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Reading ACCIDENT INVESTIGATION AND REPORTING
OVERVIEW .....................................................................................................................1 SECTION 1: GETTING STARTED.................................................................................2 SECTION 2: THE INVESTIGATION ..............................................................................7 SECTION 3: RESEARCH ............................................................................................14 SECTION 4: ANALYSIS...............................................................................................16 SECTION 5: REPORTING ...........................................................................................20 SUMMARY ....................................................................................................................24
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what equipment is needed. This reading is designed to be a complete overview.READING – ACCIDENT INVESTIGATION AND REPORTING OVERVIEW "An investigation is a search for the truth. identify components of an investigation. where to start." P G Nendick . how to analyse your results. describe methods of implementing investigation components. and describe methods of reporting. Objectives After reading this information you should be able to: describe the purpose of an accident investigation. consequently each area will not be visited in great depth. to enable the learner to understand the A to Z of investigation and reporting. Author Ron E Reid JANUARY 2009 SAFETYLINE INSTITUTE PAGE 1 . what research is required. and what to do with the report when you have completed it. in the interests of justice and within the constraints of the law. what evidence to look for.The Investigation Handbook The objective of this reading is to provide learners with an overview of what is involved in an accident or incident investigation.
We have orders to fill and deadlines to meet. We can't stop the plant. firstly from the equipment being out of service. Interesting and compelling reasons for not conducting an investigation.READING – ACCIDENT INVESTIGATION AND REPORTING Section 1: GETTING STARTED Introduction An accident has happened at work.Perhaps someone has been injured. We have already lost enough productivity as a result of the accident. and now trying to replace the injured person.productivity . our employers very viability is productivity based.let's face it. What can we achieve from conducting an accident investigation? We can't stop the person from being injured. PAGE 2 SAFETYLINE INSTITUTE JANUARY 2009 . we will have a huge loss of productivity. If we conduct an investigation as well. people away from their usual job being interviewed. consequently other employees relying on their work are at a standstill. then waiting for the ambulance to arrive. After the accident or incident has been notified and recorded.a buzz word . building or equipment from being damaged or rendered unserviceable. We need to be pro-active. We can't stop the equipment involved in the accident from malfunctioning. The person best placed to initiate this action is the person who was involved in the accident or incident and it should be made to their immediate superior. Loss of productivity! Wow! . To investigate is reactive. . our pay and pay rises are based on productivity. there should also be an automatic system in place to enable notification to the appropriate personnel responsible for investigating these occurrences including elected worker health and safety representatives (if any).What is the basic first step that needs to be taken? Where do we start? The initial and fundamental step to commence the process of accident investigation and reporting is the notification to management that an accident or incident has happened. and the rest of the operators seem to be working slower than usual. The workplace should have a system in place for notification and recording of all incidents and injuries that have happened at the workplace. .
you cannot stop the loss of productivity that has occurred. The direct cost of worker's compensation claims does not take into account the indirect or uninsured costs of an accident. establish the causal factors of the accident from which the hazard or hazards can be identified.READING – ACCIDENT INVESTIGATION AND REPORTING 1. you cannot stop the equipment or plant being damaged. Any employee. however. at this or similar workplaces. you cannot stop the person being injured. The other compelling reason for investigating a work related accident is to ensure the employer is fulfilling their legal duty of care obligation. Conservative estimates place uninsured. children and friends have the right to expect the employee to return from work each day in the same state of health that they were when they left for work. training and re-training of employees to take over the injured persons duties. indirect costs of an accident between 4 and 7 times the insured cost whereas Davis and Teasedale (1995) suggest the ratio is between 8:1 and 36:1.1 Why investigate? Agreed. You can then identify the risks associated with the hazards and develop preventative strategies to reduce the risk of this or similar accidents happening. again. State or Country has a major impact on productivity. The reduction of lost time injuries in a workplace. There is a long established legal duty of care under common law on an employer to provide a working environment that will enable this expectation to be attained. legal costs associated with civil claims and prosecutions mounted by enforcement agencies and the cost of any penalties or fines imposed. You can. hospital operating costs and legal fees associated with permanent disability claims. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 3 . parents. industry. The indirect costs or expenses associated with an accident include: down time of machinery and equipment. public liability insurance costs. initially due to the obvious factors outlined above and ultimately circumstances such as reduced costs due to effective reductions in worker's compensation insurance costs. their partners. loss of orders due to inability to supply or late delivery.
