INTRODUCTION

• Thousands of accidents occur throughout the United States

every day
• Accident investigations determine how and why these
failures occur
• Conduct accident investigations with accident prevention in
mind - Investigations are NOT to place blame
• Investigate all accidents regardless of the extent of injury or
damage
 THE ACCIDENT

WHAT IS AN ACCIDENT?
 THE ACCIDENT

An
unplanned and unwelcome event
that interrupts normal activity
Accident is What Happens to
Somebody Else

BUT REMEMBER:
YOU
are somebody else
to somebody else
 THE ACCIDENT

MINOR ACCIDENTS:

• Such as paper cuts to fingers or dropping a

box of materials
 THE ACCIDENT

MORE SERIOUS ACCIDENTS

• Such as a forklift dropping a load or someone

falling off a ladder
 THE ACCIDENT

• Accidents that occur over an extended time

frame:
– Such as hearing loss or an illness resulting from
exposure to chemicals
 THE ACCIDENT
NEAR-MISS

• Also known as a “Near-Hit”

• An accident that does not quite result in injury or
damage (but could have)
• Remember, a near-miss is just as serious as an
accident!
 THE ACCIDENT

ACCIDENTS HAVE TWO THINGS IN COMMON

 THE ACCIDENT
They all have outcomes from the accident
 THE ACCIDENT

They all have contributory factors that cause

the accident
 OUTCOMES OF ACCIDENTS
• NEGATIVE Results
– Injury & possible death
– Disease
– Damage to equipment & property
– Litigation costs, possible citations
– Lost productivity
– Low morale
 OUTCOMES OF ACCIDENTS
• POSITIVE Results
– Accident investigation
– Prevent repetition of accident
– Change of safety programs
– Change of procedures
– Change of equipment design
 ACCIDENT INVESTIGATION
• Accidents are usually complex
• An accident may have 10 or more events that can
be causes
• A detailed analysis of an accident will normally
reveal three cause levels:
– direct
– indirect
– root
 Direct Cause
• An accident results only when a person or object
receives an amount of energy or hazardous material
that cannot be absorbed safely. This energy or
hazardous material is the DIRECT CAUSE of the
accident

The direct cause is usually the result of one or

more unsafe acts or unsafe conditions or both
 Indirect and Root Causes
• Unsafe acts and conditions are the indirect causes
or symptoms of accidents
• Indirect causes are usually traceable to:
– poor management policies and decisions
– personal or environmental factors
• Root causes are the actual policies and decisions by
management and the actual personal and
environmental factors of the workplace
 ACCIDENT INVESTIGATION
You Must:
• Conduct a preliminary investigation for:
– serious injuries with immediate
symptoms

• Document the investigation findings

 ACCIDENT INVESTIGATION
• Do Not move equipment involved in a work or work
related accident or incident if :
– There’s a death
– There’s a probable death
– 3 or more employees were sent to the hospital
(WISHA -2)
• Unless, Moving the equipment is necessary to:
– Remove any victims
– Prevent further incidents and injuries
 ACCIDENT INVESTIGATION
• Within 8 hours of a work-related incident or
accident you must contact the nearest office of
the OSHA in person or by phone to report:
– A death
– A probable death
– 3 or more employees are sent to the hospital
• (OSHA) 1-800-321-6742
• WISHA 1-800-4BE-SAFE (423-7233)
 ACCIDENT INVESTIGATION
• Assign witnesses and other employees to
assist OSHA personnel who arrive to
investigate the incident
Include:
– The immediate supervisor
– Employees who were witnesses to the incident
– Other employees the investigator feels are
necessary to complete the investigation
 ACCIDENT INVESTIGATION
•Make sure your preliminary investigation is
conducted by the following people:
– A person designated by the employer
– The immediate supervisor
– Witnesses
– An employee representative
– Other persons with experience and skills to
evaluate the facts
 ACCIDENT INVESTIGATION
A preliminary investigation includes noting
information such as the following:
–Where did the accident or incident occur?
–What time did it occur?
–Who were the people present?
–What was the employee doing at the time?
–What happened during the accident or incident?
 ACCIDENT INVESTIGATION
Provide the following information to OSHA within 30
days concerning any accident involving a fatality or
hospitalization of 3 or more employees:
– Name of the work place
– Location of the incident
– Time and date of the incident
– Number of fatalities or hospitalized employees
– Contact person
– Phone number
– Brief description of the incident
Why Not Rely On OSHA & Police
To Investigate?
• Focus On Culpability
• Minor Accidents Not Investigated
• PREVENTION
• Protect Company Interests
• OSHA Requirements
 Investigating Accidents

How to find out what really happened

 Why Investigate Accidents

• Find the cause

• Prevent similar accidents
• Protect company interests
At which level do we investigate?

