Procedures: Accident investigations

What is Accident Investigation?

• Accident investigation is a process that allows management to identify and
evaluate the true causes of an accident or incident.
• It is used to formulate solutions to the underlying problems so as to avoid
or minimize future accidents from the same source.
• If we choose not to investigate accidents, we are destined to repeat them
over and over.
• Accident investigation is one of the fundamental principles of Loss Control
management.
What is Accident Investigation?
• All supervisors need to be aware of the need for and the benefits of an effective accident
investigation program.
• They should also be provided with the skills to consistently and thoroughly investigate
workplace accidents and incidents.
• It is an important part of any safety management system.
• It highlights the reasons why accident occur and how to prevent them.
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;
• Identifying remedies to improve the health and safety management system by improving
risk control, preventing a recurrence and reducing financial losses.
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 than
accidents.
Benefits of Accident Investigation:
Some of the benefits includes:
• Prevention of future similar losses.
• Accident Investigation helps in contribution to the bottom line
• Helps in reduction of human suffering.
• Lead to the continuous improvement process.
When to conduct an Accident / Incident Investigation?
• All incidents, whether a near miss or an actual injury-related event, should be
investigated.
• Near miss reporting and investigation allows you to identify and control
hazards before they cause a more serious incident.
• Accident / incident investigations are a tool for uncovering hazards that either
were missed earlier or have managed to slip out of the controls planned for
them.
• It is useful only when done with the aim of discovering every contributing
factor to the accident/incident to “fool proof” the condition and/or activity and
prevent future occurrences.
• In other words, your objective is to identify root causes, not to primarily set
blame.
Who should do accident / Incident Investigation?
• The usual investigator for all incidents is the supervisor in charge of the involved
area and/or activity. It generally represents a good way to involve employees in
safety and health.
• Employee involvement will not only give you additional expertise and insight, but
in the eyes of the workers, will lend credibility to the results.
• Employee involvement also benefits the involved employees by educating them on
potential hazards, and the experience usually makes them believers in the
importance of safety, thus strengthening the safety culture of the organization.
• The safety department or the person in charge of safety and health should
participate in the investigation or review the investigative findings and
recommendations.
• Many companies use a team or a subcommittee or the joint employee –
management committee to investigate incidents involving serious injury or
extensive property damage.
Training for Accident Investigation?
• No one should investigate incidents without appropriate
accident investigation training.
• Many safety and health consultants and professional
organizations provide this type of training.
• Before committing resources to training, one might want to
check the course contents against the information found in
the National Safety Council’s pamphlet,
“Accident Investigation ……. A New Approach.”
Accident Investigation: A 6-step Process
Accident Investigation is a six step process.
1. Collect Information
2. Analyze All causes
3. Asses Future Accident Potential
4. Develop Corrective Action
5. Report Data and Recommendations
6. Take Corrective Action and Monitor
 Step 1. Collecting Information : ON Site
• Securing the scene: Once we have an accident or incident to investigate, several activities
will take place at the actual accident scene.
• When is it appropriate to begin the investigation?
• What are effective methods to secure an accident scene?
• Investigating at the scene: If warranted by the circumstances, the scene may be need to be
barricaded and physically segregated against further or merely to preserve the scene for the
initial investigation.
• List methods to document the scene and collect data about what happened.
• What documents will you be interested in reviewing?
• Why?
• Recording Key information: Information will be largely determined by the nature of the
accident.
• Equipment is needed.
 Collecting Information : OFF Site
Interview key people:
• Consider interviewing to collect more information about an accident: When, Who and Where
• Initially, the injured person and any eye – witnesses.
• Every effort should be made to interview any witnesses.
• Witnesses can be very good source of information regarding the cause of an accident and the conditions associated
with it.
• Eye – witnesses can provide critical information about an accident as far as the activities and events that led up to the
accident itself.
• Witnesses should be interviewed as soon as possible after the accident.
• Record the names, addresses and telephone nos. of witnesses and other persons with information.
• Have witnesses document their statements and ask them to date and sign.
• Depending on the accident, one may want to also interview others, such as the personnel manager, maintenance
foreman, other supervisors and employees.
• The interview process should include the injured employee, if possible.
• Do not ask the employee to re-enact the accident. As a second accident is possible through the re-enactment process).
 Collecting Information : Reviewing
Records
What were the standard work practices?
Have you done the job safety analysis.?
Have you read its Material Safety Data Sheets?
Had you gone through the Employee Personnel Records?
If the Maintenance Logs were up to date?
Was there any past accident History?
What actually the Inspection Records say?