regardless of any other reasons. elected by workers at the workplace.2 Who investigates? Having established that an investigation is desirable. where additional comments. draw conclusions and make recommendations to reduce the risk of a recurrence of the circumstances. trained person who is delegated to manage safety at the workplace. who also should investigate and prepare a report on the accident or incident. should be reviewed at regular safety committee meetings. For this reason alone. has broken down. PAGE 4 SAFETYLINE INSTITUTE JANUARY 2009 . it is highly desirable to have an elected health and safety representative. 1. These reports. A person trained to seek out. as prescribed in the majority of OHS legislation. together with enterprise accident and incident statistics. the employer should investigate the accident to establish and eliminate the hazard and the associated risk that ultimately caused the accident.3 Internal investigations The workplace should have a competent. In addition to this employer nominated safety officer. An investigator is a facilitator. record.READING – ACCIDENT INVESTIGATION AND REPORTING 1. free of hazards. Accident investigations fall into two main categories. regardless of whether a person is injured or not. internal and external. A workplace has no control over external investigations unless it is one they have commissioned on their own behalf. and included in this delegation should be a requirement to investigate all accidents and incidents. and report on the circumstances and causal factors. it must then be determined who is to conduct the investigation. there is a strong chance that the employer's duty of care to provide a safe workplace. ideas and expertise may throw fresh light on causal factors or preventative strategies. If an accident happens at work.
the public liability insurer of the employer or the public liability insurers of plant or equipment involved in the accident. or any. This type of investigation is normally only undertaken where it appears that the injured person may have suffered an injury that will result in some form of permanent disability that may result in civil litigation. Bureau of Air Safety. They do. gas or water). an investigation may be carried out by many various investigators apart from any investigation carried out internally by the enterprise. however. The first type of external investigator that may be encountered is one representing a Statutory Authority. Employers should refer these matters to their legal representative or insurance company. or where there has been substantial damage to plant. etc.). The next type of external investigator that may be encountered is private inquiry agents or consultants. a health and safety enforcement agency (WorkSafe WA. collect evidence and in some cases stop the work process. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 5 . electricity. or indeed any person. equipment or property that may also result in civil litigation. These investigators have a legal right to be at the premises to interview witnesses. or a public utility (fire service. there may be some access to these documents by members of the public and interested parties nominated above. legal rights as those representing a statutory authority. That is a person representing a Government Agency which administers legislation which embraces the activity being undertaken at the workplace involved. These investigators do not have the same. Comcare.READING – ACCIDENT INVESTIGATION AND REPORTING 1. This investigator may represent the Coroner or Police Service if the injured person dies. or if a statutory authority investigated and reported on the incident. have some rights under discovery provisions of the legal system. under the provisions of Freedom of Information legislation. If the injured person was employed by a Government authority. These investigators are normally commissioned to undertake an investigation by an insurance company representing the worker's compensation insurer. Once again these investigators do not have the same rights as investigators from a statutory authority.4 External investigations Depending on the seriousness of the accident or the injuries received.
PAGE 6 SAFETYLINE INSTITUTE JANUARY 2009 . destruction or relocation due to the need to remove the evidence to rescue an injured person. rain. If the investigator cannot get to the accident scene immediately. These factors will be discussed further in the investigation phase. they should arrange with some other responsible person to secure the scene and protect the evidence.). the recollection of the human mind and the ability of a persons sub-conscious memory to fill in gaps in what they saw or their own visual experience being corrupted by another person's verbal description of what happened. Depending on the time lapse between the incident and the commencement of the investigation. and the most fragile of all evidence. who may be potential witnesses.READING – ACCIDENT INVESTIGATION AND REPORTING 1.5 When to investigate accidents The ideal time to investigate accidents is now! As close as possible to the time of the accident is the most desirable. before evidence starts to deteriorate. temperature etc. Obviously the physical location of the accident site compared to the location of the investigator will have a significant bearing on how quickly an accident or incident investigation will commence. it may be desirable to have another person take photographs if practicable and prepare a list of persons who were at or near the scene. Preferably the investigator should be one of the first people on the scene. destruction due to unauthorised persons or vehicles moving around the immediate vicinity. to enable the scene to be secured and evidence preserved or captured. The deterioration of evidence can take many forms such as deterioration due to weather conditions (wind.
