ACCIDENT INVESTIGATION AND ANALYSIS

6.1 NOTIFICATION OF ACCIDENTS, DANGEROUS

OCCURRENCE, OCCUPATIONAL POISONING AND
DISEASES-OSH REGULATION
6.2 ACCIDENT CAUSATION
6.3 ACCIDENT INVESTIGATION METHODOLOGY
6.5 CORRECTIVE ACTION AND REPORT
Accident and Incident Investigation

COMPILE BY BULAN ABDULLAH

APRIL 2018
 Objectives of this Section

1. To define the reasons for investigating accident

and incidents.
2. To outline the process for effectively
investigating accidents and incidents.
3. To facilitate an effective investigation.
• Crime Scene Investigation (CSI) Techniques
• https://youtu.be/tqtS4wMfZYo
 Accident Investigation
• Important part of any safety  Identifying remedies to improve the
management system. Highlights health and safety management
system by improving risk control,
the reasons why accidents occur
preventing a recurrence and reducing
and how to prevent them. financial losses.
• 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;
 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 1
the one shown below is Major injury
Or illness
based on studies carried
out by the Health & Safety 7
Executive. Minor injuries or illnesses

189
Non Injury Accidents/Illnesses
 Accident Studies

• In all cases the ‘non injury’ incidents had wrong within the management’s
the potential to become events with system.”
more serious consequences. • All events represent a degree of failure
in control and are potential learning
• Such ratios clearly demonstrate that experiences. It therefore follows that all
safety effort should be aimed at all accidents should be investigated to
accidents including unsafe practices at some extent.
the bottom of the pyramid, with a
resulting improvement in upper tiers. • This extent should be determined by the
loss potential, rather then just the
• Peterson (1978) in defining the immediate effect.
principles of safety management says
that “an unsafe act, an unsafe condition,
an accident are symptoms of something
 Stages in an Accident/Incident Investigation

Deal with immediate

The stages in an accident/incident investigation risks.

are shown in the following diagram.

Select the level of
investigation.

Deal with immediate risks

Investigate the event.

Select the level of investigation.

Investigate the event. Record and analyse the

results.

Record and analyse the results.

Review the process.

Review the process.
 Dealing with Immediate Risks

• When accidents and incidents occur immediate

Deal with immediate
risks. action may be necessary to:
1. Make the situation safe and prevent further
Select the level of
investigation.
injury.
2. Help, treat and if necessary rescue injured
Investigate the event.
persons.

Record and analyse the

• An effective response can only be made if it has
results.
been planned for in advance.
Review the process.
 Selecting the level of investigation

Deal with immediate

risks. The greatest effort should be put into:
Those involving severe injuries, ill-health or loss.
Select the level of Those which could have caused much greater
investigation.
harm or damage.

Investigate the event.

These types of accidents and incidents demand
more careful investigation and management time.
This can usually be achieved by:
Record and analyse the
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
investigation. 1. The way things were and how they came to be.
2. What happened – the sequence of events that led
Investigate the event. to the outcome.
3. Why things happened as they did analysing both
the immediate and underlying causes.
Record and analyse the
results. 4. 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 &
Video Camera
• Cassette Tape Recorder
• Flash and Batteries
• Mobile Telephone / Walkie-Talkie
• Clipboard, Pre-printed Forms
• PPE
• Containers for Taking and Storing
Samples
• Barrier Tape

Copyright@NIOSH 2005/1 14
 Interviews
• Interviewing the person(s) involved and • Interviews should be separate to stop
witnesses to the accident is of prime people from influencing each other.
importance, ideally in familiar • Questions when asked should not be
surroundings so as not to make the intimidating as the investigator will be
person uncomfortable. seen as aggressive and reflecting a
• The interview style is important with blame culture.
emphasis on prevention rather than
blame.
• The person(s) should give an account of
what happened in their terms rather
than the investigators.
 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 follow it?

