Accident and Incident

Investigation
 Objectives of this Section

• To define the reasons for investigating accident and

incidents.
• To outline the process for effectively investigating
accidents and incidents.
• To facilitate an effective investigation.
 Accident Investigation

• Important part of any safety management system.

Highlights the reasons why accidents occur and how to
prevent them.
• The primary purpose of accident investigations is to
improve health and safety performance by:
 Exploring the reasons for the event and identifying both the
immediate and underlying causes;
 Identifying remedies to improve the health and safety
management system by improving risk control, preventing a
recurrence and reducing financial losses.
 What to Investigate?
• All accidents whether major or minor are caused.

• Serious accidents have the same root causes as minor

accidents as do incidents with a potential for serious loss.
It is these root causes that bring about the accident, the
severity is often a matter of chance.

• Accident studies have shown that there is a consistently

greater number of less serious accidents than serious
accidents and in the same way a greater number of
incidents then accidents.
Many accident ratio studies have been undertaken and the
one shown below is based on studies carried out by the
Health & Safety Executive.

1
Major injury
Or illness

7
Minor injuries or illnesses

189
Non Injury Accidents/Illnesses
 Accident Studies
• In all cases the ‘non injury’ incidents had the potential to
become events with more serious consequences.

• Such ratios clearly demonstrate that safety effort should

be aimed at all accidents including unsafe practices at the
bottom of the pyramid, with a resulting improvement in
upper tiers.

• Peterson (1978) in defining the principles of safety

management says that “an unsafe act, an unsafe
condition, an accident are symptoms of something wrong
within the management’s system.”
 Accident Studies
• All events represent a degree of failure in control and are
potential learning experiences. It therefore follows that all
accidents should be investigated to some extent.

• This extent should be determined by the loss potential,

rather then just the immediate effect.
 Stages in an Accident/Incident
Investigation
The stages in an accident/incident investigation are shown in
the following diagram.
Deal with immediate risks Deal with immediate
risks.

Select the level of investigation.

Select the level of
investigation.
Investigate the event.

Investigate the event.

Record and analyse the results.

Review the process. Record and analyse the

results.

Review the process.

 Dealing with Immediate
Risks
Deal with immediate
• When accidents and incidents occur
risks.
immediate action may be necessary to:
Make the situation safe and
Select the level of
investigation. prevent further injury.
Help, treat and if necessary
Investigate the event.
rescue injured persons.

Record and analyse the

results. • An effective response can only be made
if it has been planned for in advance.
Review the process.
 Selecting the level of
investigation
The greatest effort should be put into:
Deal with immediate  Those involving severe injuries, ill-health
risks.
or loss.
 Those which could have caused much
Select the level of
investigation.
greater harm or damage.
These types of accidents and incidents
Investigate the event. demand more careful investigation and
management time. This can usually be
Record and analyse the
achieved by:
results.  Looking more closely at the underlying
causes of significant events.
Review the process.  Assigning the responsibility for the
investigation of more significant events to
more senior managers.
 Investigating the Event

Deal with immediate

risks.
The purpose of investigations is to
establish:
Select the level of • The way things were and how they came to be.
investigation.
• What happened – the sequence of events that
Investigate the event.
led to the outcome.
• Why things happened as they did analysing
both the immediate and underlying causes.
Record and analyse the
results. • What needs to be done to avoid a repetition
and how this can be achieved.
Review the process.
A few sources should give the investigator all that is
needed to know.
Observation
Information from physical
sources including:
 Premises and place of
work
 Access & egress
 Plant & substances in use
 Location & relationship of
physical particles
 Any post event checks,
sampling or
reconstruction
Documents
Information from:
 Written instructions;
Procedures, risk
assessments, policies
 Records of earlier
inspections, tests,
examinations and
surveys.
 Checking reliability, accuracy
 Identifying conflicts and resolving differences
 Identifying gaps in evidence
Interviews
Information from:
 Those involved and
their line
management;
 Witnesses;
 Those observed or
involved prior to the
event e.g. inspection
& maintenance staff.
 Investigation Kit Preparation