together with a written list of where all other items that may be required. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 7 . sequential report of the events with recommended preventative strategies. On the other hand. The amount of equipment to be taken will depend on the mode of transport to be utilised (e. why it happened and to analyse the processes involved to minimise the risk or prevent a recurrence. can be located. if an enterprise group safety officer has workplaces that are spread throughout the State or Country they would need to have a fully equipped case. unemotional undertaking to collect and interpret information about an event to establish the extent of an injury or loss.g. their pre-planning will probably only require adequate stationery to be physically at hand. This situation is the scenario faced by most external investigators. 2.1 Pre-planning The amount of pre-planning required is dependent on the number and type of discreet workplaces the investigator is likely to be called to.READING – ACCIDENT INVESTIGATION AND REPORTING Section 2: THE INVESTIGATION An investigation is a methodical. systematic. A major need for preplanning is to enable an investigator to reach an investigation site as soon as possible after the event and to have all of the equipment required to conduct the investigation at their disposal. motor vehicle or aircraft). The investigation will normally result in the preparation of a logical. bag or other container ready to go at any time. and their geographical location. If a person such as a health and safety representative is only responsible for investigating accidents in their immediate workplace or location within the workplace.
One of the most fragile pieces of evidence is the recollection of a witness. stationery. tape measure. containers for taking and storing samples. roadworthiness. with spare film. If an aircraft is to be used. transport at the destination arranged. handouts. screwdriver. respiratory protection.READING – ACCIDENT INVESTIGATION AND REPORTING Basic equipment that may be required includes: mobile telephone with back-up power pack. maps/directories). as well as financial arrangements for paying for these services (cash advance. wet weather gear). torch. hearing protection. flash and batteries. particularly when their sub-conscious memory starts to fill in the events they saw with what other people have stated they saw or even theorised what might have happened. distortion or loss which makes the evidence unusable. recording equipment. bookings are required.2 Commencing the investigation The investigation involves the collection of evidence some of it extremely fragile. writing/sketching materials. gloves. hard hat. Other items that may need addressing are transport. PAGE 8 SAFETYLINE INSTITUTE JANUARY 2009 . etc. for communication. pre-printed forms. camera. 2. and small hand tools. batteries. purchase order book). consequently it is highly desirable to collect the evidence in descending order of fragility. particularly to distant or remote locations. accommodation and expenses. with spare tapes. personal protective equipment (safety glasses. the vehicle should be suitable for that task and ready for use (fuel. If a motor vehicle is to be the chosen form of transport. Fragility of evidence can be described as breakage. safety shoes. company credit card. as this can change with time. accommodation booked. pliers.
2. The overview phase allows the investigator to get a feel of the workplace. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 9 . this broader macro view is invariably the extent of working knowledge of the workplace by some senior management. Depending on the size of the workplace. the macro view.3 Examination Overview or preliminary investigation During the preliminary investigation an overview of the events is obtained. and who you speak to and what information they can contribute. what they produce. as soon as possible. take a video tape recording or photographs if practicable. It may be necessary to make the scene safe before attempting to commence first aid on an injured person. If it is necessary to disturb the site to either remove the injured person or to secure any hazards.READING – ACCIDENT INVESTIGATION AND REPORTING The rescue of an injured person and securing the accident scene from contamination by other people moving around the area is of the highest priority. Alternatively make a note or sketch of what is done or what the scene looked like prior to the changes. It is a sound practice to make brief written notes on what steps you have taken and when. particularly which witnesses to interview and in what order. The investigator then has a chronological list of actions taken which will enable prioritising further actions. what they do. and to restrict access to the scene so as to leave it as close as possible to the conditions existing at the time of the accident. Once the injured person has been treated and removed then the scene should be secured to ensure the safety of yourself and other persons from any hazards that may still exist. a broad picture of the workplace. It enables the investigator to locate the accident scene in the overall plan of things and where this scene is located in the process.
