Accident / Incident

Investigation
Prepared by:
Aldrin B. Lopez, CIE, AAE, RSO
 Why Report?
O To be able to make an analysis of the
incident
O To avoid unsafe act and unsafe condition.
O To break the chain of eents
 Accidents that Should Be
Reported
O Five consecutive first aid cases per week
O Medical treatment cases
O Lost work cases
O Fatality
O Property Damage
O Environmental Damage
O Near misses
 Rule 050 Section 1051
Definitions
O Medical Treatment Injury an injury which does
not result in a disabling injury but which requires
first aid and medical treatment of any kind.
O Disabling Injury a work injury which results in
death, PTD, PP or TTD.
O Permanent Total Disability an injury or
sickness other than death which permanently
and totally incapacitate an employee from
engaging in any gainful occupation which results
in the lost or complete loss of use of any of the
body parts.
 Rule 050 Section 1051
Definitions
O Permanent Partial Disability an injury
other than death or PTD which results in the
loss of loss with use of any member or part
of a body regardless of any pre existing
disability of the injured member or impaired
body function.
O Temporary Total Disability an injury or
illness which does not result in death or
PTD, PPD but which results in disability of
the from work for a day or more.
 Rule 050 Section 1051
Definitions
O Days of Disability any day which an
employee is unable, because of injury or
illness to perform effectively throughout a
full shift the essential functions of a
regularly established job which is open and
available to him.
O Total Days Lost Combined total of all
injuries or illness due to TTD injuries/illness
or scheduled charges to a fatality, PTD, PPD.
 Rule 050 Section 1051
Definitions
O Exposure The total number of employee
hours worked by all employees of the
reporting establishments or units including
overtime.
O Disability Injury Frequency Rate Number
of disabling injury per 1,000,000 employees
hours of exposure rounded to nearest 2
decimal places.
 Rule 050 Section 1051
Definitions
O Lost Time Incident Any occupational injury
or illness that result in an employee being
unable to return to full duty on the next day.
Fatality not recognized as Lost Time
Incident.
O Lost Time Incident Rate = number of LTI x
2000,000 / number of man hours worked.
O Total Recordable Incident Rate = number of
recordable incident x 200,000 / number of
man hours worked.
 TYPES OF ACCIDENT
Personal Injury or Illness and Deviation
Factors regarding the physical aspects
Property Damage
Combination of personal injury and property
damage
Near miss incident
 Accident Categories
O Serious Accidents
O Non Serious Accidents
Roles and Responsibilities
O Department
O Ensure accidents involving their operations or
workers are investigated.
O Ensure corrective actions are taken.
O Supervisors
O Participate in incident investigation
O Take corrective actions
O EHS
O Investigate incidents promptly and thoroughly
O Issue accident investigation report.
O Provide training in investigation methods and
techniques when requested.
 What is an Incident?
O Incident is an undesired event that has or
could result in harm to people, environment,
damage to property or assets or a breach of
security.
O Near miss It is an incident with negligible
actual consequences, but with potential for
harm / illness or damage / loss, pollution or
combination of all.
O Accident It is an incident which results in
actual injury / illness and / loss or damage/ to
environment to material / production.
 Overview
O Purpose of Investigation
O Managing the Accident Scene
O Steps in Conducting Investigation
 Purpose
O Investigation are conducted to:
O Prevent reoccurrence
O Comply with polices and regulatory
requirements
O Maintain employee awareness
 Accidents are result of

O Unsafe Act Behaviors which could permit

the occurrence of an accident or incident.