includes: • Records of inspections, tests,

examination and surveys undertaken
• Written instructions, procedures and risk
before the event. These provide
assessments which should have been in
information on how and why the
operation and followed. The validity of
circumstances leading to the event
these documents may need to be
arose.
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
 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.
 Hierarchy of Controls
Generally, remedial actions should Elimination/Substitution

follow the hierarchy of risk Most

Requires a physical

control: Effective
change to the
workplace

• Eliminate Risks by substituting the

dangerous by the inherently less Requires worker or
dangerous. employer to do
• Combat risks at source by engineering something
controls and giving collective protective
Requires
measures priority. worker to
• Minimise risk by designing suitable wear
something
systems of working.
• Use PPE as a last resort. Least
Effective
 Recording & Analysing the Results
Deal with immediate
risks. • Recorded in a similar and systematic manner.
• Provides a historical record of the accident.
Select the level of • Analysis of the causes and recommended
investigation.
preventative protective measures should be listed.
• 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 have to
results. be implemented by such supervisors.
• Investigation reports and accident statistics should be
Review the process. analysed from time to time to identify common
causes, features and trends not be apparent from
looking at events in isolation.
 Reviewing the Process
Deal with immediate
risks. Reviewing the accident/incident
investigation process should
consider:
Select the level of – The results of investigations
investigation.
and analysis.
– The operation of the
Investigate the event. investigation system (in terms
of quality and effectiveness).
Line managers should follow
Record and analyse the
through and action the findings of
results. investigations and analysis. Follow
up systems should be established
where necessary to keep progress
Review the process. under 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.
EXAMPLE INCIDENT REPORT
EXAMPLE INCIDENT REPORT
 Report - Malaysia

Notification of Accident, Dangerous Occurrence, Occupational Poisoning

and Occupational Disease (NADOPOD) - JKKP 6, 7, 8, 9, 10

pdf1. Notification of Occupational Accident/Dangerous Occurrence - JKKP 6

pdf2. Notification of Occupational Poisoning/Occupational Disease - JKKP 7
pdf4. Data on Accidents - JKKP 9
pdf5. Data on Occupational Poisoning and Diseases - JKKP10

Download form-
http://www.dosh.gov.my/index.php/en/form-download/nadopod-1
Report- US

Report
Report- US
Report- US
CASE STUDY AT MALAYSIA
(REFER TO ATTACHMENT)
THE END
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
1. What kind of ladder was used? Load
rating?
2. What was the condition of the ladder?
3. Where did the ladder break?
4. Was the ladder inspected for damage
prior to use?
5. What kind of training has the employee
had to use and inspect ladders prior to
use?
6. What was the employee carrying? How
much did it weigh?
7. Did the load on the ladder exceed the
load rating?
8. How was the ladder stored? Where?
9. Has the ladder ever been dropped or
damaged? If so, how?
10.How did the ladder rung break?
11.What is the procedure for cleaning
gutters?
12.Is there a fall protection plan in place?
13.What was the weather?
14.What was going on around the work
location at the time?
 Investigation Findings - Ladder
1. Ladder is a Type II, metal, load capacity 6.
of 225 pounds.
2. The ladder is kept on a rack on the
truck and the truck is parked outside.
3. The ladder was placed up against a wall 7.
at a 1:4 ratio.
4. Employee was wearing tool belt which
weighed approximately 30 pounds. The 8.
total load was above maximum load
capacity.
5. Three days ago the ladder fell off the 9.
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 Basic causes
1. Supervisor not enforcing
Indirect causes procedures
1. Ladder overloaded 2. Inadequate training
2. Improper storage caused ladder
damage (not tied down)
3. Not inspected prior to each use
4. Improper selection of equipment
5. Using defective equipment
 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 the 5/17/07
task K. Gregg
Improper storage caused ladder Provide proper means and equipment for 5/17/07
damage (not tied down) storage and provide training on ladder T. Kinman
storage
Not inspected prior to each use Develop, carry out and enforce policy for 6/15/07
inspection of ladders B. Dorris
Improper selection of equipment Provide training on proper ladder 5/16/07
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, selection, 5/17/07
inspection and storage L. Schneider
GROUP WORK
 DIRECTIONS
 Divide into small work groups (not causes (direct, indirect and basic)
more than 6). and corrective actions to be taken
 Each group will be given a case for each cause.
study to work on.  List causes and corrective actions
 From the accident description, on causation summary sheet.
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
 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