• Camera & • Clipboard, Pre-printed

Video Camera Forms
• Cassette Tape Recorder • PPE
• Flash and Batteries • Containers for Taking
• Mobile Telephone / and Storing Samples
Walkie-Talkie • Barrier Tape

Copyright@NIOSH 2005/1 13
 Interviews
• Interviewing the person(s) involved and witnesses
to the accident is of prime importance, ideally in
familiar surroundings so as not to make the
person uncomfortable.
• The interview style is important with emphasis on
prevention rather than blame.
• The person(s) should give an account of what
happened in their terms rather than the
investigators.
 Interviews

• Interviews should be separate to stop people

from influencing each other.
• Questions when asked should not be intimidating
as the investigator will be seen as aggressive and
reflecting a blame culture.
 Observation
The accident site should be inspected as soon as
possible after the accident. Particular attention
should/must be given to:

• Positions of people.
• Personnel protective equipment (PPE).
• Tools and equipment, plant or substances in use.
• Orderliness/Tidiness.
 Documents
Documentation to be looked at includes:
• Written instructions, procedures and risk assessments
which should have been in operation and followed. The
validity of these documents may need to be checked by
interview. The main points to look for are:
 Are they adequate/satisfactory?
 Were they followed on this occasion?
 Were people trained/competent to follow it?
• Records of inspections, tests, examination and surveys
undertaken before the event. These provide information
on how and why the circumstances leading to the event
arose.
 Determining Causes
• Collect all information and facts which surround the
accident.
• Immediate causes are obvious and easy to find. They are
brought about by unsafe acts and conditions and are the
ACTIVE FAILURES. Unsafe acts show poor safety attitudes
and indicate a lack of proper training.
• These unsafe acts and conditions are brought about by
the so called ‘root causes’. These are the LATENT FAILURES
and are brought about by failures in organisation and the
management’s safety system.
Determine what changes are needed

The investigation should determine what control measures

were absent, inadequate or not implemented and so
generate remedial action for implementation to correct this.
 Generally, remedial actions should follow the
hierarchy of risk control:

• Eliminate Risks by substituting the dangerous by the

inherently less dangerous.
• Combat risks at source by engineering controls and giving
collective protective measures priority.
• Minimise risk by designing suitable systems of working.
• Use PPE as a last resort.
 Recording & Analysing the
Results
• Recorded in a similar and systematic manner.
• Provides a historical record of the accident.
Deal with immediate
risks. • Analysis of the causes and recommended
preventative protective measures should be
Select the level of listed.
investigation.
• Completed as soon after the accident as
possible.
Investigate the event. • Information on the accident and remedial
actions should be passed to all supervisors.
Record and analyse the
• Appropriate preventative measures may also
results. have to be implemented by such supervisors.
• Investigation reports and accident statistics should
Review the process. be analysed from time to time to identify common
causes, features and trends not be apparent from
looking at events in isolation.
 Reviewing the Process
Reviewing the accident/incident
Deal with immediate investigation process should consider:
risks.
– The results of investigations and analysis.
– The operation of the investigation system (in
Select the level of
investigation. terms of quality and effectiveness).
Line managers should follow through
Investigate the event.
and action the findings of
investigations and analysis. Follow up
Record and analyse the
results.
systems should be established where
necessary to keep progress under
Review the process. control.
 The investigation system should be examined
from time to time to check that it consistently
delivers information in accordance with the stated
objectives and standards. This usually requires:
• Checking samples of investigation forms to verify the
standard of investigation and the judgements made about
causation and prioritisation of remedial actions.
• Checking the numbers of incidents, near misses, injury
and ill-health events;
• Checking that all events are being reported.
CASE STUDY AT MALAYSIA
(REFER TO ATTACHMENT)
• CASE STUDY
CASE STUDY - Ladder