more confined accident scene. controlled or managed so as not to place any other person at risk. taking into account the fragility of their evidence. and commencing with eye witnesses to the event or accident. A visual image will record all items and their location relative to each other and the immediate accident site. At this stage it is desirable to take photographs of the accident scene. samples and sketches should be taken or made. These hazards should be eliminated.READING – ACCIDENT INVESTIGATION AND REPORTING Accident scene The investigator then turns their attention to the smaller. On arriving at the accident scene it is essential that the investigator makes an assessment of any hazards that may be present. The next step is to identify and speak to witnesses. plant or equipment which were not originally thought to be involved in the accident. People who can only advise on the usual work practice or procedure would receive a much lower priority. PAGE 10 SAFETYLINE INSTITUTE JANUARY 2009 . Witnesses A witness is a person who has first hand knowledge of some fact related. appropriate photographs. subsequently are identified to have had a contributory effect. a video recording if equipment is available and sketches or notes about the site. either the pre-existing cause or hazards that have arisen as a result of the accident that could cause further injury or harm. together with a notation of the time this was done. As each factor is identified. to an accident or incident. directly or indirectly. It may be that items. to ascertain what information they can contribute to the actual event and the normal procedures that were in place. From this list of witnesses the investigator needs to prioritise the order in which to interview them. This zone is where a lot of the physical evidence will be located. initially briefly. and this is the area that should be secured and preserved immediately.
the ultimate objective is to have a written record of all the facts so that a word picture can be prepared of all events leading up to and including the incident or accident. Apart from an accident victim. once again for future legal processes if they are commenced. or deleted from. When taping a record of interview it is important to record on the tape the time the interview starts and finishes and the time any interruptions take place. Inquiry agents will also take some written statements. The main advantage of a record of interview that is taped is that you have a verbatim record of what a person said . The reason for recording the time is to have a permanent record of the time it took to record the interview which can be used to prove that nothing has been added to. In other circumstances the investigator may prefer to make notes of what is said.not what you thought they said. conversation about their own job. for example. signed statement or a record of interview which is initially taped and then transcribed into a written format. and for evidence for legal purposes if deemed necessary. people rarely observe the full circumstances of an accident or incident and not being trained observers rarely see in detail what they are looking at and even if they do. they cannot remember the detail.READING – ACCIDENT INVESTIGATION AND REPORTING The investigator then needs to determine the method of recording what the witness has to say. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 11 . it is highly likely that they will insist on a written. The investigator should attempt to gain rapport with the witness. their own list of duties and generic questions about the workplace. the recorded interview. Evidence that is collaborated can be recorded in confidence. which can then be presented in a report. This requirement is necessary to preserve the evidence in a permanent record for reporting to other authorities. This will be strongly influenced by the type of investigation being undertaken. Uncorroborated evidence needs to be treated with caution. It is a good idea to commence with some general conversation to relax the person and give them confidence in replying to questions. If the investigation is being undertaken by a statutory authority. although not discounted unless collaborated evidence refutes it. The investigator will need to ask appropriate questions in order to obtain relevant answers.
Positions. Whilst an interview is in progress a witness may provide information that has not previously been identified or recorded as part of the process or equipment involved in the accident or incident. Evidence and exhibits What is the difference between evidence and exhibits? Raymond Kuhlman in his publication Professional Accident Investigation categorises evidence into four categories in descending order of fragility as: People. any mannerisms they may display. or any reactions to questions that may give the impression of the type of answers they should give. as a result of this new information. either in writing or electronically. Parts. and Papers Exhibits are physical evidence which can be used in a Court of Law. should be considered as a confidential communication between two people. this confidentiality should be respected. In the preliminary overview of the accident scene and discussions with potential witnesses. A recorded witness statement. re-interview persons who have already been interviewed. however the copies of the person's statement should not be given to a third party without firstly obtaining the permission of the witness. If any gaps appear in the picture the investigator can then formulate meaningful questions to elicit information from the witnesses. the investigator should be developing a clear picture of the process that was taking place before and leading up to the accident or incident. and as such. It may be necessary.READING – ACCIDENT INVESTIGATION AND REPORTING The investigator also has to be extremely careful not to influence the witness by the type of questions they ask. to change or add to the questions being asked. and in some cases. It is perfectly acceptable to use the information gleaned in the interview in any subsequent report. PAGE 12 SAFETYLINE INSTITUTE JANUARY 2009 .
