ACCIDENT INVESTIGATION

What Is An Incident?
Unplanned and unwanted event which disrupts the work process and has the potential of resulting in injury, harm, or damage to persons or property.
An incident disrupts the work process, does not result in injury or damage, but should be looked as a “wake up call”. It can be thought of as the first of a series of events which could lead to a situation in which harm or damage occurs. Employers should investigate an incident to determine the root cause and use the information to stop process and behaviors that could just as easily have resulted in an accident. Example of an incident:: A 50 lb carton falls off the top shelf of a 12’ high rack and lands near a worker. This event is unplanned, unwanted, and has the potential for injury.

What Is An Accident?
Unplanned, unwanted, but controllable event which disrupts the work process and causes injury to people.

Most everyone would agree that an accident is unplanned and unwanted. The idea that an accident is controllable might be a new concept. An accident stops the normal course of events and causes property damage, or personal injury, minor or serious and occasionally results in a fatality.

What Is An Accident?
• An accident is not “just one of those things”. • Accidents are predictable and preventable events. • They don’t have to happen.
Most workplace injuries and illness are not due to “accidents”. The term accident is defined as an unexpected or unintentional event, that it was “just bad luck”. More often than not it is a predictable or foreseeable “eventuality”. By “accidents” we mean events where employees are killed, injured, or become ill from exposure to toxic chemicals or microorganisms (TB, Hepatitis, HIV, etc). A systematic plan and follow through of investigating incidents or disasters and altering behaviors can help stop a future accident. Let’s take the 50 lb carton falling 12’, for the 2nd time, only this time it hits a worker, causing injury. Predictable? Yes. Preventable? Yes. Investigating why the carton fell will usually lead to solution to prevent it from falling in the future.

Incidents should also be reported and investigated. The 50 pound carton falls off the top shelf of a 12’ high rack and lands near a worker. . The outcome of an investigation might include correction of sloppy storage at several locations in the warehouse. then the incident should be investigated with the same thoroughness as an actual accident investigation. refresher training of stockers on proper methods is done.“The Tip of the Iceberg” Accidents Accidents or injuries are the tip of the iceberg of hazards Investigate incidents since they are potential “accidents in progress” Incidents Don’t just investigate accidents. equipment damage. unstable/heavy items will be stored at floor level if possible. Criteria for investigating an incident: What is reasonably the worst outcome. or injury to the worker? What might the severity of the worst outcome have been? If it would have resulted in significant property loss or a serious injury. supervisor begins doing daily checks.

hazards do not have to exist..or fail to do..”. Fatalities Severe Injuries Minor injuries Close calls Hazardous conditions . • From experience and analysis: they are “caused occurrences” – Predictable . “unexpected happening.”. They are caused by things people do -.chance.What is an “Accident”? By dictionary definition: “an unforeseen event”.the logical outcome of hazards – Preventable and avoidable . “.

• Maintain worker morale. • Expose deficiencies in process and/or equipment. • Identify and eliminate hazards. • The rule requires you to investigate serious accidents.Why Investigate? • Prevent future incidents (leading to accidents). . • You lose money when regular work stops.

investigation tools and policies and procedures should be developed before the incident or accident.How To Investigate • Develop a plan • The time to develop your company’s Accident Investigation Plan is before you have an incident or an accident. when. what and how should be developed before the incident. where. The who. . • Accident Investigation Training.

Evidence disappears. When investigating incidents or accidents be thorough in your capture of all available facts. You might discover that many other items were also improperly stored and that when employees were questioned there had been several other “near misses” . the 50 lb carton of material was cleaned up and memory fades…the employee was not encouraged to report the near-miss incident and forgot about the whole thing.How To Investigate •Assemble an investigation kit • Investigate all incidents and accidents immediately • Collect facts It is important to begin your investigation immediately.

don’t point out poor judgment. . Verify with them the training they have received and ask them if they know what happened to cause the accident.How To Investigate • Interview witnesses Interview witnesses and victims in a timely manner. be sympathetic…LISTEN If you know for a fact that someone broke a rule it is not important to point that out to them at this time. it doesn’t do anyone any good at this stage to be told ”it was your fault” or “you knew better” As an investigator. LISTEN Don’t blame. It is most important to determine why they engaged in an unsafe act as well as verify that they did or did not know better. you will often come to the conclusion that someone engaged in an unsafe act. Again.