Accident Description:
“I was going to clean gutters.
I set up the ladder and when
I stepped on the fourth rung
up, it broke. I fell to the
ground and felt extreme pain
in my leg.”
 QUESTIONS TO UNCOVER CAUSES
 What kind of ladder was used? Load rating?
 What was the condition of the ladder?
 Where did the ladder break?
 Was the ladder inspected for damage prior to use?
 What kind of training has the employee had to use and inspect ladders prior to
use?
 What was the employee carrying? How much did it weigh?
 Did the load on the ladder exceed the load rating?
 How was the ladder stored? Where?
 Has the ladder ever been dropped or damaged? If so, how?
 How did the ladder rung break?
 What is the procedure for cleaning gutters?
 Is there a fall protection plan in place?
 What was the weather?
 What was going on around the work location at the time?
 Investigation Findings - Ladder
 Ladder is a Type II, metal, load capacity of 225 pounds.
 The ladder is kept on a rack on the truck and the truck is parked outside.
 The ladder was placed up against a wall at a 1:4 ratio.
 Employee was wearing tool belt which weighed approximately 30 pounds.
The total load was above maximum load capacity.
 Three days ago the ladder fell off the truck while transporting because it
was not secured properly.
 The employee says he inspected the ladder after and did not note any
deficiencies. It had not been inspected since.
 Employee received training on ladder safety when first employed seven
years ago.
 Procedures are in place for ladder inspections but not followed or
enforced.
 No procedures in place for cleaning gutters.
 Accident Causes – Ladder
Direct causes
 Rung Failed

Indirect causes
 Ladder overloaded
 Improper storage caused ladder damage (not tied down)
 Not inspected prior to each use
 Improper selection of equipment
 Using defective equipment

Basic causes
 Supervisor not enforcing procedures
 Inadequate training
 CAUSATION SUMMARY
POSSIBLE CAUSES CORRECTIVE ACTIONS FOLLOW UP
Rung failed Take ladder out of service Immediately
(Destroyed) K. Colby
Ladder overloaded Provide equipment that is suitable for 5/17/07
the task K. Gregg
Improper storage caused ladder Provide proper means and equipment 5/17/07
damage (not tied down) for storage and provide training on T. Kinman
ladder storage
Not inspected prior to each use Develop, carry out and enforce policy 6/15/07
for inspection of ladders B. Dorris
Improper selection of Provide training on proper ladder 5/16/07
equipment selection J. Collins
Using defective equipment Provide training on ladder inspection 5/15/07
G. Jacobson
Supervisor not enforcing Enforce safety rules/discipline policy Immediately
procedures R. Nunamaker
Inadequate training Provide training on ladder use, 5/17/07
selection, inspection and storage L. Schneider
GROUP WORK
 DIRECTIONS
 Divide into small work groups (not more than 6).
 Each group will be given a case study to work on.
 From the accident description, come up with questions to ask
to uncover the causes.
 Once questions are complete we will give each group the
findings of the case study they are working on.
 From the findings determine all causes (direct, indirect and
basic) and corrective actions to be taken for each cause.
 List causes and corrective actions on causation summary
sheet.
 CASE STUDY- Meat Slicer
Accident Description:

“I was slicing roast beef with a meat slicer. My

hand slipped into the rotating blade cutting
my thumb and forefinger.”
 QUESTIONS TO UNCOVER CAUSES

 How was the employee cutting the meat?

 What was she doing before she cut meat?
 How long had she been using the meat cutter?
 Who taught her how to use it?
 Are there procedures for using it correctly?
 Does the blade have a protective guard? Was it functional?
 Have there been other injuries on this cutter?
 Is there any protective equipment available?
 Who was around before, after?
Investigation Findings – Meat Slicer
 Meat being sliced is slippery.
 There is a guard on the meat cutter. The configuration of the meat
cutter would have prevented a cut if the guard were used.
Procedures required the use of the guard.
 The employee was not trained in the safe use of the meat cutter,
although she was an experienced kitchen worker.
 The employee says guard was used, but the person who cleaned the
cutter after the accident said the guard was NOT engaged.
 There have been no other accidents on this equipment. However,
there have been several employee injuries in this kitchen.
 Employee was talking to another employee and looked away just
before the accident.
 There were cut-resistant gloves available but not used. No procedures
mandated their use.
 Accident Causes – Meat Slicer
Direct causes
 Unguarded rotating blade

