What object or substance directly harmed the employee:

WITNESSES: Attach witness information and statements

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Section II. DESCRIPTION OF ACCIDENT (Describe sequence of events prior to, during, and immediately
after the accident. Attach separate page if necessary)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Section III. FINDINGS AND JUSTIFICATIONS (Attach separate page if necessary)

Indirect Cause(s) – Unsafe conditions and/or behaviors at any level of the organization;
& justification: Describe evidence or proof that substantiates your findings.
__________________________________________________________________________
__________________________________________________________________________

Root Cause(s) – Missing/inadequate programs, plans, policies, processes, procedures; &
justification: Describe evidence or proof that substantiates your findings.
__________________________________________________________________________
__________________________________________________________________________
Section IV. RECOMMENDATIONS (Attach separate page if necessary)
1.

Immediate Corrective Actions (To eliminate or reduce the hazardous conditions/unsafe
behaviors that directly caused the accident.)
_______________________________________________________________________________
_______________________________________________________________________________
Results (Describe the intended results and positive impact of the change.)
_______________________________________________________________________________

2.

Long Term Corrections (policies, procedures, training, etc. to ensure unsafe conditions and/or
practices do not recur)
_______________________________________________________________________________
_______________________________________________________________________________
Results (Describe the intended results and positive impact of the change.)
_______________________________________________________________________________

Section V. SUMMARY (Brief review of the causes of the accident and recommendations for corrective
actions, including estimated costs of accident and costs and benefits of corrective action)
_______________________________________________________________________________
Section VI. REVIEW AND FOLLOW-UP ACTIONS (Appropriate, timely, etc.)
Immediate Corrective Actions Taken:
Responsible Individual:
Date Correction Due:
Date Closed:
Long Term (System Improvements) Made:
Responsible Individual:
Date Correction Due:
Date Closed:
Person(s) monitoring status of follow-up actions: _______________________

Prepared by __________________Title _________________ Date ________
Reviewed by _________________ Title _________________ Date ________
Reviewed by _________________ Title _________________ Date ________
Section VII. ATTACHMENTS (Photos, sketches, interview notes, etc.)
Introduction to Accident Investigation

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Step 6: Write the Report
Let’s review some important points about writing the report.

1.

Your primary objective, as an accident investigator, is to:
a. inform the employer about options
b. place blame on those responsible
c. hold the employer accountable for compliance with OSHA
d. uncover the causal factors that contributed to the accident

2.

The accident report form should be designed to make it possible to determine:
a.
b.
c.
d.

3.

indirect causes
root causes
direct causes
All of the above

The accident report should not be considered closed until:
a. It is signed by the investigators
b. It is presented to management
c. All actions are complete
d. The accident is recorded on the OSHA forms

Introduction to Accident Investigation

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This material is for training purposes only.

Putting It Together
Group Exercise:
Putting it All Together
Instructions: Now that you’ve been introduced to the sixstep process, it’s time to do an accident investigation on
your own. Using some of the training aids from the
course (Sequence of Events, Cause Analysis Diagram,
Report) conduct your own investigation. This exercise
will give you practice in completing using a lot of the
information gained from this course. Be thorough and
use extra paper if needed.

Introduction to Accident Investigation

45