How To Investigate • Write a report The report should include: • An accurate narrative of “what happened” • Clear description of unsafe ACT or CONDITION • Recommended immediate corrective action • Recommended long-term corrective action • Recommended follow up to assure fix is in place • Recommended review to assure correction is effective. .

reducing the chance for evidence to be lost and witnesses to forget. need to be listed out as step-by-step procedures. etc. forms.Tips for Developing A Plan • Develop your action plan ahead of time. You might wish to develop a flow chart to quickly show the major components of program. notifications. All procedures. • Your plan might include: – Who to notify in the workplace? – How to notify outside agencies? – Who will conduct the internal investigation? Preplanning will help you address situations timely. .

Develop a Plan Tips (continued) – What level of training is needed? – Who receives report? – Who decides what corrections will be taken and when? – Who writes report and performs follow up? Some expansion questions on the above points are: • Who will be trained to investigate? • Who is responsible for the finished report and what is the time frame? • Who receives copies of the report? • Who determines which of the recommendations will be implemented? • Who is responsible for implementing the recommendations? • Who goes back and assures that fixes are in place? • Who assures that fixes are effective? .

What Should Be In The “Investigation Kit” Camera equipment First aid kit Tape recorder Gloves Tape measure Large envelopes High visibility tape Report forms Scissors Graph paper Scotch tape Sample containers with labels Personal protective equipment These are some common items for a kit. What else might be useful? Anything for specific business or workplace that might be needed? .

horseplay. inadequate labeling. What is the cause? It is not just the saw or knife or the sharp nail. defective PPE. . Was it a broken tool and no one reported? Did someone ignore a hazard because of lack of training.Investigate All Incidents/Accidents • Conduct and document an investigation that answers: – Who was present? – What activities were occurring? – What happened? – Where and what time? – Why did it happen? Root causes should be determined. or a policy that discourages reporting? What are other examples of root causes? Enforcement failure. Example: An employee gets cut. no recognition plan.

Investigate All Incidents/Accidents • Also answer: – Is this a company or industry-recognized hazard? – Has the company taken previous action to control this hazard? – What are those actions? – Is this a training issue? .

Begin Investigations Immediately • It’s important to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget. .

the immediate supervisor.How Do You Investigate? • Notify individuals according to your “plan” • You must involve an employee representative. and other people with knowledge • Grab your “investigation kit” • Approach the scene .

make sure you and others don’t become victims! Always check for stillpresent dangerous situations. Separate witnesses from one another • If physical evidence is stabilized. • Secure the scene and initiate chains of custody for physical evidence. • Identify witnesses and physical evidence. then begin as quickly as possible with interviews. REMEMBER. Then. BE A GOOD LISTENER .Actions At The Accident Scene • Check for danger • Help the injured • Secure the scene • Identify and separate witnesses • Gather the facts • First. help the injured as necessary.

charts.Fact Finding • Witnesses and physical evidence • Employees/other witnesses • Position of tools and equipment • Equipment operation record. • Equipment identification numbers .

give a description of what is captured in the photo and directionality. air quality • Take samples • Note housekeeping and general working environment • Note floor or surface condition • Take many pictures • Draw the scene Some scenes are more delicate then others. The plot should describe the date. Are you prepared to be able to recreate the scene from your documentation? Consider creating a photo log. If items of evidence are numerous then you may need additional assistance. Link to sketch of accident scene. If items of physical evidence are time sensitive address those first.Fact Finding • Take notes on environmental conditions. time. Some scenes will return to normal very quickly. .

just get facts • Talk to witnesses as equals • Keep conversations informal .Interview Witnesses • LISTEN • Don’t blame.

are you the best person to conduct the interview? If the issue is highly technical consider a specialist. how to determine the truth bases on a limitation of numbers of witnesses.Interview Witnesses • Choose a private place to talk • Ask open ended questions • Interview promptly after the incident • Ask some questions you know the answers to Your method and outcome of interview should include: who is to be interviewed first. who is credible. . this may be an internal resource or it may be an outside resource. who can corroborate information you know is accurate. Be respectful.