Indirect causes
 Employee’s hand slipped
 Employee was distracted
 Meat cutter could be operated without guards in place
 Cut-resistant gloves were available but not used

Basic causes
 Supervisor not enforcing procedures for equipment
 Procedures not in place for use of gloves (PPE)
 Employee was not aware that guard use was mandatory
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP
Unguarded rotating blade Ensure guard is in place Immediately by all

Employee’s hand slipped Ensure guard is in place 1/15/07

Jo Donahoe
Employee was distracted Develop, implement and enforce 1/15/07
safety procedures Charlotte Harper
Meat cutter could be operated Retrofit guard so it cannot be Immediate -
without guards in place disabled Lance Wells
Cut-resistance gloves were Develop, implement, and enforce 5/15/07
available but not used procedure for glove use Pam Milleson
Supervisor not enforcing Enforce safety rules/discipline Immediate –
procedures for equipment policy Louise Matzner
Procedures not in place for use Develop, implement and enforce 5/15/07
of gloves (PPE) procedures for glove use Shirley Schaeffer
Employee was not aware that Train staff on use of equipment Immediate -
guard use was mandatory and procedures Amy Kimberling
 CASE STUDY - Bus
Accident Description:

“I was checking the steering fluid in bus engine. I

had to climb up on the front tire and when I
was getting down, I felt my left knee pop.”
 QUESTIONS TO UNCOVER CAUSES
 Why did employee have to stand on the tire?
 Are there other ways of checking fluids?
 What is the process for getting down?
 What type of training did you receive for checking fluids? By
 who?
 What is the distance between tire and first step to get down?
 Each additional step?
 Tell me what you did from the time you arrived at work?
 What was going on/happening around you at the time you were
 getting down?
 What type of shoes were you wearing?
 Have there been similar incidents? Explain.
 What was the weather?
 Investigation Findings – Bus
 Driver was not trained how to check fluids on this type of bus.
 There are two step ladders available, but none close by.
 No process or procedures in place for checking fluids.
 Ladder use is covered in Accident Prevention Program but there was no
training specific to ladder use provided to drivers.
 Distance from tire to the peg step is 34 inches, step to ground is 20
inches.
 Driver had washed bus prior to checking fluids and area
 around the bus was still wet.
 Shoes being worn did not have good tread on soles to
 prevent slipping. ($3 slip-ons)
 Another driver came up and started talking as driver was
 getting down.
 Accident Causes – Bus
Direct causes
 Improper body movement

Indirect causes
 Failure to use proper equipment - step ladder
 Wearing inappropriate footwear
 Lack of step ladders available and not close by
 Employee was distracted

Basic causes
 Inadequate training in pre-trip procedures for all types of buses
 No designated bus wash area
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP
Improper body movement Develop procedures and train 12/15/05
drivers on procedures R Nicholson
Failure to use proper Enforce safety rules/discipline Immediately
equipment – step ladder policy T Head
Wearing inappropriate Develop, implement and 12/15/05
footwear enforce safety procedures P Pocinich
Lack of step ladders Ensure adequate number of 11/30/05
available and not close by step ladders and ensure they B Petersen
are readily available
Employee was distracted Safety awareness training Immediate,
Ongoing
T Kinman
Inadequate training in pre- Train staff on use of all 3/16/07
trip inspections for all types equipment and procedures J Peterson
of buses

No designated bus wash Designate bus wash area 6/30/07

area J Mills
 CASE STUDY - Student
Accident Description:

“A severely Autistic high school student struck

me in the back while I was walking him to the
time out room.”
 QUESTIONS TO UNCOVER CAUSES
 What training has employee had in dealing with
autistic students? And this student?
 Has the child ever acted out in this way before?
When and under what circumstances
 Is there a behavior plan in place for this student?
Was employee following it?
 How did employee take student to time out room?
 What was going on prior to the misbehavior?
 Is there any personal protective equipment?
 Investigation Findings – Student

 Teacher was a substitute. Has a Special Ed endorsement but

has only taught in a Special Ed classroom twice before.
 Student is not familiar with substitute teacher.
 Substitute teacher was informed of the student’s behavior.
 Substitute teacher was not informed of how to handle the
situation.
 Teacher was holding student’s hand and leading him to the
room, she was in front of him.
 Teacher put her arm around student.
 Accident Causes – Student
Direct causes
 Student hit teacher

Indirect causes
 Teacher was walking in front of student (unsafe act) and touched student
(behavioral plan identifies the child is uncomfortable with being touched)
 Teacher was not able to de-escalate the student

Basic causes
 Inadequate practices regarding staff selection
 Inadequate training
 Inadequate experience/skills
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP

Student hit teacher Evaluate and make necessary 03/01/07

changes to remove trigger(s) L. Wallis
Teacher was walking in Develop, implement and enforce 6/30/07
front of student and safety procedures E. Rudeen
touched student
Teacher was not able to Provide other personnel trained in Immediately
de-escalate the student de-escalation to assist sub when L Muchlinski
needed

Inadequate practices Evaluate sub selection process 06/30/07

regarding staff selection C. Bailey
Inadequate training Evaluate and modify sub training 06/30/07
policies L. Bush
Inadequate Evaluate sub selection process 06/30/07
experience/skills C. Bailey
 CASE STUDY - Chair
Accident Description:

“I was standing on student desk to hang art

work from the ceiling. When I stepped back on
to the chair to get down, it collapsed.”
 QUESTIONS TO UNCOVER CAUSE
 Why was employee standing on desk?
 Is there a step ladder available? Where are they located?
 What is the age, style and condition of desk & chair?
 What type of shoes were they wearing?
 Have there been similar incidents?
 What was employee doing prior to getting on the desk?
 What was going on at the time employee got off the desk?
 What other ways do employees have for hanging items?
 What training have employees received for hanging items?
 What are the procedures for hanging items from the ceiling?
 Investigation Findings – Chair

 Desks are for kindergarten students.

 Desks and chairs are new this year.
 Current practice is to use desks for hanging items.
 Teacher changes items hanging from ceiling once a month.
 Stepladders are available in every wing.
 There are no procedures in place for using stepladders.
Ladder use is covered in Accident Prevention Program.
 There has been no training on stepladder use.
 Accident Causes – Chair
Direct causes
 Chair broke

Indirect causes
 Improper use of equipment
 Failure to use proper equipment

Basic causes
 Safety procedures not in place
 Inadequate training
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP

Chair broke Take out of service (tag or destroy) Immediately

J Cornaggia

Improper use of Train staff on use of equipment 4/15/06

equipment J Klundt

Failure to use proper Enforce safety rules/discipline Immediately

equipment policy R Johnson

Safety procedures not in Develop, implement and enforce 3/17/06

place safety procedures D Heider

Inadequate training Train staff on use of equipment 4/15/06

and procedures M Mayberry
CASE STUDY - Groundsperson

“I was unloading 50
pound bags of
fertilizer from
truck, twisted
wrong and hurt my
back.”
QUESTIONS TO UNCOVER CAUSE
 What are the procedures for unloading fertilizer from a truck?
 What type of truck were the bags on?
 Where were the bags on the truck?
 How were the bags stacked?
 Where was the employee unloading bags from?
 Where was the employee moving the bags to?
 Where were you located?
 How often do you perform this type of lifting?
 What were you doing before the incident?
 Have you been trained in lifting?
 Did you have help? Did you ask for help?
 What were the conditions at the time?
 How was the employee dressed?
 Investigation Findings - Groundsperson
 Employee had been trained in lifting properly.
 This unloading requires two people in its current
configuration.
 Employee did not seek a lifting partner.
 The bags were being removed from inside the bed of the
truck and swung to landing them on the ground beside him.
 Employee was performing an unsafe act by twisting his body
while lifting.
 This employee has had previous on the job injuries due to
lifting.
 Location for unloading puts employees in awkward positions
for lifting.
 Accident Causes – Groundsperson
Direct causes
 Twisted back– bodily motion

