Accident Reporting, Investigation and Analysis

Those who cannot remember the past are condemned to repeat it

Consultnet Ltd

Accident Reporting, Investigation and Analysis

Presentation Contents
Introduction
Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

Types of incident(as %) reported to HSA(>3days lost) 2002

Injured while handling, lifting or carrying Slips, trips or falls on same level Injured by hand tools

Injured by falling objects

0.4 0.4 2.1 2.4 3 3.9 2 1.5

0.3 0.1 10.9 32.2

Fall from height Contact with moving machinery parts Injured by a person malicious Transport (excluding road traffic accidents)

4.6 5.3 5.3 6.3 19.4

Exposure/contact with harmful substance Road traffic accidents Injured by a person non-malicious Struck by something collapsing/overturning Contact with electricity Injured by an animal Fire or explosion Drowning or asphyxiation Miscellaneous or not otherwise classified

Introduction

Why report and investigate accidents?

PREVENT A RECURRENCE OF THE SAME ACCIDENT

It is worth doing it well!

Learn from what went wrong Determine the causes Prevent recurrence Improve the work environment Meet regulatory requirements Cost of incidents Moral Obligation Define trends Provision of information in case of litigation Reduction of operating costs by control of accidental losses Expression of concern by management

Introduction

Incident Definitions
ACCIDENT - an undesired event that results in personal injury or property damage. INCIDENT - an unplanned, undesired event that adversely affects completion of a task. NEAR MISS - incidents where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and/or injury easily could have occurred. Lost Time Accident an accident resulting in time off work Dangerous Occurrence - escape of flammable substance, explosion,
fire, collapse of load bearing apparatus, pipeline ruptures, pressure vessel ruptures, transport incidents, bursting of reveolving wheel, O/H electric line contact, building collapse(1993 Safety Health & Welfare at Work( General Application
)Regulations )

Reportable Incident

injured cannot return to work within 3 days of incident(1993 Safety Health & Welfare at Work( General Application )Regulations Form to be submitted to HSA( downloadable at www.hsa.ie )

Introduction

Incident Classification for Reporting

Near Miss Incident: a near miss incident where there is no loss be it injury or property damage however it could have resulted in personal harm/damage under slightly different circumstances, such incidents are reported to the Supervisor and formally logged on a Near Miss Report. Level 1 - Minor Incident: a level one incident can typically be dealt with by the person identifying the problem. The supervisor should be informed and the incident formally logged on an Incident Report; this will permit assessment of the incident particularly with regard to the possibility of reoccurrence and the potential for a more serious event. Examples: minor localised fire, minor first aid injury(less than one day off work) Level 2 - Serious Incident: immediate action should be taken where possible by the person identifying the incident. The supervisor should be immediately informed and should assess the situation. Thereafter, the supervisor will contact the necessary emergency services and officials as per the emergency plan. Examples: injury (person is likely to be out of work for more than one day but less than three days), containable fire, containable environmental damage. Level 3 - Severe Incident: immediate action should be taken where possible by the person identifying the incident. The supervisor should be immediately informed and should assess the situation. The supervisor will contact the necessary emergency services and necessary personnel as per the site emergency plan. Examples:persons trapped, serious fire, threat to the safety of personnel, serious environmental damage, serious injury( person likely to be out of work > 3days), fatality.

Level of Incident and Investigation involved

RISK Level 1 Low
First Aid Medical Aid (<1 day off work)

Level 2 Moderate
Medical Aid (1<days off<3)

Level 3 High
Fatality Lost Time Accident (>3 days) Serious Incident Reportable to HSA Disabling injury
Over E200,000

Injury Severity

Damage Severity Production Loss Customer Impact

Up to E30,000

Up to E100,000

Less than 3 hours

3 hours to one day

1 day or more

Product requires work to meet customer standards

Product will not meet customer standards

Loss of Customer Major customer dissatisfaction

Personnel involved in investigation

Investigation Report Responsibility Responsibility for Remedial Actions

* Front line supervisor * Worker(s) /Witnesses involved * Area Safety Representative

* Front line Supervisor * Worker(s) /Witnesses involved * Area Safety Representative * Safety Manager
Supervisor - Immediately after personnel and area are safe Head of Department

* Front line supervisor * Worker(s)/Witnesses involved * Area Safety Representative * Head of Department * Safety Manager
Supervisor -Immediately after personnel and area are safe Head of Department

Supervisor - Within the same shift

Head of Department

Accident or Incident Occurs

Initial response

Supervisor actions as per emergency plan

Safety Manager
Contact insurance Contact hsa if required

Medical Aid Prevent secondary accidents Notify emergency services

Is the Incident Level 1?