 Step 2. Determining Causes
• The root cause is the most fundamental and direct cause of an accident or
incident.
• There may be one or more contributory causes, in addition to the root
cause. However, the root cause is the one event or condition that
precipitated the accident.
• The key is that if we were to remove the root cause, the accident would not
have occurred. If we removed the contributory causes, the accident still may
have occurred, although the severity of the accident may have been less.
• Accident Investigation is ineffective unless all causes are determined and
corrected.
Categories of Root Causes
Root causes can generally be grouped as either being workplace factors or
employee factors.
Workplace Factors: These are largely under the control of management.
Examples: Improper tools and equipment, Inadequate Maintenance, Lack
of job procedures, poor workstation se –up, Lack of job training
Employee Factors: These are under the control of the individual
employee.
Examples: Fitness for Duty (Substance Abuse, Fatigue, Effects of
Medication, Emotional Distress), Failure to apply Training, Risk-taking
behavior
 Step 3. Asses Future Accident Potential
• Step 3 in the six step Accident Investigation process is to Asses future
Loss Potential.
• It helps to assign priority to the Corrective Actions that we will
recommend and helps us “sell” the need for improvements to upper
management.
• Loss severity can be thought of, in three classes,
1. Class A represents the potential for major injuries or damage,
2. Class B for serious injuries or damage, and
3. Class C for minor injuries or damage.
Class “A” Hazard (Major)
A condition or practice likely to cause permanent disability, loss of life, body part and/or extensive
property loss or damage.
Examples:
• An unguarded machine with the potential to amputate a finer or hand,
• An unprotected floor opening, that could lead to fall from an elevation greater than 10 feet, and
badly worn brakes on a motor vehicle that could lead to an intersection collision.

Class “B” Hazard (Serious)

A Class B Hazard represents a condition or practice that could cause serious injury or illness such
as temporary disability, or property damage that is serious but less severe than those under Class A.
Examples:
• An unguarded floor opening that may lead to a fall from an elevation of less tha 10 feet
• An unguarded pinch points in a machine that may lead to serious bruises or broken bones but not
amputations
Class “C” Hazard (Minor)
A Class C Hazard is minor in nature and is likely to cause non-disabling
injuries or illnesses or non – disruptive property damage.
Examples:
• The use of a chemical that may cause dermatitis without the practice of
using gloves or barrier creams,
• A process that creates dust but work practices do not call for the use of
ventilation or the wearing of eye goggles, etc.
Correcting the Causes:
In order to make the corrective action successful, one need to have a
corrective action for each and every root cause, identified.
However, more than one control may be needed for each root cause
depending on the circumstances.
The “Control Hit List” is a simple tool that spells out the desired levels of
controls available so that the “best” type of control may be selected as first
choice and so that one consider all of the possible controls without just
reaching for most obvious one.
Control Hit List
It helps to think of controls in six categories (listed in priority order, with most
effective control at the top and the least effective control at the bottom)
because some categories have proven more effective than others.
1. Eliminate the Hazard
2. Substitute a less hazardous material
3. Use Engineering Controls
4. Use Administrative Controls
5. Personal Protective Equipment (PPE)
6. Training of Employees
Process Safety Hierarchy
Statistics on occupational accidents
The statistics of factories is collected and compiled by the Labor Bureau on the basis of
the Annual Returns/ Reports in respect of the Factories Act 1948, furnished by various
States and UTs.
Under the Factories Act, 1948, injuries resulting from industrial accidents, by reasons of
which the person injured is prevented from attending to work for a period of 48 hours or
more immediately following the accident, are recorded.
The important indices on injuries are Frequency rate (FR) and Incidence Rate (IR).
The Frequency Rate is defined as number of total injuries per 1,00,000 man-days
worked.
The Incidence Rate is number of injuries per 1000 workers employed in the factories.
 Step Report Data & Recommendations
• All accidents to employees, however minor, should be reported. This is
a requirement under social security legislation. All near misses,
incidents and accidents should be reported, no matter how slight they
may appear.
• Fatal accidents
• Accidents causing minor injuries
• Notifiable accidents & dangerous occurrences
• Reportable accidents & dangerous occurrences
• Reportable accidents & dangerous occurrences
• Written records
Report Data & Recommendations
• The company encourages employees to report all accidents no matter how minor.
• Accidents that involve very minor injuries and would not normally require any action
on behalf of the company do not have to be reported (although employees could
report them if they want).
• On the other hand, accidents that involve (or could have involved) more severe
injuries and require investigation and action from the company must be dutifully
reported.