Indirect causes
 Failure to seek assistance
 Lifting improperly – swinging, too heavy, no help
 Loading, placing supplies improperly

Basic causes
 Injury repeater
 Insufficient supervision/enforcement policies
 Unsafe layout for loading/unloading
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP

Twisted back – bodily motion Enforce safety rules/discipline Immediately

policy D Glaser
Failure to seek assistance Enforce safety rules/discipline Immediately
policy D Schell
Lifting improperly - Retrain in proper lifting 3/1/07
swinging, too heavy, no help techniques T Triplett
Loading/placing supplies Develop proper loading/storage 2/29/07
improperly procedures, train employees R Nunamaker
Injury repeater Enforce safety rules/discipline Immediately
policy D Schell
Insufficient Enforce safety rules/discipline Immediately
supervision/enforcement policy D Schell
policies
Unsafe layout for Relocate storage area 6/30/06
loading/unloading M Wallace
 SUMMARY
Purpose of Investigation
● Establish the facts
● Ensure similar incidents do not occur
● Reduce the number and severity of losses

Five Step Investigation Process

● Gather the facts
● Review the facts to find causes
● Document findings and actions
● Take preventative action
● Follow up
 Questions?
Contact Info:

Suzanne Reister
Program Manager
Workers’ Compensation/Unemployment Cooperative
North Central ESD
509-667-7100
suzanner@ncesd.org

Paula Vanderpool
Program Assistant
Workers’ Compensation/Unemployment Cooperative
North Central ESD
509-667-7110
paulav@ncesd.org
THE END
REVIEWS
 Certified Safety Construction
Business CB106
Presented By:
Construction Compliance
Training Center

This material was developed by Compacion Foundation Inc and The Hispanic Contractors Association de Tejas under Susan Harwood Grant
Number SH-20-843-SH0 Occupational Safety and Health Administration, U.S. Department of Labor. It does not necessarily reflect the views or
policies of the U.S. Department of Labor, nor does mention of trade names, commercial products, or organizations imply endorsements by the U.S.
Government.
Provide participants with the basic skills necessary to
conduct an effective accident investigation in your
workplace.

 You will identify;

 Primary Reasons, Benefits, and
 Employer Responsibilities to
conducting an accident
investigation
 Three Steps for an
Effective Investigation
 Investigate and Analysis

CB106 Accident Investigation

The most important things in an accident are:

 When an accident happens, the most important

thing is taking care of the victim or victims.

– After that, the most important thing is

finding the causes of the accident.
– All of us, including employers, need help
and advice to identify the causes of
accidents.

CB106 Accident Investigation

Accidents also cause great economic losses
 Lost efficiency due to break-up of crew.
 Damage to tools and equipment.
 Damage from accident due to fire, water,
chemicals, spills, crashes, etc.
 Loss of customers because products and
services are not provided.
 Training costs for replacement worker.

CB106 Accident Investigation

What is an accident ?

An unwanted, unplanned event that

causes injuries, illnesses, or property
damage.

What is an incident ?

An unwanted, unplanned event

that ALMOST causes injuries,
illnesses, or property damage.

CB106 Accident Investigation

 For each accident,
1
ACCIDENT • 300 incidents occurred, or
• you lost 300 chances to
300 INCIDENTS prevent the accident!

If we are going to
prevent accidents,
we have to investigate the
accidents and the incidents!