First Aid Medical Aid (<1 day off work) Damage < E30,000 Production Loss < 3 hours Product requires work to meet customer standards

Is the Incident Level 2? No

Medical Aid(1<days off<3) E30,000<Damage<E200,000 1 day >Production Loss > 3 hours Product will not meet customer standards

Is the Incident Level 3? No

Fatality Serious Injury - Lost Time(>3 days) Serious Incident Reportable to HSA Damage>E200,000 Production Loss < 1 day Loss of Customer or major customer dissatisfaction

Yes

Yes

Yes

Accident Team Investigates

Front line supervisor Worker(s)/Witnesses involved Area Safety Representative

Accident Team Investigates

Front line supervisor Worker(s) /Witnesses involved Area Safety Representative Safety Manager

Accident Team Investigates

Front line supervisor Worker(s) /Witnesses involved Area Safety Representative Safety Manager Head of Department

Incident Report
Supervisor Responsible for completion and forward to Safety Manager within 24 Hours

Management Actions
Head of Department
track remedial actions

Managing Director

Management Actions

Interview witnesses Photographs Sketches, survey, site maps Relative positions Examine equipment & machinery Failed parts Examine Materials Examine records

Collect Evidence

Response and loss limiting actions Immediate causes (Substandard acts and conditions) Basic causes (personal & job factors) Program management (standards and compliance)

Analyse

review at next management meeting

No Collect more evidence and re-analyse

Head of Department
track remedial actions

Does analyses show what happened, what should have happened and why? Yes Analyse causes

Safety Manager

Safety Manager
add to incident database Include in incident analysis

Issue incident information add to incident database Review at next safety committee meeting Include in incident analysis

Report findings and actions

Incident Investigation Flowchart

Develop Remedial Actions inc. timescales and responsibilities

Accident Reporting, Investigation and Analysis

Introduction

Incident Response
Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

Introduction

Reporting Incidents
Employee must report to Supervisor

Supervisor responsible for initiating reporting procedure

Supervisor responsible for complete of incident report for near-miss, Level 1 and Level 2 incidents involves Safety Manager and Area Safety Representative

Supervisor in conjunction with relevant Head of Department responsible for completion of Level 3 incident reports and also involves Safety Manager and Area Safety Representative

Head of Department responsible for completion of corrective actions

Reports to Senior Manager and Safety Manager

Initial Response

Typical Procedure
All incidents must be reported immediately by the employee concerned to their Supervisor:
If a Near Miss incident the Supervisor shall ensure a Near Miss Report is completed immediately. If a Level 1 incident the Supervisor in conjunction with the area Safety Representative completes the Incident Report Form and forwards to Safety Manager within 24 hours. If a Level 2 incident immediately after attending to any victim and minimisation of property damage the Supervisor ensures the accident scene is secured, prevents access by unauthorised persons and calls the Safety Manager and the area Safety Representative who will assist the Supervisor in completing the Incident Report Form, taking witness statements and completion of the investigation. If a Level 3 incident the Supervisor immediately after attending to any victim and minimisation of property damage ensures the accident scene is secured, prevents access by unauthorised persons and calls the Safety Manager, the area Safety Representative and the relevant Head of Department, who will assist the Supervisor in completing the Incident Report Form, taking witness statements and completion of the investigation.

Initial Response

The Supervisor
Takes control of the scene Calls first aid and emergency services Controls secondary incidents Identifies sources of evidence Preserves evidence from alteration or removal Determines the loss potential Notifies appropriate management
Discuss you companys emergency response procedures in the event of fire, injury, chemical spill

Accident Reporting, Investigation and Analysis

Introduction Incident Response

Incident Investigation
Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

Incident Investigation and Analysis Tips for investigation and analysis

Encourage a no-blame reporting culture Focus must be to improve working conditions and methods Approach with an open and objective mind All facts learnt corrective action taken Fact finding not fault finding An opportunity for employees and management to work together to correct an unacceptable situation An incident will happen again if underlying causes are not corrected Delve deep to establish underlying causes do not accept all answers given at face value Be prepared to look beyong the injured person, his co-workers, supervisor, manager Consider communication skills and language barriers Get as much factual information as possible to get the complete picture

Incident Investigation

Effective Incident Investigation

Establish the facts: Who? What? When? Where? The size? Analyse the facts isolating contributary factors:
Who or what was involved What hazards were present? What controls failed?