• As a result of workplace injury, an employee may need to claim for benefits in the
future, and relevant checks will be made to confirm that the accident occurred at
work.
• Employers need to sure that they satisfy all legal reporting requirements for
employees and non- employees, and take measures to monitor accidents.
Report Data & Recommendations
• Accidents happen for a reason, it could be machine failure, unsafe work
practices or poor housekeeping, but reporting theses occurrences can help
identify the cause and help prevent this accident monitoring.
• As part of the reactive monitoring process, accident records are needed to asses
whether the existing controls are adequate or to identify if trends are developing
and to implement new procedures.
• Records may also have to be produced for the Health and Safety Executive, to
parents/guardians, or in the course of civil proceedings if a claim is brought
following an accident.
• Reporting and recording procedures varies from organization to organization as
procedures are different. Usually the most effective way of reporting
incidents/accidents is through specific reporting form.
Report Data & Recommendations
• The form should contain a detailed description of the incident, the
persons and tasks involved, injuries obtained, any medical treatment
given and witness statements if they are available.
• If possible pictures of the scene should also be included.
• All reports should be submitted to management as soon as possible so
the incident can be investigated.
Report Data & Recommendations
The form is divided into some general sections to cover all relevant information.
Section 1. Background
Section 2. Description of Accident
Section 3. Findings
Section 4. Recommendations
Section 5. Summary
Section 6. Follow-up: Actions
Section 7. Comments/Attachments
 Report Data & Recommendations
• Document facts only
• Determine if the corrective action applies to more than one employee,
more than one job function, more than one shift, etc.
• Prioritize corrective actions based on future accident potential.
• Submit both short term and long term solutions, if necessary.
• Example: If employees are exposed to an excessive vapor
concentration, a short term control may be the wearing of PPE, while
the long teem control may be installing a ventilation system.
 Step 6: Recommend corrective actions and
improvements
• The step is to actually implement the corrective action identified and
recommend through the Accident Investigation process.
• It is essential that long term solutions do not get lost in the shuffle and get
implemented as originally planned.
• Over time, the effectiveness of the controls we have chosen can be assessed
through such means as employee interviews, job safety analysis and finally, the
presence or lack of additional accidents and incidents from the same causes.
Recommend corrective actions and improvements
To make corrective actions, various control strategies can be used:
• Engineering Controls: Helps in eliminating or reducing hazards
through equipment redesign, replacement, substitution, etc.
• Management Controls: It helps in eliminating or reducing exposure
to hazards by controlling employee behaviours.
• Interim Measures: They include strategies that are used a a
temporary fix while permanent controls are being developed.
Recommend corrective actions and improvements
Various improvements should be made to policies, programs, plans, processes,
and procedures in order to have proper and better investigations and less
accidents.
It can be done within one or more of the following elements of the safety
management system:
Management Commitment
Employee Involvement
Hazard Identification and control
Incident and accident analysis
Education and training
System evaluation
Recommend corrective actions and improvements
Making system improvements might include some of the following:
• Including “safety” in a mission statement.
• Improving safety policy so that it clearly establishes responsibility
and accountability.
• Changing a training plan to include using checklists.
• Revising purchasing policy to include safety consideration as well
as cost.
• Changing the safety inspection process to include all supervisors
and employees.
 Recommend corrective actions and improvements
• 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.
Why Accident Investigation Fail…
The investigation system should be modified time to time in order to avoid the
failure of accident investigation.
Some of the reasons of the failure are:
Investigation stopped short and didn’t reveal the root cause of the accident
No time to complete
No motivation to complete
Lack of accountability
Lack of skills & knowledge
 Accident Prevention
Accidents can be prevented by early detection, reporting and abating!
Step 1 Hazard Identification
Step 2 Report hazards
Step 3 Hazard Abatement
Here are some ways to prevent accidents:
• Ensure work areas are not cluttered and trash is removed regularly.
• Provide necessary training/retraining for all employees.
• Ensure that necessary controls are in place [ engineering (e.g., machine guarding), administrative
(e.g., labels/signs), PPE (e.g. safety goggles)].
• Have spills cleaned up immediately
• Ensure proper lifting/ carrying techniques are being used.
(Cont……)
• Ensure mechanical handling equipment, or MHE, is being used properly.
• Ensure walking/working surfaces are free of slip, trip and fall hazards.
• Enforce safety rules, policies and procedures.
• Ensure safety inspections are being conducted regularly.
 Summary
• Regulatory requirements for investigating workplace incidents and dangerous
occurrences.
• Collect evidence for an investigation.
• Analyze evidence for an investigation.
• Develop a workplace investigation report.
• Take action following a workplace investigation.