CB106 Accident Investigation

 Causes of Accidents
• Unsafe Conditions
◦ Poorly maintained machinery or equipment.
◦ Defective or missing personal protective equipment.
◦ Unguarded machinery or equipment.
◦ Missing or inadequate
warnings or safety and health
signs.
◦ Lack of housekeeping.

CB106 Accident Investigation

 Causes of Accidents
• Unsafe Acts
◦ Conduct work operations without
prior training
◦ Block or remove safety devices.
◦ Clean, lubricate, or repair
equipment while its in operation.
◦ Working without protection in
hazardous places.

CB106 Accident Investigation

• Investigate

• Analyze

• Report

CB106 Accident Investigation

 Seal the accident area.
 Interview witnesses.
 Draw and take
measurements of the
accident area.
 Take samples.

CB106 Accident Investigation

 Say what happened step-by-step.
 Analyze the events with the 6 key questions:
◦ Who? Who saw the crash?

◦ What? What happened to the

brakes?
◦ When? When did the brakes fail?
◦ Where? Where were the
replacement brakes?
◦ Why?
Why wasn’t the mechanic
◦ How? told?
How did the crash happen?
.

CB106 Accident Investigation

 Say what happened.
 Say which were the surface
causes.
 Say which were the root
causes.
 Say what needs to be done
so the accident doesn’t
happen again.

CB106 Accident Investigation

Accidents must be investigated and analyzed from
three different points of view:

1 . Direct cause of injury

2. Surface causes of
accident
3. Root causes of the
accident

CB106 Accident Investigation

A harmful transfer of energy that
produces injury or illness.

 The worker suffered two

broken legs when the truck
crashed into the wall.

CB106 Accident Investigation

Specific unsafe conditions or unsafe behaviors
that result in an accident.
 The truck crashed into the wall because the
brakes failed.

CB106 Accident Investigation

Common conditions and behaviors that
ultimately result in an accident.
 The company did not have a maintenance
program for its vehicles.

CB106 Accident Investigation

 Weed out the causes of injuries and
illnesses Strains
Burns
Direct Causes of
Cuts Injury/Illness

Surface
Causes of the
Accident

Conditions Behaviors
Lack of time Fails to enforce

Inadequate training

No discipline procedures Inadequate labeling procedures

No orientation process Outdated Procedures

Inadequate training plan

No accountability policy No inspection policy

- Accident Weed
Root Causes of the
Accident
CB106 Accident Investigation
 Summary
 Secure the accident scene
 Collect facts about what happened
 Develop the sequence of events
 Determine the causes
 Recommend
improvements
 Write the report

CB106 Accident Investigation

 Summary
Be ready when accidents happen
1. Write a clear policy statement.
2. Identify those authorized to notify
outside agencies (fire, police, etc.)
3. Designate those responsible to
investigate accidents.
4. Train all accident investigators.
5. Establish timetables for conducting
the investigation and taking
corrective action.
6. Identify those who will receive the
report and take corrective action.

CB106 Accident Investigation

CB106 Accident Investigation
 Photos shown in this presentation may depict situations that are not in compliance with applicable OSHA
requirements.

 It is not the intent of the content developers to provide compliance-based training in this presentation, the intent
is more to address hazard awareness in the construction industry, and to recognize the overlapping hazards
present in many construction workplaces.

 It should NOT be assumed that the suggestions, comments, or recommendations contained herein constitute a
thorough review of the applicable standards, nor should discussion of “issues” or “concerns” be construed as a
prioritization of hazards or possible controls. Where opinions (“best practices”) have been expressed, it is
important to remember that safety issues in general and construction jobsites specifically will require a great
deal of site - or hazard-specificity - a “one size fits all” approach is not recommended, nor will it likely be very
effective.

 It is assumed that individuals using this presentation, or content, to augment their training programs will be
“qualified” to do so, and that said presenters will be otherwise prepared to answer questions, solve problems,
and discuss issues with their audiences.