O Unsafe Conditions Circumstances which

could permit the occurrence of an accident
or incident.
 Prevention is the reason for
conducting an Accident Investigation
Unless the unsafe acts/conditions
O Identified
O Eliminated or controlled
 All accidents must be
investigated:
O LTI
O Non LTI
O Near Miss
O Chemical Spill
O Property Damage
O Fire and Eplosion
 Advantages of Supervisors
Over Other Investigators
O More familiar with the people involved
O Better understanding of the operations
O Personal interest in investigations
Managing the Accident Scene
O Two Priorities
O Care & Treatment of the injured
O Elimination or control of remaining hazards
 Care & Treatment of the
injured
O Supervisors can increase their ability to
respond to Medical Emergencies by:
O Training in First Aid
O Drills under normal and abnormal condition
O Liaison with hospitals
 Controlling Remaining
Hazards
If a hazardous environment or toxic materials
exist:
Notify necessary personnel
Provide PPE to potentially exposed
Refer to SDS
 Controlling Remaining
Hazards
Isolate the Site
To protect people from further injury
To preserve evidence and valuable clues
Successful Investigation is done .
Immediately
Completely
Thoroughly
Investigate immediately, because
Operations are disrupted
Memories Fade
Employee are at risk
 Investigation Strategy
O Gather Information
O Search for & Establish facts
O Isolate essential contributing factors
O Find root Causes
O Determine corrective actions
O Implement corrective actions
 Secure the Scene
O Eliminate the hazards
O Control Chemicals
O De energize
O De pressurize
Accident Reports Remedial
Action
General report form contents.
O Location
O Time of occurrence
O Identification of primary people involved
O Description of Accident
O Type of accident/ incident
O Analysis of Causes
O Evaluation of potentially severity and frequency
O Remedial action plan for prevention
O Follow up action plan
 Reports should be
O Clear