. witness statements Remember that your report needs to be based on facts.Write The Report • How and why did the accident happen? – A list of suspected causes and human actions – Use information gathered from sketches. photographs. physical evidence. All recommendations should be based on accurate documented findings of facts and all findings and recommendations should be from verifiable sources.

Write The Report Answer the following in the report: • When and where did the accident happen? • What was the sequence of events? • Who was involved? • What injuries occurred or what equipment was damaged? • How were the employees injured? .

. Having a comprehensive plan in place will allow for the success of your investigation. Success of an investigation is the implementation of viable corrections and their ongoing use. If additional resources are needed during the implementation of recommendations then provide options.Report Conclusions • What should happen to prevent future accidents? • What resources are needed? • Who is responsible for making changes? • Who will follow up and insure implementation of corrections? • What will be future long-term procedures? Conclusions must always be based upon facts found during your investigation.

Phone number 7.Location of the incident 3.Report A Death or Hospitalization (Catastrophe) • Report the death.Name of the work place 2.Contact person 6.Time and date of the incident 4.Brief description of the incident . probable death. or the in-patient hospitalization of 2 or more employees within 8 hours.Number of fatalities or hospitalized employees 5. The required information that must be provided 1.

the easier it will be for management to take effective corrective actions. All incidents should be investigated. . the investigation or analysis must produce factual information leading to corrective actions that prevent or reduce the number of incidents. • The more complete the information. As such.• The ultimate purpose of incident investigation and analysis activities is to prevent future incidents. regardless of severity of injury or amount of property damage.

part-time. or seasonal employee.The minimum data set that investigators should record includes the following: • If data will be used to compare one company with another. • Record employee characteristics. The victim's age and sex. Describe exactly the injury or injuries and the part or parts of the body affected by the incident. . Questions about the victim's experience are also asked. and whether a full-time. record data about employer characteristics. • How long has the victim been with the company? • How long in current occupation? • How often had the employee repeated the activity engaged in when the incident occurred? Employee training records may be examined and assessed during this part of the investigation. the department and occupation in which he or she worked. This includes the type of industry and the size of the company (number of full-time equivalent employees). • Record the characteristics of the injury.

and – The investigators should include only the facts obtained during the investigation. • Record the characteristics of the task being performed when the incident happened: the general task (such as repairing a conveyor) and the specific activity (such as using a wrench). – conditions such as temperature.• Prepare a narrative description and accident sequence that provides the exact location of the incident (attach any maps or diagrams to the report). • Record the characteristics of the equipment associated with the incident. noise. and weather pertaining to the incident. specific breakdown of the sequence of events leading to the injury or near-miss. light. size. and any distinguishing features of the equipment. brand. These data should be incorporated into the narrative description on the report form. – what objects or substances were involved in the incident. – a complete. and the specific part involved. they should not record opinions or place blame. its condition. – whether any preventive measures had been in place. Include the type. .

• Record the time factors. indirectly. The investigation should record the time of day and whether it was the victim's first hour of the shift. Be as specific and complete as possible. record the specific activity in which the employee was engaged. Record the task and activity factors. or later. Record the events and conditions that contributed to the incident. second hour. First. Record the causal factors. or not at all at the time of the incident. Indicate in the appropriate place on the form whether the employee was being supervised directly. describe the general type of task the employee was performing at the time the injury occurred. • • • • . Second. Describe the corrective actions taken immediately after the incident to prevent a recurrence. including temporary actions. Record supervision information.