 No representation is made as to the thoroughness of the presentation, nor to the exact methods of
recommendation to be taken. It is understood that site conditions vary constantly, and that the developers of this
content cannot be held responsible for safety problems they did not address or could not anticipate, nor those
which have been discussed herein or during physical presentation. It is the responsibility of each employer
contractor and their employees to comply with all pertinent rules and regulations in the jurisdiction in which they
work. Copies of all OSHA regulations are available form your local OSHA office. This presentation is intended to
discuss Federal Regulations only – your individual State requirements may be more stringent.

 As a presenter, you should be prepared to discuss all of the potential issues/concerns, or problems inherent in
those photos particularly.

CB106 Accident Investigation

EMPLOYEE ACCIDENT
INVESTIGATION
FOR
SUPERVISORS
 TRAINING OBJECTIVE

To provide supervisors
information and tools to
investigate employee
accidents thoroughly to
prevent them from
happening again.
 TOPICS TO BE COVERED
 Definition of an Accident
 Purpose of Investigation
 Five Step Investigation Process
 Case Studies
 WHAT IS AN ACCIDENT?

“An unplanned, unwanted, but

controllable event which disrupts the work
process and causes injury to people.”
Source Labor and Industries Accident
Investigation Basics PPT 2006
Once An Accident Happens
Ensure Safety of
Get Emergency
Others
Services – 911, If
Preserve and Secure Needed
Scene
Assist Employee
Investigate As Soon with Completion of
As Possible Incident Report
 PURPOSE OF INVESTIGATING

Why do we investigate employee accidents?

* To establish the facts of the incident (exactly what happened).

* To help ensure that a similar type of accident doesn't happen

again - people don't get hurt and property doesn't get
damaged.

* It is a DOSH requirement for all serious injuries (WAC 296-800-

320).

How do we investigate employee accidents?

 FIVE STEPS TO BASIC ACCIDENT
INVESTIGATION

 GATHER THE FACTS

 REVIEW THE FACTS TO FIND CAUSES
 DOCUMENT FINDINGS AND ACTIONS
 TAKE PREVENTATIVE ACTION
 FOLLOW UP
 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION

1. GATHER THE FACTS

Answers what happened

 Look at the accident scene

 Record information: who, what, when, and where
 Preserve the accident scene and any evidence
 Interview witnesses independently
 Ask open ended questions
 THINGS TO CONSIDER
WHEN FACT FINDING
Environment/facility
Equipment, clothing, personal protective
equipment (PPE)
Procedures/practices
Training - in procedures and safety
Employee readiness – mental and physical
 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION
2. REVIEW THE FACTS TO FIND CAUSES

Answers why it happened

 Review all the information you gathered

 List all possible causes (direct, indirect, basic)
 Identify all the contributing factor(s)
 CAUSES

 Direct Cause – the actual energy (movement or

source) that caused injury to employee. If this
energy wasn’t present, the injury would not have
occurred.
 Indirect Causes – any unsafe acts or conditions
that contribute to the injury occurring.
 Basic Causes – policies, procedures, environment
or personal factors that contribute to the injury
occurring.
 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION
3. DOCUMENT FINDINGS AND ACTIONS

 Complete the INCIDENT REPORT

 State only the facts in the incident
report (no opinions)
 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION

4. TAKE PREVENTATIVE ACTION(S)

 Corrective actions must address the cause(s) of the

accident
 Look for both short-term and long-term solutions
 Include dates for completion of the corrective
actions and identify those responsible
 Report corrective actions to the safety committee
 DOSH’s
SOLUTION TO HAZARDS
 Eliminate the hazard or use less hazardous processes
or materials
 Use operational controls - SOPs
 Use administrative controls (policies, rules, training,
signage)
 Use engineering controls (mechanical means –
substitution, ventilation, isolation)
 Use personal protective equipment and/or
safety equipment
 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION

5. FOLLOW-UP

 Follow-up to ensure that corrective action has

been taken and is effective at reducing
accidents
 Monitor the progress of both short-term and
long-term corrective actions.