Any reports or advice provided will form part of the evidence in the investigation and the person who provides the advice or information are usually known as an "Expert Witness. The examination and inspection of parts that are suspected of having caused an accident through distortion or failure may be required to be undertaken by a person who is appropriately qualified to examine the part. during and after the accident. certificates of competency. To ascertain the position of people and parts prior to and at the time of an accident will normally depend on the affirmation of witnesses. induction records. maintenance records. equipment. job procedures.READING – ACCIDENT INVESTIGATION AND REPORTING People provide eye or ear evidence relating to events prior to. at the time and after the accident. or accidentally due to the site not being adequately secured. Positions are the physical location of people and parts prior to. during or after the accident. Parts are visible. operating instructions. durable part of evidence. particularly if they are removed or repositioned during recovery of an injured person. They take numerous forms and consist of written records such as: job standards. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 13 . material pieces of plant. tangible. tools. This information is recorded as witness statements as described above. The position of parts after the accident can be extremely fragile. contracts and quotes. buildings at or around the accident scene that may or may not have had some influence prior to. qualifications of personnel." Papers are the most stable. training records. maintenance manuals. or has sophisticated equipment required to undertake comprehensive testing.
3. PAGE 14 SAFETYLINE INSTITUTE JANUARY 2009 . although where an enterprise has more than one workplace.2 Check for similar accidents Numerous statutory authorities throughout the world produce executive summaries of accident reports. trade and business journals. including the victim. WorkSafe’s SafetyLine has one of the best on-line collections of summaries. recommendations and preventative strategies. significant incident reports and significant incident summaries.1 Determine existing work procedures The research phase of determining existing work procedures is normally undertaken at the workplace itself. These are known by a variety of names such as safety alert. findings. These are accessible through various mediums such as safety magazines. written procedures may be located at the head office.READING – ACCIDENT INVESTIGATION AND REPORTING Section 3: RESEARCH 3. The disturbing aspect of reading these summaries is that the same type of accidents are happening all around the world. or undertaken the process that was involved in the accident. By researching these other accidents the investigator will be able to benefit from other investigators' research. direct mailing lists. a copy should be obtained and the contents should be compared with the verbal descriptions supplied by persons. On the positive side. the accident that the investigator is examining is probably not unique. and compared with similar procedures at kindred industries. safety information. These procedures can be analysed to determine any weaknesses in the system. health and safety libraries and of course the internet. With a little research it is probable they will locate other accidents that have taken place in very similar circumstances. indicating that people are not learning from accidents in which some people have been seriously injured or even died. time after time. who have performed the duties or functions. Where written procedures are available.
it must be made in a controlled environment. remember. or may relate to preventative methods or strategies. At this stage it is important to recognise that there is a distinct difference between reconstruction and re-enactment. It may be associated with establishing methods of eliminating a hazard. Re-enactment is description of events played out. Reconstruction is a rebuilding of the accident and is primarily used to establish the sequence and reason parts and equipment failed. Where reconstruction of the circumstances or part of the circumstances are deemed necessary. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 15 .READING – ACCIDENT INVESTIGATION AND REPORTING Some investigators attempt to reconstruct the circumstances of the accident. This is not a recommended practice as reconstruction goes hand in hand with recurrence. Reconstruction can be an extremely important tool. The best place to start research is in a library. primarily to obtain time-frames and sequences of events prior to the actual incident or accident. Research may be undertaken to establish the strength of tools and equipment. all hazards are not necessarily visible or can be smelt.the Internet. You are currently operating in the largest resource “library” in the world . particularly when there are no witnesses to the event and there is minimal or no physical evidence.3 Other research Research is not confined to existing work procedures and similar accidents. 3.the information super highway . substitutes for the hazard. effects of exposure to unseen hazards such as gasses or electrically induced magnetic fields. reducing the risk of the hazard. either physical or electronic.