Method for Estimating • • • To be of maximum usefulness. Estimated costs of incidents in general do not take into account differences in hazards from one industry to another. Because of the differences between direct and indirect costs are difficult to maintain. for the purpose of cost analysis. Definition of Work Incidents for Cost Analysis • Work incidents. . Using these data.ESTIMATING INCIDENT COSTS • Although most executives want to make their company a safe place to work. a company can estimate its incident cost with reasonable accuracy. they also have a responsibility to run their business profitably. cost figures should represent as accurately as possible the specific experience of the company. instead they use more precise terms "insured" and "uninsured" costs. These incidents fall into two general categories: (1) incidents resulting in work injuries or illnesses (2) incidents causing property damage or interfering with production. are unintended occurrences arising in the work environment.

such as wages paid to the injured employee for downtime on the day of the injury. These items include the uninsured element of the total incident cost. . • In addition to these costs. uninsured (also called "indirect") costs are more difficult to assess. • Although the expense of damaged equipment is easily identified. others. many other costs arise in connection with incidents. These costs are definite and known. They include the insured element of the total incident cost.Insured Costs • Every organization paying compensation insurance premiums recognizes such expense as part of the cost of incidents. are hidden. Uninsured Costs • While insured costs can be determined easily from accounting records. medical expenses too. may be covered by insurance. The method described here is one way to calculate these added expenses associated with many incidents. In some cases.

. • Once average costs have been established for each incident class. Class 3-Medical treatment cases requiring only first aid • local dispensary treatment and resulting in property damage of less than $100 or loss of less than eight hours in work time 4. they can be used as multipliers to obtain total uninsured costs in subsequent periods. or loss of eight or more employee-hours. and that result in property damage of $100 or more. These costs are then added to known insurance premium costs to determine the total cost of incidents. Class 4-Incidents that either cause no injury or cause minor injury. Class 2-Medical treatment cases • requiring the attention of a physician outside the facility 3. Class 1-Cases involving lost workdays • days away from work or days of restricted work activity 2.The first step is to conduct a pilot study • Determine approximate averages of uninsured costs for each of the following four classes of incidents: 1. not • requiring the attention of a physician.

30 Class 2 incidents. (A separate record could be kept of the number of Class 4 incidents. 50 Class 3 incidents. the ratio of the number of Class 4 to Class 1 incidents found in the pilot study was used. and since there were 34 Class 1 incidents during the year. • Included in the study were 20 Class 1 incidents.000 Class 3 incidents. Costs were determined and averages developed in Table 7-A. and 4. and 20 Class 4 incidents.Example of a Cost Estimate • An estimate of costs made by one company is given in the following example. • During the entire year.) . First. • This ratio was shown to be about 1 to 1. the company had 34 Class 1 incidents. No record was kept of the Class 4 incidents after the pilot study was completed. a pilot study was conducted to obtain the average cost of each class of incident. Instead. 148 Class 2 incidents. it was assumed there were about 34 Class 4 incidents.

000 in compensation. the analyst reported to the plant manager.TABLE 7-A Average Cost Determined by Pilot Study ___________________________________________________ Class of Number of Average of Accidents Accident Reported Uninsured cost ______________________________________________ Class 1 20 $251. incidents cost this company about $155. in this instance.10 • The average cost for each incident class was applied to these totals to secure the results shown in Table 7-B." • The average costs determined in this pilot study represent the actual experience of this particular organization.70 Class 4 20 507. As a result.80 Class 3 50 15. "During the past year. medical expense. and property damage. . • The estimate should be rounded to three significant digits-in this case. lost time. to the nearest thousand dollars.10 Class 2 30 80.

800.000 15.937.10 $ 8.10 17.70 62.40 Class 3 4.40 Class 2 148 80.537. Estimate of Yearly Accident Costs ________________________________________________________ Average Cost Total Class of Number of per Accident Uninsured Accident Accidents (from pilot study) Cost ________________________________________________________ Class 1 34 $251.20 .Table 7-B.80 11.400.40 Total Uninsured Cost Insurance Premiums Total Accident Cost for the Period $100.958.20 54.537.00 Class 4 34 507.241.00 $154.