Identify actions to prevent a recurrence Implement the corrective actions

Incident Investigation

Who should lead investigation? The Supervisor( ), why?

of those involved

They have a personal interest They know the people and conditions They know how best and where to get the information needed They will initiate or take any remedial action They benefit from investigating

Where there is major loss or loss potential or where multiple supervisors are involved it is beneficial that the investigation also involves the Head of Department for the area. In all cases it is recommended that the Supervisor involves the safety professional on his/her site to assist in the investigation

Incident Investigation

Collecting evidence and information

Record: Pre-accident conditions, Accident sequence, Post-accident conditions
Position evidence people(witnesses), equipment, materials & environment, use sketches maps, photos, video (Consider plant line up, valve alignment, tools labels, signs) People evidence statements from all involved and witnesses, interview separately Parts evidence machinery, tools and other equipment that could have contributed to the incident Paper evidence all relevant records such as training records, equipment records( maintenance, servicing), MSDS, procedures, codes of practice, pre-start checklists, permits, area rules, standards
Consider reconstructing incident from above information

Initial Response
Typical Procedure
In the event of a Level 2 or Level 3 incident, immediately following the incident the Supervisor shall ensure the following:

Photographs of the scene are taken If there is a possibility that the accident could become a fatality the scene must remain undisturbed until viewed by HSA Inspector and Gardai where required. Arrange for survey plans of the site to be prepared. These are to include the following :
Locality Plan & details of accident site; Detailed plan of view showing details after the accident and include such things as: Equipment used in rescue operations; Position of materials, ladders, equipment, etc. involved in the accident; Position from where photographs were taken; Position of persons involved in the accident; and other relevant information. A sectional view (if necessary). Any sections made are to be marked on the detailed plan.

Take evidence from witnesses at the scene and make note of any piece of evidence. Check relevant equipment, maintenance and training records Analyse condition of equipment materials with specalist input where necessary Prepare a report detailing the circumstances of the accident within 24 hours and submit to the Safety Manager. The report will include the Incident Report Form and witness incident analysis forms which provides for systematically identifying immediate causes, basic causes and lack of control.

Incident Investigation

Accident Photography
Photograph the scene from all sides
Use long, medium, close-up sequence Accompany with good notes and sketches

Identify by number, time, date & name of photographer

Incident Investigation

Interviewing Witnesses
Calm, objective, impartial, open mind, search for facts not opinions Do not interrogate/cross examine As soon as possible( theorising increases as memory decreases) Interview separately and privately, use a tape recorder only with witness permission If significant conflict follow up interviews may be necessary Assure them the information is being used for accident prevention not to apportion blame Get the individuals version Use open questions (cannot be answered with a simple yes or no) Do not express an opinion or argue Record critical information quickly If not at the site of the accident use visual aids, sketches etc. End on a positive note and keep the line open Review completed statement with witness and have it signed
Helpful Interview Questions

What were you doing? Where were you working? How were you injured? How do you think the accident occurred? What is the safety procedure for the job? How were you trained for the job? Have you fully described the circumstances of the accident as you know them?
Take a look at the Witness Incident Analysis form recommended for Level 2/3 incidents

Incident Investigation

Parts Examination
Parts machinery, tools and other equipment that could have contributed to the incident

Proper item for task Damage - type, extent, pattern Previous damage defects, misuse Wear Safeguards machine guards, emergency cut-offs Labels, signs, markings

Accident Reporting, Investigation and Analysis

Introduction Incident Response Incident Investigation

Incident Analysis
Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

Incident analysis Whats involved?

Determine what happened immediate cause unsafe practices/conditions ( ask the question would the
accidnet have happened if this particular factor was not present?)

Determine why it happened basic causes personal/job factors Cover deficiencies in the management system
WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT?

Determine appropriate remedial action based on the immediate and basic causes Apportion responsibility to implement corrective actions Report findings to senior management Follow-up and monitor corrective actions

Incident Analysis

THE DOMINO SEQUENCE

How Accidents Happen
The domino described below is a model that will help you see how accidents happen.
Lack of Control Basic Cause Immediate Cause Accident Loss

Organizational Failure to: - Plan Direct Organize Control

Lack Of: Training Resources Belief

Undesired, Unsafe Act Unsafe Condition Unplanned Event Which Disrupts Work Activity

Death Injury Property damage Lost Time Lost Productivity

Incident Analysis

Lack of Control
Organisational failure means that the organisation, at one or more levels, did not effectively/properly plan, direct, organize, control or combination thereof, its resources
Resources are: Time, Tools, Equipment, Materials, Manpower

Failure to PLAN means: All aspects of the job, task or operation were not planned effectively so that an unexpected accident was not eliminated. Failure to DIRECT means: Personnel involved in the job, task or operation were not instructed and trained as to the potential hazards involved and means to eliminate or control those hazards. Failure to ORGANIZE means: All resources that were needed to do the job safely were not present, proper, and/or in safe operating condition.