Learning from Accidents in Industry 4. There will usually be tangible evidence Most of the immediate causes will be established in the early stages of the investigation when the investigator is gathering preliminary information. however. and it is essential to establish these to determine any underlying causes. identifying witnesses and what they can contribute to the investigation. particularly when they are interviewed within a close time frame to the event. it is essential that the investigator avoids leading the witness.” Trevor Kletz . They provide a starting point for the investigation. PAGE 16 SAFETYLINE INSTITUTE JANUARY 2009 . positions and parts. taking photographs. position and parts. The information will be gathered from people. The immediate causes will be the details immediately provided by people.READING – ACCIDENT INVESTIGATION AND REPORTING Section 4: ANALYSIS “Accident investigation is like peeling an onion. Paperwork invariably will not provide information on the immediate cause of accidents. The outer layers deal with the immediate causes while the inner layers are concerned with the underlying causes such as weakness in the management system.1 Determine immediate causes The immediate causes are normally the easiest to ascertain. Beneath one layer of causes there are other layers. Witnesses will provide most of the detail of the immediate causes with minimal prompting or questioning. Some prompting may be necessary to obtain confirmation of points raised by another witness.
usually they have not fulfilled their duty of care.. To establish the underlying causes the investigators will need to ask probing questions of witnesses. The immediate causes have told us how the accident happened.all injuries are preventable and are ultimately caused by management failure. and whether they are being implemented and adhered to. amongst other things. primarily to establish their understanding of the health and safety practices and procedures in place at this site. Some of the witnesses the investigator will need to interview will not have first hand knowledge of the accident that is being investigated but should be fully aware of the health and safety practices and procedures of the enterprise Major writers on accident investigation such as Trevor Kletz. espouses. whilst the underlying causes will tell us why the accident happened. for example: to provide sufficient safe working procedures or policies that will identify the hazard before the risk associated with that hazard becomes unacceptable. one of the worlds largest enterprises and manufacturers. but.READING – ACCIDENT INVESTIGATION AND REPORTING 4." This does not mean that management have deliberately created situations where a person will be injured... DuPont. all agree that the responsibility for the basic underlying causes of accidents rests with management..2 Determine underlying causes The determination of the underlying causes will be dependent on the immediate causes supported by information provided by witnesses and established by undertaking appropriate research. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 17 . or to provide and enforce sufficient maintenance and replacement policies to prevent a piece of equipment becoming distorted or failing. quoted at the start of this section. the theory that: ".
management have failed in their duty of care! We all know that ropes and cables are disposable or consumable items that are subject to wear and tear and there should have been inspection. If our research reveals that the inspection. the type of research that has to be undertaken. The immediate cause of the accident is that a rope or cable failed. Was there a procedure in place to regularly check the rope or cable for wear? Was there a procedure in place to replace the rope or cable after a pre-described period of time or usage? If not. However it is essential that adequate follow up is maintained to ensure these delegated responsibilities are implemented and continued. PAGE 18 SAFETYLINE INSTITUTE JANUARY 2009 . until you find the root cause of the accident. causing the injured person to be struck by the load or item.READING – ACCIDENT INVESTIGATION AND REPORTING Take an example of a person being injured because a rope or cable used to lift or restrain some load or item. management have failed to provide adequate training to ensure that their employees work in a safe environment! Our further research indicates the procedures were in place. the person responsible for implementing the procedures was fully aware of their responsibilities and had received adequate training and were competent to carry out the tasks. maintenance and replacement procedures were in place. our research has ruled out all of these factors. The cable was inspected. fails. maintenance and replacement procedures in place. maintained and was not due for replacement. in a methodical structured format. It broke! The important thing to establish is why did it break. Once again. Ah-ha! The careless worker! WRONG! Management failure again! Lack of supervision. eliminating potential for failure as you go. what do we do? The next step is to establish were these procedures observed? Did the person who was responsible for implementing these procedures know about the procedures and their role? Have they been trained to assess the conditions of the rope or cable? If not. What next? Was the rope or cable adequate for the purpose it was being used? Was the rope or cable for industrial use? Was the rope or cable quality tested? Was the load excessive? These are the type of questions that have to be asked. It is fine to delegate a responsibility after ascertaining the delegated person is adequately trained and skilled.