• These are employees who stopped work to watch or assist after the incident or who lost time because they needed the equipment damaged in the incident or because they needed the output or the aid of the injured worker. but a substantial cost is incurred in reorganizing material or equipment. and other extra services. • The following items of uninsured or indirect costs are clearly the result of work incidents and are subject to reasonably reliable measurement. 1. • Payments made under workers' compensation laws for time lost after the waiting period are not included in this element of cost. 4. • The validity of property damage as a cost can hardly be questioned. • The charge against an incident for overtime work is the difference between normal wages and overtime wages for the time needed to make up lost production. 2.Items of Uninsured Cost • Important to a pilot study is a careful investigation of each incident to determine all the costs arising out of it. Occasionally. Cost of Wages Paid for Time Lost by the Injured Worker. there is no property damage. and the cost of extra supervision. other than Workers' Compensation Payments. Cost of Wages Paid for Time Lost by Workers Who were not Injured. . 3. Nature and Cost of Damage to Material or Equipment. Extra Cost of Overtime Work Necessitated by the Incident.

7. the incident should be charged with 40% of the worker's wages during the period of low output. Uninsured Medical Cost Borne by the Company. cost of above-normal spoilage by new employees. Wage Cost Caused by Decreased Output of Injured Worker after Return to Work. Miscellaneous Costs.5. Cost of Learning Period of New Worker. 9. losses due to cancelled contracts or lost orders if the incident causes an overall reduction in total sales. equipment rental. cost of hiring new employees if this expense is significant. Cost of Wages Paid to Supervisors for Time Spent on Activities Concerning the Incident. If the injured worker's previous wage payments are continued despite a 40% reduction in output. . If a replacement worker produces only half as much in the first two weeks as the injured worker would have produced in the same time for the same pay. or settling claims arising from it. 6. Cost of Time Spent by Management and Clerical Workers on Investigations or in the Processing of Compensation Application Forms. 10. is chargeable to the incident. This cost is usually that of medical services provided at the plant dispensary. Among such possible costs are public liability claims. Time spent by management or supervision and by clerical employees in investigating an incident. 8. then half of the new worker's wages for the two weeks' period should be considered part of the cost of the incident. The most satisfactory way of estimating this cost is to charge the wages paid to the supervisor for the time spent away from normal activities as a result of the incident. There is no great difficulty in estimating an average cost per visit for this medical attention. loss of company bonuses.

a new worker does not produce at the same level as an experienced worker.THE . • Therefore. OFF . Some of the costs are hidden. the decreased productivity of the new worker indirectly increases the manufacturing overhead. such as insurance premiums and wages paid to absent employees.Conducting a Pilot Study • The purpose of the pilot study is to develop average uninsured costs for different classes of incidents that can be applied to future incident totals. it is desirable not to include the costs of deaths and permanent total disabilities. thus. such as training for new or transferred workers and medical staff time demanded for workers returning to work after an incident. Such incidents occur so seldom that the costs should be calculated individually and not estimated on the basis of averages. • • . Some of the costs are obvious. a major portion of the costs are borne by employers. For example.JOB DISABLING INJURY COST • When incidents take place off the job.

–directly associated with the employee who sustained the O T J D I injury are included in this expense subcategory. – incurred by personnel other than the employee who sustained the OTJ DI injury are included in this subcategory. equipment damage. affect profit margins. transportation. • Insured Costs – worker productivity cost. However. these costs are associated with all O T J D I incidents and. • Uninsured Costs – worker productivity cost. product loss. and equipment damage. most organizations do not keep records of uninsured costs.Categorizing OTJ Disabling Injury Cost • The cost of off the job disabling injuries (O T J DI) to an organization falls into the following two categories: insured and uninsured. or other miscellaneous expenses. . • Most uninsured costs are hidden. product loss. and administrative cost. therefore. telephone calls. • Miscellaneous costs –This subcategory includes loss of profit for cancelled contracts or orders and the costs of demurrage (compensation). Aside from wage costs.