Failure to CONTROL means: Failure to ensure that the job or task was actually conducted as planned, organized and directed.

Incident Analysis

Personal and job factors - lead a person to commit an unsafe condition or act

Basic Cause of Resources Job factor - Lack of Training/ Lack

No training at all Training that was incomplete or inadequate or not understood Training that was not repeated frequently enough Resources (time, tools, equipment, materials, manpower) necessary to do the job safely are not provided Resources not proper (skills, size, abilities, type) Resources not in safe operating condition Inadequate supervision Inadequate work standards, procedures, work practices, maintenance

Personal factor - Lack of Belief

There is a belief that a negative consequence will not result because of their action. Lack of belief is almost always caused by past experience. Factors that can contribute to it are: Poor morale/low motivation/stress Peer pressure Productivity pressures Inadequate resources Inadequate capability

Incident Analysis

Immediate Cause
Immediate causes are the unsafe acts and/or conditions that lead directly to the accident. Unsafe acts account for 85% of accidents; unsafe conditions account for 14% of accidents. However, 85% of the unsafe conditions were caused by an unsafe act. Therefore, we can say that 97% of all accidents are caused directly or indirectly by an unsafe act.

Incident Analysis

Accident
An accident is: An unplanned, undesirable event which disrupts work activity An accident always results in a loss.

Incident Analysis

Loss
The loss is the result of an accident. (Disruption of work activity). Approximately 30 different losses have been identified as potential results of accidents, for example: Death Injury Lost Time Damaged Morale Damaged Tools Damaged Equipment Lost Materials Lost Productivity Civil Penalties Replacement Costs Economic Loss Loss of Client Goodwill Lost Competitiveness

Human Element of Accident Causation

Organisational Process Local Working Conditions Active Failures Defences

Latent Failures

Latent Failures

Latent Failures

Active Failures

Active & Latent

Fallible Decisions
Training & Skills Work Atmosphere

Line Management Deficiencies

Planning Supervision

Psychological Precursors of Unsafe Acts

Communication Job Factor Team Work

Unsafe Acts
Communication Person Factor

Inadequate Defences
Tools & Equipment

Senior Management

Line Management

Frontline Supervisor

Operators Maintenance Crews

Safety Equipment

Casual Sequence

Human Elements of Accident Causation (Reason 1990)

Incident analysis Loss Causation Model

Lack of Control
Inadequate Systems Standards

Basic Causes

Immediate Causes
Substandard Acts/practices Substandard Conditions

Incident

Loss

Unintended

Personal Factors Job/system factors

Event Contact with energy or surface

harm or damage People Property Processes

Compliance

Problem Solving Model

In an incident analysis situation use this model and write down the loss, incident event, immediate, basic causes and relevant lack of controls under each heading in list form as per the Incident Report Form This makes it possible to identify the causes and relevant corrective actions to prevent a reoccurrence.

Incident Form: Immediate Causes

Immediate Causes (What sub standard actions & Conditions caused the event):
Tick all applicable below and explain here:

SUBSTANDARD ACTIONS Operating equipment without authority Failure to warn Failure to secure Operating at improper speed Making safety devices inoperable Removing safety devices Using defective equipment Using equipment improperly Failure to use PPE properly Improper loading Improper placement Improper lifting Improper position for task Servicing equipment in operation Horseplay Under influence of alcohol or drugs Working in dangerous situation Non-adherence to rules/standards

SUBSTANDARD CONDITIONS Inadequate guards or barriers Inadequate or improper protective equipment Defective tools equipment or materials Congested or restricted action Inadequate warning system Fire and explosion hazard Poor housekeeping disorder Hazardous environmental conditions(gas, dust etc.) Noise exposures Radiation exposure High or low temperature exposures Inadequate or excess illumination Inadequate ventilation Defective PPE

Incident Form: Basic Causes

Basic Causes (What personal factors & job factors caused the event):
Tick all applicable below and explain here:

Personal factors

Inadequate capability Lack of knowledge Lack of skill Stress Improper motivation

Job Factors

Inadequate Leadership Inadequate engineering Inadequate purchasing Inadequate maintenance Inadequate tools & equipment Inadequate work standards Wear & Tear Abuse or misuse

Accident Reporting, Investigation and Analysis

Introduction Incident Response Incident Investigation Incident Analysis Incident Report Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

Remedial Actions

Incident analysis Remedial Actions

Temporary Actions correct substandard actions and conditions Permanent Actions remedy personal factors and job factors Remedial Actions must be:
Communicated clearly Responsible person identified and timescale established for their completion Follow-up conducted by Investigation Team Department Manager responsible to ensure completion

Accident Reporting, Investigation and Analysis

Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Near Miss Reporting Cost of incidents Incident Statistics Summary of Responsibilities

Incident Report

Incident Report Typical Contents

Title, date and time Location of the accident Type of injury or damage/who and what was involved Cost of losses Description of what happened including emergency response sequence How the accident occurred/extent of damage Immediate(direct(energy sources, haz. materials etc.) & indirect causes(unsafe acts and conditions) & basic causes (personal/environmental factors) Lack of control(management policies) Remedial actions temporary & permanent Management review Other

Note: Timeliness of report is critical, best reports are written promptly Accident reports are usually discoverable this means they can be used by parties to an action for damages or criminal charges

Incident Report

Where to?
Incident reports forwarded to the Safety Manager are processed as follows : All incident reports are analysed and the summary information is presented at the next monthly management meeting and safety committee meeting All Level 2 and Level 3 incidents are reviewed at the next weekly management meeting. Any lessons learned are communicated to management and employees from information distributed to all Supervisors(for inclusion in tool box talk ) and on Company Notice Boards Incident reports are copied to the relevant Head of Department and General Manager in the case of Level 2 and Level 3 incidents

Accident Reporting, Investigation and Analysis

Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report

Near Miss Reporting

Cost of incidents Incident Statistics Summary of Responsibilities

Near Miss Reporting

Reporting of Near Miss Incidents is critical

1 Accident Ratio Study
Serious or Major Injury

10
Minor Injuries

30
Property Damage

600
Incidents with no visible injury or damage
Near miss

Near misses provide a much larger base for more effective control of accidental loss Eliminate the causes of near misses, reduce the potential for more serious accidents, this is the basis of any proactive safety management system High potential incidents should be analysed thoroughly

Accident Reporting, Investigation and Analysis

Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting

Cost of incidents
Incident Statistics Summary of Responsibilities

Analysis of costs Consider the following:

Cost of dealing with incident( such as first aid, emergency supplies, staff downtime) Costs of incident investigation( such as staff time, consultants time) Cost of getting back to business( such as rescheduling, clean-up, hire of equipment) Business Costs( such as cost of injured persons salary, replacement salary, lost orders) UK HSE useful incident cost calculator template next slide

Consultnet Ltd

Accident Reporting, Investigation and Analysis

Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents

Incident Statistics
Summary of Responsibilities

Accident Statistics Analysis

Accident data base should be established Identify trends and focus systems where they can produce the greatest return on invested time and energy Accident analysis statistics should be:
produced regularly by the Safety Department reviewed at regular management and safety committee meetings summary available to all employees Identify repetitive or signifcant items

Accident Statistics Analysis

Statistics may include:
Number of near-miss, property damage, first aid, medical aid, lost time incidents, fire, environmental events Lost time injury frequency rates and severity rates
Lost Time Incident Frequency Rate(LTIFR)=(Total Lost Time Incidents/Total Hours Worked) x 100,000 Lost Time Incident Severity Rate(LTIFR)=(Total hours lost/Total Hours Worked) x 100,000

Costs Cause and control analysis

Type of accidents by department, work section, occupation Equipment/substances involved Activity at time of injury Age of person/length of service Time of day Immediate causes(substandard acts and conditions) Basic causes( Personal and job factors) Lack of control(inadequate programme standards or compliance with standards) Remedial action completion by department Problem solving project teams to address critical problems identified

Accident Reporting, Investigation and Analysis

Introduction Incident Response Incident Investigation Incident Analysis Remedial Actions Incident Report Near Miss Reporting Cost of incidents Incident Statistics