READING – ACCIDENT INVESTIGATION AND REPORTING Hopefully. you will see a trend. and admits it. the investigator should have been cognisant that they have to make recommendations and provide preventative strategies as part of their investigations and reporting. All of the scenarios outlined in the example all ultimately pointed to a management failure. Failure to have safe working procedures! Failure to have adequate training for employees! Failure to have adequate instructions for employees! Failure to have adequate supervision for employees. by now. as well as being mindful of the hierarchy of control. it still does not absolve management from having sufficient systems. Whilst in some accidents the employee may have done the wrong thing. training. Could the system have been changed to avoid using the rope or cable? Could the rope or cable be substituted with another method of restraint or lifting? Was it necessary to restrain or shift this item or load? Was it necessary for the injured person to be in a position where they could be struck by the load if the rope or cable failed? Could a barrier be placed between the load and the location of the injured person? JANUARY 2009 SAFETYLINE INSTITUTE PAGE 19 . Whilst undertaking the research and analysis of the immediate and underlying causal factors of this scenario. instruction and supervision in place that should have detected and prevented the employee doing the wrong thing.
like that of a witness." 5. in this case the investigator.READING – ACCIDENT INVESTIGATION AND REPORTING Section 5: REPORTING An accident report provides a condensed formal record of facts and recommendations surrounding an accident. giving each level of management information with which to decide and prioritise remedial action. The investigator does have the advantage of photographs. Remember the old adage: "The job's not done until the paperwork is finished. also needs to be a methodical.1 Preparation of report When preparing a report the author. unemotional record of the facts and events that led to an accident. exhibits. systematic. PAGE 20 SAFETYLINE INSTITUTE JANUARY 2009 . evidence. however the best approach is to prepare a written report as soon as possible. is fragile and will tend to sub-consciously fill in gaps where no evidence exists: it is a peculiarity of the human mind. preferably before they get involved in another investigation. The investigator's memory. in a concise format. The report. Every aspect will need to be spelt out. Remember there must be a beneficial outcome for the resources expended on the investigation. must assume the reader does not have any knowledge about the workplace or the work practices. being careful not to become verbose. notes taken at the time and statements to refer to which will refresh their memory. like the investigation. together with an analysis of the causal factors and recommendations for preventative strategies. description of evidence and exhibits collected. Indeed they may not have knowledge of safe work practices.
will cost money. in an internal investigation report. work procedures etc. For example: The weather was fine with light breezes and moderate temperature which would have had no influence on this accident. time of day. the analysis of the causal factors and recommendations will be influenced by the seriousness of the accident. working conditions. which also may have had some influence. Be aware that any modification or change to equipment.. and will normally address issues such as: the qualifications or training of the injured person. These headings will probably be fairly common to all investigations. and will be less influenced by the seriousness of the injury but more by the extent of any breach of legislation. An internal investigation will be looking primarily at developing preventative strategies. actions or failures of other persons which may have led to the accident and perhaps other physical factors such as weather. length of work shift. 5.2 Format of report The report should contain sufficient information to enable a decision maker to act on the investigator's recommendations. or which can be discounted as having an influence. lighting. the contributory influence. what and to whom. followed by a broader outline of the workplace. consequently cost benefit factors should be included with recommendations. the work being undertaken at the time of the accident and the events leading up to the accident.READING – ACCIDENT INVESTIGATION AND REPORTING The depth of the report. The report should commence with a brief overview of the accident. by whom and for what purpose. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 21 . whereas an investigation by a statutory authority will probably be looking at breaches of legislation. housekeeping. when. the suitability or condition of any plant or equipment involved in the event. the extent of the injuries received and what type of investigation is being undertaken. The format of the body of the report will depend on the circumstances of the accident. It is better to make a brief statement like this than to have the reader wondering if the weather was an influence and if the investigator overlooked this matter or just failed to comment on it. etc. where.