Death
Lost Time
Injury
Reportable Injury

Minor Injuries

Near Misses

Acts Conditions

Maintenance
Knowledge

Motivation

Design
Ability

Others
Action
of
Investigation Strategy
• Need For Investigation
• Control the Scene
• Gather Facts
• Analyze Data
• Establish Causes
• Write Report
• Take Corrective Action
 Investigative Procedures
• The actual procedures used in a particular
investigation depend on the nature and results of
the accident
• All investigations start with a collection of data and
are followed by analysis of that data
• An investigation is not complete until all data is
analyzed and a final report is completed
 The Aim of the Investigation
• The key result should be to prevent
a repeat of the same accident
• Fact finding:
– What happened?
– What was the root cause?
– What should be done to prevent
repeat of the accident?
 The Aim of the Investigation
IS NOT TO:
• Exonerate individuals or management

• Satisfy insurance requirements

• Defend a position for legal argument

• Or, to assign blame

COMPANY ACCIDENT FORMS

• Must be filled out completely by the

employee and employee’s immediate
supervisor (this includes foremen)
• Must be turned in to Safety within 24
hours of incident
 BENEFITS OF ACCIDENT
INVESTIGATION
• Prevent repeat of the accident
• Identifying outmoded procedures
• Improvements to the work environment
• Increased productivity
• Improvement of operational & safety procedures
• Raise safety awareness level
 BENEFITS OF ACCIDENT
INVESTIGATION

• WHEN AN ORGANIZATION REACTS SWIFTLY

AND POSITIVELY TO ACCIDENTS AND
INJURIES, ITS ACTIONS REAFFIRM ITS
COMMITMENT TO THE SAFETY AND WELL-
BEING OF ITS EMPLOYEES!
 Who Should Investigate?
Investigation TEAM
• Employer Designee (Management)
• Immediate Supervisor of affected area/personnel
• Experts (if needed)
• Employee Representative (one of the following:)
– Employee selected representative
– Employee representative of safety committee
– Union representative or shop steward
 **Immediate Actions
• Assess the scene
• CALL 911
• Activate In-House Response
• Scene Safety
• Provide Aid to Injured
• Provide Assistance to Affected
• Secure the Scene of Accident
 Isolate the Scene
• Barricade the area of the accident, and keep
everyone out!
• The only persons allowed inside the barricade
should be Rescue/EMS, law enforcement, and
investigators
• Protect the evidence until investigation is complete
 Provide Care to the Injured
• Ensure that medical care is provided to the injured
people before proceeding with the investigation
 Secure the Scene for Safety
• Eliminate the hazards:
– Control chemicals
– De-energize
– De-pressurize
– Light it up
– Shore it up
– Ventilate
Fact Finding
• Gather evidence from
many sources during an
investigation
• Get information from
witnesses and reports as
well as by observation
• Don’t try to analyze data as
evidence is gathered
 Gather Evidence
• Examine the accident scene - look for things that
will help you understand what happened.
– Dents, cracks, scrapes, splits, etc. in equipment
– Tire tracks, footprints, etc.
– Spills or leaks
– Scattered or broken parts
– Any other possible evidence
 Gather Evidence
• Diagram the scene:
– Use blank paper or graph
paper. Mark the location of all
pertinent items, equipment,
parts, spills, persons, etc.
– Note distances and sizes,
pressures and temperatures
– Note direction (mark north on
the map)
 Gather Evidence
• Take photographs
– Photograph any items or scenes which may provide an
understanding of what happened to anyone who was not there
– Photograph any items which will not remain, or which will be
cleaned up (spills, tire tracks, footprints, etc.)
– 35mm cameras, Polaroids, and video cameras are all acceptable
• Digital cameras are not recommended - digital images can be
easily altered
 Photographs