Summary of Responsibilities

Incidents

Summary of Responsibilities
All Employees must report all incidents to their Supervisor All Supervisors responsible for initiaiting accident investigations All Heads of Department are responsible for taking appropriate action on the conclusions and results of any incident investigation within their Department. All Heads of Departments are responsible to ensure that the supervisors in their department are fully aware of, understand and initiate the Incident Reporting and Investigation Policy and attend relevant training. The Safety Manager will be responsible for providing technical support to the Supervisor in the course of the incident investigation, issuing incident information for communication to all employees, producing the incident statistics and presentation to monthly management and safety committee meeting The Safety Manager will ensure that management, employees and their representatives are adequately consulted and informed on the incident investigation policy and provision of training as regards implementation of the policy In the event that a Level 2 or Level 3 incident meets the requirement of reporting to the Health & Safety Authority, the Safety Manager contacts the relevant Inspector, submits the completed statutory report form and coordinates any subsequent investigation with the Inspector. The Safety Manager is responsible for reporting Level 2 & 3 incidents to the Company Loss Adjuster and Company Insurance Co-ordinator and coordinating any subsequent follow-up investigation.

Accident or Incident Occurs

Initial response

Supervisor actions as per emergency plan

Safety Manager
Contact insurance Contact hsa if required

Medical Aid Prevent secondary accidents Notify emergency services

Is the Incident Level 1?

First Aid Medical Aid (<1 day off work) Damage < E30,000 Production Loss < 3 hours Product requires work to meet customer standards

Is the Incident Level 2? No

Medical Aid(1<days off<3) E30,000<Damage<E200,000 1 day >Production Loss > 3 hours Product will not meet customer standards

Is the Incident Level 3? No

Fatality Serious Injury - Lost Time(>3 days) Serious Incident Reportable to HSA Damage>E200,000 Production Loss < 1 day Loss of Customer or major customer dissatisfaction

Yes

Yes

Yes

Accident Team Investigates

Front line supervisor Worker(s)/Witnesses involved Area Safety Representative

Accident Team Investigates

Front line supervisor Worker(s) /Witnesses involved Area Safety Representative Safety Manager

Accident Team Investigates

Front line supervisor Worker(s) /Witnesses involved Area Safety Representative Safety Manager Head of Department

Incident Report
Supervisor Responsible for completion and forward to Safety Manager within 24 Hours

Management Actions
Head of Department
track remedial actions

Managing Director

Management Actions

Interview witnesses Photographs Sketches, survey, site maps Relative positions Examine equipment & machinery Failed parts Examine Materials Examine records

Collect Evidence

Response and loss limiting actions Immediate causes (Substandard acts and conditions) Basic causes (personal & job factors) Program management (standards and compliance)

Analyse

review at next management meeting

No Collect more evidence and re-analyse

Head of Department
track remedial actions

Does analyses show what happened, what should have happened and why? Yes Analyse causes

Safety Manager

Safety Manager
add to incident database Include in incident analysis

Issue incident information add to incident database Review at next safety committee meeting Include in incident analysis

Report findings and actions

Incident Investigation Flowchart

Develop Remedial Actions inc. timescales and responsibilities

Accident Investigation Case Study

Form teams for the investigating and reporting Analyse the facts Identify the immediate and basic causes Recommend remedial actions Complete Incident Report Present findings
Remember Rudyard Kipling's I keep six honest serving men, They taught me all I knew, Their names are What and Why and How and Where and When and Who

Accident Reporting, Investigation and Analysis

Conclusion
WHEN AN ORGANIZATION REACTS SWIFTLY AND POSTIVELY TO ACCIDENTS AND INJURIES, ITS ACTIONS REAFFIRM ITS COMMITMENT TO THE SAFETY AND WELLBEING OF ITS EMPLOYEES

Accident Reporting & Investigation

Further information(click to follow link):

Irish HSA Accident Notification information and accident statistics UK IChemE comprehensive information source on major incidents UK HSE Report on Accident Investigation UK guidance on use of digital images as evidence EU research on work related accidents US site on injury research and control The Investigation Process Research Library US based OSHA accident investigation information, safety pays software and fatal facts information CHEMSAFETY.gov is the US Chemical Safety and Hazard Investigation Board's site, it investigates major chemical accidents US based OSHA Studies of Occupational Fatalities. Links to OSHA reports of fatality/catastrophe investigations United States Chemical Safety & Hazard Investigation Board Australian guidance on learning from accidents Canadian based information on reporting and investigating accidents New Zealand information on Aftermath - The Social and Economic Consequences of Workplace Injury and Illness
Investigation Process Research Library