1. How was the employee cutting the meat?

2. What was she doing before she cut meat?
3. How long had she been using the meat cutter?
4. Who taught her how to use it?
5. Are there procedures for using it correctly?
6. Does the blade have a protective guard? Was it functional?
7. Have there been other injuries on this cutter?
8. Is there any protective equipment available?
9. Who was around before, after?
 Investigation Findings – Meat Slicer
1. Meat being sliced is slippery.
2. 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 6.
the guard.
3. The employee was not trained in the
safe use of the meat cutter, although 7.
she was an experienced kitchen worker.
4. The employee says guard was used, but
the person who cleaned the cutter
after the accident said the guard was
NOT engaged.
5. 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
1. Employee’s hand slipped
2. Employee was distracted
3. Meat cutter could be operated
without guards in place
4. Cut-resistant gloves were
available but not used
Basic causes
1. Supervisor not enforcing
procedures for equipment
2. Procedures not in place for use of
gloves (PPE)
3. 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 safety 1/15/07
procedures Charlotte Harper
Meat cutter could be operated without Retrofit guard so it cannot be disabled Immediate -
guards in place Lance Wells
Cut-resistance gloves were available but not Develop, implement, and enforce procedure for 5/15/07
used glove use Pam Milleson
Supervisor not enforcing procedures for Enforce safety rules/discipline policy Immediate –
equipment Louise Matzner
Procedures not in place for use of gloves Develop, implement and enforce procedures for 5/15/07
(PPE) glove use Shirley Schaeffer
Employee was not aware that guard use was Train staff on use of equipment and procedures Immediate -
mandatory 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
1. Why did employee have to stand
on the tire?
2. Are there other ways of checking
fluids?
3. What is the process for getting
down?
4. What type of training did you
receive for checking fluids? By
5. who?
6. What is the distance between
tire and first step to get down?
7. Each additional step?
8. Tell me what you did from the
time you arrived at work?
9. What was going on/happening
around you at the time you
were
10. getting down?
11. What type of shoes were you
wearing?
12. Have there been similar
incidents? Explain.
13. What was the weather?
 Investigation Findings – Bus
1. Driver was not trained how to
check fluids on this type of bus.
2. There are two step ladders 6.
available, but none close by.
3. No process or procedures in
place for checking fluids. 7.
4. Ladder use is covered in Accident
Prevention Program but there
was no training specific to ladder 8.
use provided to drivers.
5. 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 Basic causes
 Inadequate training in pre-trip
Indirect causes procedures for all types of buses
 Failure to use proper equipment -  No designated bus wash area
step ladder
 Wearing inappropriate footwear
 Lack of step ladders available and
not close by
 Employee was distracted
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP
Improper body movement Develop procedures and train drivers on 12/15/05
procedures R Nicholson
Failure to use proper equipment – step Enforce safety rules/discipline policy Immediately
ladder T Head
Wearing inappropriate footwear Develop, implement and enforce safety 12/15/05
procedures P Pocinich
Lack of step ladders available and not Ensure adequate number of step ladders 11/30/05
close by and ensure they are readily available B Petersen
Employee was distracted Safety awareness training Immediate, Ongoing
T Kinman
Inadequate training in pre-trip Train staff on use of all equipment and 3/16/07
inspections for all types of buses procedures J Peterson

No designated bus wash area Designate bus wash area 6/30/07 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
1. What training has employee had in dealing with autistic students?
And this student?
2. Has the child ever acted out in this way before? When and under what
circumstances
3. Is there a behavior plan in place for this student? Was employee
following it?
4. How did employee take student to time out room?
5. What was going on prior to the misbehavior?
6. Is there any personal protective equipment?
 Investigation Findings – Student

1. Teacher was a substitute. Has a Special Ed endorsement but has only taught in a
Special Ed classroom twice before.
2. Student is not familiar with substitute teacher.
3. Substitute teacher was informed of the student’s behavior.
4. Substitute teacher was not informed of how to handle the situation.
5. Teacher was holding student’s hand and leading him to the room, she was in front
of him.
6. Teacher put her arm around student.
 Accident Causes – Student
Direct causes
 Student hit teacher Basic causes
 Inadequate practices regarding
Indirect causes staff selection
 Teacher was walking in front of  Inadequate training
student (unsafe act) and touched  Inadequate experience/skills
student (behavioral plan identifies
the child is uncomfortable with
being touched)
 Teacher was not able to de-
escalate the student
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP

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

remove trigger(s) L. Wallis
Teacher was walking in front of Develop, implement and enforce safety 6/30/07
student and touched student procedures E. Rudeen

Teacher was not able to de- Provide other personnel trained in de- Immediately
escalate the student escalation to assist sub when needed L Muchlinski