O Detailed

O Neat

O Legible
Investigative Procedures
1. Define the scope of the investigation.
2. Select the investigators. Assign specific tasks
to each (preferably in writing).
3. Present a preliminary briefing to the
investigating team, including:
a. Description of the accident, with
damage estimates.
b. Normal operating procedures.
c. Maps (local and general). d. Location of
the accident sit
Investigative Procedures
e. List of witnesses.
f. Events that preceded the accident.
4. Visit the accident site to get updated information.
5. Inspect the accident site.
a. Secure the area. Do not disturb the scene
unless a hazard exists.
b. Prepare the necessary sketches and
photographs. Label each carefully and keep
accurate records.
6. Interview each victim and witness. Also interview those
who were present before the accident and those who
arrived at the site shortly after the accident. Keep accurate
records of each interview. Use a tape recorder if desired and
if approved.
Investigative Procedures
7. Determine
a. What was not normal before the
accident.
b. Where the abnormality occurred.
c. When it was first noted.
d. How it occurred
Investigative Procedures
8. Analyze the data obtained in step 7. Repeat any
of the prior steps, if necessary.
9. Determine
a. Why the accident occurred.
b. A likely sequence of events and probable
causes (direct, indirect, basic).
c. Alternative sequences.
10. Check each sequence against the data from
step 7.
11. Determine the most likely sequence of events
and the most probable causes.
Investigative Procedures
12. Conduct a post-investigation briefing.
13. Prepare a summary report, including the
recommended actions to prevent a
recurrence. Distribute the report according to
applicable instructions.
 Fact Finding
o Gather evidence from many sources during an
investigation.
o Get information from witnesses and reports as
well as by observation.
o Interview witnesses as soon as possible after an
accident.
o Inspect the accident site before any changes
occur.
o Make photographs and sketches of the
accident scene. Record all pertinent data on maps.
 Fact Finding
o Get copies of all reports. Documents containing
normal operating procedures, flow diagrams,
maintenance charts, or reports of difficulties or
abnormalities are particularly useful.
o Keep complete and accurate notes in a bound
notebook.
o Record pre-accident conditions, the accident
sequence, and post-accident conditions. In
addition, document the location of victims,
witnesses, machinery, energy sources, and
hazardous materials.
 Fact Finding
o Include laws in the notes taken during the
investigation or in the later analysis of data.
o In addition, gather data during the
investigation that may lend itself to analysis
by these laws, principles, or properties.
o An appendix in the final report can include
an extended discussion.
 Interviews
1. Appoint a speaker for the group.
2. Get preliminary statements as soon as
possible from all witnesses.
3. Locate the position of each witness on a
master chart (including the direction of view).
4. Arrange for a convenient time and place to talk
to each witness.
5. Explain the purpose of the investigation
(accident prevention) and put each witness at
ease.
 Interviews
6. Listen, let each witness speak freely, and be
courteous and considerate.
7. Take notes without distracting the witness. Use a
tape recorder only with consent of the
witness.
8. Use sketches and diagrams to help the witness.
9. Emphasize areas of direct observation. Label
hearsay accordingly.
10. Be sincere and do not argue with the witness.
 Interviews
11. Record the exact words used by the witness to
describe each observation. Do not "put
words into a witness' mouth."
12. Word each question carefully and be sure the
witness understands.
13. Identify the qualifications of each witness
(name, address, occupation, years of experience,
etc.).
14. Supply each witness with a copy of his or her
statements. Signed statements are desirable
 Type of Witnesses
O Extroverts will appear very convincing
witnesses. But Their evidence may be as
correct as it appears.
O Introverts will appear as poor witness.
Interviewing them may seem as waste of
time, but they might have the most
important information.
O Suspicious Will be reluctant to get involve.
They hate publicity, guard their privacy and
resent being questioned.
 Type of Witnesses
O Illiterate may appear timid and hesitant to
cover their illiteracy.
O Prejudiced are psychologically ill suited to
give testimony.
O Intoxicated should be listened to, but re
interviewed in full when sober.
O Juvenile Can give very objective evidence.
O Excitable
 Type of Witnesses
Know nothing Are the ones identified as
prime witnesses who insist they do not know
and did not see anything.
Devious may distort their testimonies to
avoid personal implication or unfavorable
reflection on an associate.
Injured Should generally not be questioned
until after they have received medical
treatment.
 PROBLEM SOLVING
TECHNIQUES
The Scientific Method
The scientific method forms the basis
of nearly all problem solving techniques. It is
used for conducting research. In its simplest
form, it involves the following sequence:
making observations, developing hypotheses,
and testing the hypotheses.
 PROBLEM SOLVING
TECHNIQUES
As with scientific research, the most difficult
part of any investigation is the formulation of
worthwhile hypotheses. Use the following
three principles to simplify this step:
1. The principle of agreement.
An investigator uses this principle to
find one factor that associates with each
observation
 PROBLEM SOLVING
TECHNIQUES
The principle of differences.
This principle is based on the idea that
variations in observations are due only to
differences in
one or more factors.
The principle of concomitant variation.
This principle is the most important
because it combines the ideas of both of the
preceding principles. In using this principle, the
investigator is interested in the factors that are
common as well as those that are different in the
observations.
 PROBLEM SOLVING
TECHNIQUES
O Change Analysis - this technique
emphasizes change.
O Gantt charts are sequence diagrams. Use
them for scheduling investigative
procedures. They can also aid in the
development of the most probable
sequence of events that led to the accident.
Such a chart is especially useful in depicting
events that occurred simultaneously.
 PROBLEM SOLVING
TECHNIQUES
O Job Safety Analysis
Job safety analysis (JSA) is part of many
existing accident prevention programs. In
general, JSA breaks a job into basic steps, and
identifies the hazards associated with each
step. The JSA also prescribes controls for each
hazard. A JSA is a chart listing these steps,
hazards, and controls.
 PROBLEM SOLVING
TECHNIQUES
O Failure Mode and Effect Analysis
Failure mode and effect analysis
(FMEA) determines where failures occurred.
Consider all items used in the task involved in
the accident. These items include people,
equipment, machine parts,materials,
 PROBLEM SOLVING
TECHNIQUES
O Fault Tree Analysis
Fault tree analysis (FTA) is a logic
diagram. It shows all the potential causes of
an accident or other undesired event.
 Report of Investigation
1. Background Information

a. Where and when the accident occurred

b. Who and what were involved
c. Operating personnel and other witnesses
 Report of Investigation
2. Account of the Accident (What happened?)
a. Sequence of events
b. Extent of damage
c. Accident type
d. Agency or source (of energy or hazardous
material)
 Report of Investigation
Discussion (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)
 Report of Investigation
Recommendations (to prevent a recurrence)
for immediate and long-range action to
remedy:
a. Basic causes
b. Indirect causes
c. Direct causes (such as reduced quantities
or protective equipment or structures)
End of Presentation