The following examples illustrate calculation procedures. The insured cost for injuries to dependents of employees is then added to the total employee cost to determine total losses.Estimating O T J D Costs • Some experts say the ratio of insured cost to uninsured cost is 3:2. In order to estimate a company's losses from employee OTJ D I s. using the 3:2 factor. . it must rise the insured cost to determine the total (insured and uninsured) employee costs. management must first determine the insured cost. • Next.

000 was required for 22 employee-dependent injuries. Twenty percent or $225.000. • • Company A Estimated OTJ DI Costs Insured cost for employee injuries = $75.000 of its annual premium charge was required to pay for its previous calendar year OTJ DI incident experience.000 Uninsured cost for employee injuries = 50.000 Insured cost for Employee – dependent injuries = 150. the total expense for employee injuries becomes $125. $75.000 was required for 11 employee injuries and the remaining $150.000 insured cost category is escalated to include the uninsured cost category. since it does not include the administrative cost incurred by the company's insurance office staff to process claims.000 Total annual estimated OTJ DI cost = $275. it should be added to the employee – dependent injury expense category. The total cost for employee-dependent injuries is a conservative figure.000 . If this cost is known. These figures include the administrative fee paid by the company to the carrier. When the $75. Of that total.Example 1 • Company A is insured by an outside carrier.

it should be added to the total employee-dependent cost. If the cost for insurance office staff claim-processing is known.000 Total annual estimated OTJ DI cost = $ 3. resulting in a cost of approximately $900.800.000 was paid for 138 employee injuries and $1.000 was paid for 279 employee-dependent injuries for its previous calendar year OTJ DI incident experience.000 .500.900. Their administrative fee to the carrier was 6% of the total cost.000 Insured cost for employee-dependent injuries = 1.000.Example 2 • Company B is insured by an outside carrier.400.900.000 Uninsured cost for employee injuries = 600. Escalation of the insured cost category for employee injuries include the uninsured cost category indicated a total of $1.000 for employee injuries and $1. Its carrier stated that $850. • • Company B Estimated OTJ DI Costs Insured cost for employee injuries = $900.000 for employee – dependent injuries.

000 = 1.520.000.700. OTJ DI incident experience for the amount of medical and health claims paid for 350 employee injuries was $2.280.700.280. and $4. $2.000 was paid for 690 employee-dependent injuries. Insurance office records indicated that for the previous calendar year. • Thus.000 4.800.000. • Insurance office staff administrative costs for claim processing should be added to the employee – dependent cost category if that cost is known.000 escalated to include the uninsured cost category for employee injuries resulted in a total cost of approximately $3.280.000 $ 8. Company C Estimated OTJ DI Costs Insured cost for employee injuries Uninsured cost for employee injuries Insured cost for employee-dependent injuries = Total annual estimated OTJ DI cost = = $2.000 .Example 3 • Company C is self-insured.500.

the $10. top management allocated $50.800. Based upon the OTJ DI loss experience.450. For example. which is a 600% return on investment.000 from the budget to initiate a safety awareness program. The estimated net return is $300. Calculations (300 x $11.500 and that employee injuries were reduced from 350 to 300.Measuring the Effects of OTJ Safety Programs • Calculations of average costs are useful tools to support initiating or accelerating off the job safety awareness programs.000. it can be used to gain management commitment to support operating budgets for safety awareness programs.500) indicate losses of $3.000 and an average cost per incident of approximately $10.000 from last year's total. • • • • • • • . it is assumed that the new average cost per incident figure is $11.000. To further support justification for operating funds. At the end of the year. the new figure will be used to calculate losses.860. safety personnel can add savings realized from reduced employee-dependent injuries to the employee savings total. 350 employees of Company C experienced OTJ injuries during the previous year for a total of approximately $3.860 average cost figure will be escalated to adjust for inflation and. thus. For illustration purposes. The calculations also can be used to measure the effects of safety programs. This type of analysis provides a management tool to evaluate the impact of off-the-job disabling injuries on profit margins. in turn. a savings of approximately $350.

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