The report should also be forwarded to the health and safety committee. The report should be submitted to the enterprise management through their normal reporting channels. together with a report from the elected worker health and safety representative (if any). to form part of the agenda and discussions for the next scheduled meeting.READING – ACCIDENT INVESTIGATION AND REPORTING Photographs and sketches should be strategically located throughout the text to enable easy reference and access by the reader. if one exists. to some extent. This report may be a joint report between these two parties. 5. At the workplace level. for information and action. it may be necessary to convene a special meeting of the health and safety committee to address the matters raised or recommendations made. the report is likely to be prepared by a safety officer or person delegated to manage safety. clearly labelled and included in a contents page as well as being referenced at the appropriate part in the body of the report. PAGE 22 SAFETYLINE INSTITUTE JANUARY 2009 . If the accident was so severe or the hazards exposed so intolerable. Other relevant documents collected during the investigation and research phases should be included as attachments. to act on or authorise any recommendations contained within the report.3 Distribution and use of report The distribution and use of an accident or incident report will depend on. who prepares the report and for what reason. Without this step the whole investigation and report have been a complete waste of time. the conclusions reached by the investigator together with appropriate recommendations including preventative strategies from the investigator. The report will conclude with comments or discussion of issues that have arisen or need to be addressed.
When implementation is left to one person. or leaves the particular work area or the enterprise. a copy will also be forwarded to the Crown Solicitor. If that agency proceeds to a prosecution for breaches of legislation arising out of the investigation. the outcomes and the recommendations. sick. particularly if an enterprise decision maker is involved in the process. the circumstances described in the report. it is easy for the process to run off the rails if that person is absent on leave.READING – ACCIDENT INVESTIGATION AND REPORTING The health and safety committee is an appropriate forum for members to discuss the report. The external investigators will in most cases produce a detailed report for the organisation they represent. It may be that the combined expertise of the committee will provide alternative. This is also an excellent forum to follow up and monitor recommendations and preventative strategies. perhaps more practicable solutions or substitutions. the Coroner will be seeking a report prepared by a Government agency. In the early section of this reading we referred to who conducts an investigation and further split the options between internal and external investigators. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 23 . to ensure they are implemented. to prevent further occurrences of these circumstances. and if the person died as a result of the accident. The safety committee will have recorded notes or minutes to ensure that the recommendations are continuously reviewed until the matter is satisfactorily completed or resolved. Pooled resources can be extremely beneficial.
The investigation is a methodical examination of the accident site. there will need to be research into: other similar accidents. and be prepared to commence an investigation immediately. and any records. The investigator should have all of the tools and equipment that they may require accessible at short notice. A variety of investigators may be involved in the investigation of a particular event. conclusions reached and recommendations for preventative strategies. and other relevant matters. the health and safety committee at the workplace. related directly or indirectly to the event. papers etc that may contribute to the outcomes of the investigation.READING – ACCIDENT INVESTIGATION AND REPORTING SUMMARY Accident investigations are undertaken to establish causal factors of the event. At the conclusion of these steps it will be necessary for the investigator to commit their investigation details and conclusions to writing. sketches made. PAGE 24 SAFETYLINE INSTITUTE JANUARY 2009 . they all need to establish the causal factors. This research will be necessary to establish the deeper causal factors. for which they will develop preventative strategies to reduce the risk of a recurrence of the circumstances surrounding the event. When advised of the circumstances of an accident they should be considering possible scenarios and tactics so when they reach the investigation site they have some concept of what avenue they will be following. witnesses interviewed and exhibits collected. Investigations need to be pre-planned. After this examination has been undertaken and photographs taken. and the quicker the investigations commences. and depending on who undertakes the investigation and for what purpose. the party or parties who commissioned the investigator's investigation. in the form of a report of the event. and whilst they may be looking at the event from different perspectives. the less risk there is of evidence being contaminated and witnesses descriptions being corrupted. When all of this information is available the investigator will be able to analyse the event to establish causal factors. the physical evidence of what happened. This report should be submitted to the management of the workplace where the accident happened. the people who have first hand knowledge of facts. existing work practices and procedures.
READING – ACCIDENT INVESTIGATION AND REPORTING Depending on the status of the investigator. Your feedback WorkSafe is committed to continuous improvement. JANUARY 2009 SAFETYLINE INSTITUTE PAGE 25 . they may or may not have any part in the implementation of their recommendations. If you take the time to complete the online Feedback Form at the SafetyLine Institute website you will assist us to maintain and improve our high standards. The implementation and follow up of recommendations will normally be the role of the management of the enterprise together with the health and safety committee and elected worker health and safety representatives of the workplace.
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