• Unbiased Recording
• Keep Log of Photos
• Overall to Close-up
• Colored if possible
• Supplement with Video
 Gather Data
• Data includes:
– Persons involved
– Date, time, location
– Activities at time of accident
– Equipment involved
– List of witnesses
 Review Records
• Check training records
– Was appropriate training provided?
– When was training provided?
• Check equipment maintenance records
– Is regular PM or service provided?
– Is there a recurring type of failure?
• Check accident records
– Have there been similar incidents or injuries
involving other employees?
 Documents
• Collect All Related Documents
– Inspection Logs
– Policy & Procedures Manual
– JSA (Job Safety Analysis)
– Equipment Operations Manuals
– Insurance Records
– Employee Records
– Police Reports
Those who do not know the past
are destined to:
Repeat
Repeat
Repeat
Repeat
Repeat
Repeat

It.
ISOLATE FACT FROM FICTION
• Use NORMS-based analysis of information
– Not an interpretation
– Observable
– Reliable
– Measurable
– Specific
• If an item meets all five of above, it is a fact
 NORMS OF OBJECTIVITY
Objective
Not an Interpretation - Based on a
factual description.
Observable - Based on what is
seen or heard.
Reliable - Two or more people
independently agree on what
they observed.
Measurable - A number is used to
describe behavior or situation.
Specific - Based on detailed
definitions of what happened.
Subjective
Interpretations - Based on
personal interpretations/biases.
Non-observable - Based on events
not directly observed.
Unreliable - Two or more people
don’t agree on what they
observed.
Non-Measurable - A number isn’t
used.
General - Based on non-detailed
descriptions.
 INVESTIGATION TRAPS
• Put your emotions aside!
– Don’t let your feelings interfere - stick to
the facts!
• Do not pre-judge
– Find out the what really happened
– Do not let your beliefs cloud the facts
• Never assume anything
• Do not make any judgements
 Record Evidence
• Keep All Notes in Bound Notebook

• Include Date - Time - Place – Vantage Point

• Keep Originals

• Rewrite in Report Form

 Samples
• Collect Perishables
First
• Fluids
• Open Containers
• Filings
• Chemicals
• Air
 Interviews
• Experienced personnel should conduct
interviews
• If possible the team assigned to this task should
include an individual with a legal background
• After interviewing all witnesses, the team
should analyze each witness' statement
 Interviews
• Analyze this information along with data from the
accident site
• Not all people react in the same manner to a
particular stimulus
• A witness who has had a traumatic experience may
not be able to recall the details of the accident
• A witness who has a vested interest in the results of
the investigation may offer biased testimony
 Interviews
• Excellent Source of first hand knowledge

• May Present Pitfalls in form of:

– Bias
– Perspective
– Embellishment
– Omissions
 Ask “What Happened?”
• Get a brief overview of
the situation from
witnesses and victims
• Not a detailed report
yet, just enough to
understand the basics
of what happened
 Interview Victims & Witnesses
• Interview as soon as possible
after the incident
– Do not interrupt medical care just
to make an interview
• Interview each person
separately
• Do not allow witnesses to
confer prior to interview
 The Interview
• Put the person at ease
– People may be reluctant to discuss
the incident, particularly if they
think someone will get in trouble
• Reassure them that this is a fact-
finding process only
– Remind them that these facts will
be used to prevent a recurrence of
the incident
 The Interview
• Take Notes!
• Ask open-ended questions
– “What did you see?”
– “What happened?”
• Do not make suggestions
– If the person is stumbling over a word or
concept, do not help him/her out
 The Interview
• Use closed-ended questions later to gain
more detail
– After the person has provided his/her
explanation, these type of questions can be used
to clarify
– “Where were you standing?”
– “What time did it happen?”
 The Interview
• Don’t ask leading questions
– Bad: “Why was the forklift operator driving
recklessly?”
– Good: “How was the forklift operator driving?”