Inadequate practices regarding Evaluate sub selection process 06/30/07

staff selection C. Bailey
Inadequate training Evaluate and modify sub training policies 06/30/07
L. Bush
Inadequate experience/skills Evaluate sub selection process 06/30/07
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
1. Why was employee standing on desk? 8. What other ways do employees have
2. Is there a step ladder available? Where for hanging items?
are they located? 9. What training have employees
3. What is the age, style and condition of received for hanging items?
desk & chair? 10. What are the procedures for hanging
4. What type of shoes were they items from the ceiling?
wearing?
5. Have there been similar incidents?
6. What was employee doing prior to
getting on the desk?
7. What was going on at the time
employee got off the desk?
 Investigation Findings – Chair
1. Desks are for kindergarten
students.
2. Desks and chairs are new this
year.
3. Current practice is to use desks
for hanging items.
4. Teacher changes items hanging
from ceiling once a month.
5. Stepladders are available in every
wing.
6. There are no procedures in place
for using stepladders. Ladder use
is covered in Accident Prevention
Program.
7. There has been no training on
stepladder use.
 Accident Causes – Chair
Direct causes
Chair broke Basic causes
Safety procedures not in
Indirect causes place
Improper use of Inadequate training
equipment
Failure to use proper
equipment
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP

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

J Cornaggia

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

J Klundt

Failure to use proper equipment Enforce safety rules/discipline policy Immediately

R Johnson

Safety procedures not in place Develop, implement and enforce safety 3/17/06
procedures D Heider

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

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
1. What are the procedures for
unloading fertilizer from a truck?
2. What type of truck were the bags
on?
3. Where were the bags on the
truck?
4. How were the bags stacked?
5. Where was the employee
unloading bags from?
6. Where was the employee moving
the bags to?
7. Where were you located?
8. How often do you perform this
type of lifting?
9. What were you doing before the
incident?
10. Have you been trained in lifting?
11. Did you have help? Did you ask for
help?
12. What were the conditions at the
time?
13. How was the employee dressed?
 Investigation Findings - Groundsperson
1. Employee had been trained in 5. Employee was performing an
lifting properly. unsafe act by twisting his body
2. This unloading requires two while lifting.
people in its current 6. This employee has had previous
configuration. on the job injuries due to lifting.
3. Employee did not seek a lifting 7. Location for unloading puts
partner. employees in awkward positions
4. The bags were being removed for lifting.
from inside the bed of the truck
and swung to landing them on
the ground beside him.
 Accident Causes – Groundsperson
Direct causes Basic causes
 Twisted back– bodily motion  Injury repeater
 Insufficient
Indirect causes supervision/enforcement policies
 Failure to seek assistance  Unsafe layout for
 Lifting improperly – swinging, too loading/unloading
heavy, no help
 Loading, placing supplies
improperly
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP

Twisted back – bodily motion Enforce safety rules/discipline policy Immediately

D Glaser
Failure to seek assistance Enforce safety rules/discipline policy Immediately
D Schell
Lifting improperly - swinging, too Retrain in proper lifting techniques 3/1/07
heavy, no help T Triplett
Loading/placing supplies Develop proper loading/storage 2/29/07
improperly procedures, train employees R Nunamaker
Injury repeater Enforce safety rules/discipline policy Immediately
D Schell
Insufficient Enforce safety rules/discipline policy Immediately
supervision/enforcement policies D Schell

Unsafe layout for Relocate storage area 6/30/06

loading/unloading M Wallace
 SUMMARY

Purpose of Five Step Investigation

Investigation Process
1. ● Establish the facts 1. ● Gather the facts
2. ● Ensure similar incidents 2. ● Review the facts to find
do not occur causes
3. ● Reduce the number and 3. ● Document findings and
severity of losses actions
4. ● Take preventative action
5. ● 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
ADDITIONAL NOTE
 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
1. Lost efficiency due to break-up of
crew.
2. Damage to tools and equipment.
3. Damage from accident due to fire,
water, chemicals, spills, crashes, etc.
4. Loss of customers because products
and services are not provided.
5. 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
ACCIDE • 300 incidents occurred,
NT
or
• you lost 300 chances to
prevent the accident!
300
INCIDENTS

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

CB106 Accident Investigation

 Causes of Accidents
◦ Unsafe Conditions
1. Poorly maintained machinery or
equipment.
2. Defective or missing personal
protective equipment.

3. Unguarded machinery or
equipment.
4. Missing or inadequate Warnings or
safety and health signs.
5. 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.
 No representation is made as to the thoroughness of the
 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.
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
THE END
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)

1. Corrective actions must address the cause(s) of the accident

2. Look for both short-term and long-term solutions
3. Include dates for completion of the corrective actions and identify
those responsible
4. Report corrective actions to the safety committee
 DOSH’s
SOLUTION TO HAZARDS
1. Eliminate the hazard or use less hazardous processes or materials
2. Use operational controls - SOPs
3. Use administrative controls (policies, rules, training, signage)
4. Use engineering controls (mechanical means – substitution,
ventilation, isolation)
5. 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.