Accident Investigation

Accident Investigation
Copyright Progressive Business Publications

Accidents and Near Misses
 An accident is:
– Any unplanned event that results in personal
injury or in property damage
– The result of the failure of people, equipment or
the surrounding environment to react as expected
– The result of a process of causes that culminates
in a final event that cause injury or illness
 A near miss is:
– An incident that could have resulted in
an accident
Consequences of Accidents
 Direct Consequences
– Personal injury
– Property loss
 Indirect Consequences
– Lost income
– Medical expenses
– Lowered morale
– Training replacements
– Lost productivity
Purpose of Accident Investigation
 Determine the sequence of events leading

to the accident
 Determine the how and why the accident
occurred by identifying causes
 Prevent similar accidents in the future by:
– Recommending corrective actions
– Eliminating clearly identified hazards
NOTE: The point of accident investigation is

NOT to place blame
Prior to Investigation
 Know the policy for accident investigation

– What are the sequence of procedures?
– Who should be informed?
– What triggers an investigation?
– What are the reporting requirements?
 Know responsibilities of investigators
 Know required paperwork

– Accident reports, witness statements, etc.
– Who receives what?
Conducting the Investigation
 Keep all notes and records in bound notebook

or 3-ring binder
 Record and make documented observation on
– Pre-accident conditions
– Accident sequence
– Post-accident conditions
 Document victim locations, witnesses,
machinery, energy sources and other
contributing factors
Accident Scene
 Control the scene

– Get medical attention for the injured
– Inspect scene for other hazards and eliminate them
– Keep everyone away from scene
– Prevent removal of evidence or change
of conditions
 Document scene before changes are made
– Take photos
– Draw scaled sketches
– Record measurements
Interview Witnesses
 Get preliminary statements as soon as possible

 Put witnesses at ease
– Explain purpose of investigation and be courteous
and polite
 Word questions carefully and be sure
witnesses understand what’s being asked
 Take notes
– Record exact words
– Only use a tape recorder with witness’ permission
 Supply each witness with a copy of his
or her statements
Questions for Witnesses
 What did you see?

 What did you hear?
 Where were you standing/sitting?
– Use sketches and diagrams to help witness
 Was there anything different today?
 What do you think caused the accident?
 Basic information: qualification of each
witness (name, address, occupation, years
experience, etc.)
Questions for Supervisors
 What is the normal procedure for activities

involved in the accident?
 What was different?
 What type of training did persons involved in

the accident have?
 What do you think caused the accident?
 What do you think could have prevented

the accident?
Watch for the Pitfalls
 Bias
 Perspective
 Embellishment
 Trauma
 Fact v. opinion

Background Records
 Maintenance records
 Inspection records
 Copies of policies
and procedures
 Accident reports
for similar incidents
 Training records
 Production schedules
 Process diagrams
Analyze the Data
 Gather all photos, drawings, interview

material and other information
 Determine a clear picture of what happened
– Determine the specified work procedure
– Include work and environmental conditions at
the time of the accident
– Formally document the sequence of events
– Immediate actions taken at the scene
– Injuries to personnel and damage to property
Change Analysis
 Define the problem – what happened?

 Establish the norm – what should have
happened?
 Identify, locate and describe the change
– What was and was not affected?
– Where, when and to what extent?
– What were the distinctive features of the change?
 List all possible causes
 Select the most likely causes
Job Safety Analysis
 Break job into basic steps

– Identify hazards associated with each step
– Identify prescribed controls for each hazard
 Review JSA if one is available for job
involved in the accident
 Perform JSA if one is not available to
determine the events and conditions that led
to the accident

The Causes of Accidents
ACCIDENT
ACCIDENT Personal Injury
Property Damage
Unplanned Release of Energy

DIRECT Causes
and/or Hazardous Material
INDIRECT Causes Unsafe Act Unsafe Condition

(Symptoms)
Management Safety Policies & Decisions

BASIC Causes Personnel Factors
Environmental Factors

Examples of Basic Causes
 Lack of safe job procedures

 Inadequate training
 Failure to establish and enforce safety rules
 Tolerance of unsafe conditions
 Inadequate design or layout
 Inadequate inspection program
 Inadequate preventive maintenance program
 Inadequate safety standards for purchases
Examples of Unsafe Conditions
 Inadequate guarding
 Defective equipment
 Hazardous arrangement
or procedure
 Unsafe design or
construction
 Improper illumination
 Improper ventilation
 Unsafe dress or apparel
Examples of Unsafe Acts
 Operating without authority

 Operating at unsafe speed
 Disabling safety devices
 Unsafe loading, mixing, combining
 Failing to secure or warn
 Taking unsafe position or posture
 Failing to use PPE
 Horseplay
Accident Report
 Background information
– Where and when accident occurred?
– Who and what were involved?
 Account of the accident – how did it happen?
– Sequence of events
– Extent of injury/damage
 Discussion/Analysis of causes – why did it occur?
– Avoid blaming a single worker or cause
– Dig deep

Report Recommendations
 Recommendations for prevention

– Analyze in tandem with causes
– List corrective actions to “foolproof” activity
 Examples:
– Repairing or replacing unsafe condition
– Redesigning process
– Re-training workers
– Drafting a new safety procedure
– Undertaking disciplinary actions
File Report
 File a copy of the

report with appropriate
individuals
 File all supporting data

(photos, interview
notes, etc.)

Accident Investigation

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Accident Investigation

Copyright Progressive Business Publications

 Determine the sequence of events leading

NOTE: The point of accident investigation is

 Know the policy for accident investigation

 Know required paperwork

 Keep all notes and records in bound notebook

 Control the scene

 Get preliminary statements as soon as possible

 What did you see?

 What is the normal procedure for activities

 What type of training did persons involved in

 What do you think could have prevented

Copyright Progressive Business Publications

 Gather all photos, drawings, interview

 Define the problem – what happened?

 Break job into basic steps

Copyright Progressive Business Publications

Unplanned Release of Energy

INDIRECT Causes Unsafe Act Unsafe Condition

Management Safety Policies & Decisions

Copyright Progressive Business Publications

 Lack of safe job procedures

 Operating without authority

Copyright Progressive Business Publications

 Recommendations for prevention

 File a copy of the

 File all supporting data

Copyright Progressive Business Publications

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