• If the witness begins to offer reasons, excuses, or

explanations, politely decline that knowledge
and remind them to stick with the facts
 The Interview
• Summarize what you have been told
– Correct misunderstandings of the events
between you and the witness

• Ask the witnesses/victims for

recommendations to prevent recurrence
– These people will often have the best solutions
to the problem
 The Interview

• Get a written, signed statement from the

witness
– It is best if the witness writes his/her own
statement; interview notes signed by the
witness may be used if the witness refuses to
write a statement
 Ask All Witnesses
• Name, address, phone number
• What did you see?
• What did you hear?
• Where were you standing/sitting?
• What do you think caused the accident?
• Was there anything different today?
 Ask Supervisors
• What is normal procedure for activities involved in the
accident?
• What type of training persons involved in accident have
had?
• What, if anything was different today?
• What they think caused the accident?
• What could have prevented the accident?
 Witness Interviews
DO DON’T
• Separate Witnesses • Suggest Answers
• Written Statements • Interrogate
• Open ended questions
• Focus on Blame
• Provide Diagrams
• Dismiss Details
• Encourage Details
• Bar Emotions
• Show Concern
• Record w/permission • Make Judgments
 Analysis of Accident Causes
• Immediate Causes
• What was done?

• What was not done?

• What hazardous condition existed?
• Root Causes
• Why did they do this?
• Why didn’t they do that?
• Why did the unsafe condition exist?
• Why wasn’t it corrected?
 Analyze Data
• Gather all photos, drawings, interview
material and other information collected at
the scene
• Determine a clear picture of what happened
• Formally document sequence of events
 CONTRIBUTING FACTORS
INVESTIGATION STRATEGY
• INVESTIGATION TEAM

• EVALUATES ALL FACTORS CONCERNED

• ISOLATES THE KEY FACTOR(S) BY ASKING THE

FOLLOWING QUESTION....

• WOULD THE ACCIDENT HAVE HAPPENED IF THIS

PARTICULAR FACTOR WAS NOT PRESENT?
 DETERMINE CAUSES
• Employee actions
• Safe behavior, at-risk behavior
• Environmental conditions
• Lighting, heat/cold, moisture/humidity, dust, vapors, etc.
• Equipment condition
• Defective/operational, guards, leaks, broken parts, etc.
• Procedures
• Existing (or not), followed (or not), appropriate (or not)
• Training
• Was employee trained - when, by whom, documentation
 Indirect Causes
• Unsafe conditions – what material
conditions, environmental conditions and
equipment conditions contributed to the
accident

• Unsafe Acts – what activities contributed to

the accident
 Breakdown of Unsafe Conditions

• Inadequately guarded or unguarded equipment

• Defective tools, equipment or materials
• Fire and explosion hazard
• Unexpected movement hazard
• Projection hazards
 Breakdown of Unsafe Conditions
• Housekeeping
• Hazardous environmental conditions
• Improper ventilation
• Improper illumination
• Unsafe dress or apparel
 Breakdown of Unsafe Acts
• Operating without authority
• Operating or working at unsafe speeds
• Making safety devices inoperative
• Using unsafe equipment
• Neglecting to wear PPE
• Unsafe loading, placing, mixing, combining
• Taking unsafe position or posture
 Basic Causes
• Management
Systems & Procedures
• Environment

• Equipment Design & Equipment

• Human Behavior
 Management
• Was a hazard assessment conducted?
• Were the hazards recognized?
• Was control of the hazards addressed?
• Were employees trained?
• Did supervision detect/correct deviations?
• Was Supervisor trained in job/accident prevention?
• What were the production rates?
 FIND ROOT CAUSES
• When you have determined the
contributing factors, dig deeper!
– If employee error, what caused
that behavior?
– If defective machine, why wasn’t
it fixed?
– If poor lighting, why not
corrected?
– If no training, why not?
Contribution of Safety Controls such as:
• Engineering Controls - machine guards, safety
controls, isolation of hazardous areas, monitoring
devices, etc.
• Administrative Controls - procedures, assessments,
inspection, records to monitor and ensure safe
practices and environments are maintained.
• Training Controls - initial new hire safety
orientation, job specific safety training and periodic
refresher training.
 What controls failed?

• List the specific engineering, administrative

and training controls that failed and how
these failures contributed to the accident
 What controls worked?

• List any controls that prevented a

more serious accident or minimized
collateral damage or injuries
 Determine

• What was not normal before the accident

• Where the abnormality occurred
• When it was first noted
• How it occurred
 Report Causes
• Analysis of the Accident – HOW & WHY
a. Direct causes (energy sources; hazardous
materials)
b. Indirect causes (unsafe acts and
conditions)
c. Basic causes (management policies;
personal or environmental factors)
 Unable to Identify Root Causes
• Timeliness
• Poor development of information
• Reluctance to accept responsibility
• Narrow interpretations of environmental causes
• Erroneous emphasis on a single cause
• Allowing solutions to determine causes
• Wrong person(s) investigating
 PREPARE A REPORT
• Accident Reports should contain the
following:
– Description of incident and injuries
– Sequence of events
– Pertinent facts discovered during
investigation
– Conclusions of the investigator(s)
– Recommendations for correcting
problems
PREPARE A REPORT (Continuation)
• Be objective!
– State facts
– Assign cause(s), not blame
– If referring to an individual’s actions, don’t use
names in the recommendation
• Good: All employees should…….
• Bad: George should……..
 Recommendations
• Action to remedy
– Basic causes
– Indirect causes
– Direct causes

• Recommendations - as a result of the finding is there a need

to make changes to:
– Employee training?
– Work Stations Design?
– Policies or procedures?
 Recommendations

• Consider
-Effectiveness -Cost
-Feasibility -Effect on Productivity
-Time to Implement -Employee Acceptance
-Management Acceptance
 Accepting Inadequate Reports

• There is no surer way to destroy a program's

effectiveness than to accept substandard work
• This immediately sends a signal to
subordinates that accident investigation is not
a high priority and does not receive significant
attention from management
 Common Problems

• Accidents not reported

• Unable to identify basic causes
• Accepting inadequate reports
• Neglecting to implement corrective
actions
 Accidents Not Reported
• Nothing is learned from unreported accidents
• Accident causes are left uncorrected
• Infections and injury aggravations result
• Neglecting to report tends to spread and
become a common practice
 Why Workers Fail to Report
• Fear of discipline
• Concern for reputation
• Fear of medical treatment
• Desire to keep personal record clean
• Avoidance of red tape
• Concern about attitudes of others
• Poor understanding of importance
 Combat Reporting Problems
• Indoctrinate new employees
• Encourage workers to report minor accidents
• Focus on accident prevention and loss control
• Be positive
• Discuss past accidents
• Take corrective action promptly
 Neglecting to Implement
Corrective Action
• The whole purpose of the investigation
process is negated if management fails to
remedy the causes
• Here again, management sends a signal to
subordinates that it's not important, and
subordinates develop the attitude that it's an
exercise in futility and "why bother?
 Improving the Quality of
Accident Investigation
• Insist on reporting of all injuries
• Adopt a well-designed accident report form
• Train all levels of management
• Insist on the investigation of all accidents
• Participate actively in serious accident investigations
Improving the Quality of Accident Investigation
• Review and comment
• Refuse to accept inadequate reports
• Establish controls to follow up on corrective actions
• Be responsive to recommendations
• Hold responsible persons accountable
• Emphasize that accident investigations are FACT-
finding, not FAULT-finding
• Encourage investigators to challenge the system
 Summary
• Most accident investigations follow formal
procedures
• An investigation is not concluded until completion of
a final report
• A successful accident investigation determines what
happened and how and why the accident occurred
• Investigations are an effort to prevent a similar or
perhaps more disastrous sequence of events
Other Accident Investigation Tools
 Problem-Solving
Fault Tree

• Deductive, top-down method of analyzing

• Identify all elements that could cause Accident
• Perform graphically using AND and OR gates
• Create symbolic representation of events
resulting in the Accident
• Entire system and human interactions are analyzed
 Problem Solving
Fault Tree

PIT Hits Wall

Failure To Stop

Environmental Equipment Procedural Human

Wet Floor Brakes Fail Steering Fails No Training No Inspection

No Fluid Did Not Know Intentional Omission

Break Line Leak NoTraining

Sudden Release Slow Leak

No Preshift Inspection
 Problem Solving
Fault Tree

PIT Hits Wall

Failure To Stop

Equipment Procedural Human

Did not Conduct Inspection

Brakes Fail Training Req'd

No Fluid Sup.Resp. Did Not Know Intentional Omission

Break Line Leak Supv. sick Training Not Received Time ltd.

Sudden Release Slow Leak NO TRAINING

No Preshift Inspection
 ISHIKAWA “FISHBONE”
DIAGRAM
Machinery Methods

EFFECT

Materials People Environment

 FIVE WHYs DIAGRAM
Undesired Event
Why?
Direct Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Contributing Cause
Why?
Root Cause
Thank You
Very Much!