Welcome to your

Accident Investigation and

Reporting Course

Your Trainer today is

Genaro R. Resuta
© TWI Gulf WLL 2008
Domestic Arrangements

© TWI Gulf WLL 2008

 Course Timing Details
Morning Break 10.45am
Lunch 12.30pm
Restart 13.30pm
Afternoon break 2.45pm
Close 16.30pm
approx

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 Introductions

Name:
Company:
Occupation:
Health and Safety Knowledge?

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 Why Investigate Accidents?
Determine cause to prevent recurrence
Identify weaknesses in management systems
Identify weaknesses in risk assessment
Demonstrate management commitment
Comply with Countries legal requirements
Collect data to establish losses
Provide information for Civil/Criminal actions
Provide information to insurance company
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 Reasons for prevention
of accidents
Humanitarian/Moral

Legal

Cost

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 Worldwide Workplace Fatalities
Region Number of Fatalities
Established Market economies 19,662
Formally Socialist economies
15,563
of Europe
India 36,740
China 68,231
Other Asia and Islands 80,586
Sub-Saharan Africa 45,864
Latin America, America,
26,374
Caribbean
Middle Eastern Crescent 41,850
WORLD TOTAL 334,870
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 Fatal Injuries by Cause UK
99/00
Falls from height 68
Struck by falling object 35
Hit by moving vehicle 34
Contact with machinery 14
Trapped by collapse or
16
overturning
Contact with electricity 18
Drowning/asphyxiation 7
Others 28
Total 220
© TWI Gulf WLL 2008
 Worldwide Work-Related Disease Deaths (ILO)
Number of deaths attributed
Causes of death
to occupation
Cancer 30+years 456,240
Cardiovascular and
cerebrovascular disease 15-60 200,025
years
Chronic respiratory disease 15+
275,000
years
Pneumoconiosis (Proportional
36,000
estimate from US figures)
Nervous system disorders 15+
12,080
years
Renal disorders 15+ years 13,100
Total 992,445

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 Legal
Fines

Jail

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 Costs of Accidents at Work
Iceberg Model of Accident Costs:

… Visible Costs
Liability insurance
$16-75

Invisible Costs
$16-75

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 Hidden Costs of Accidents

Accident investigation Loss of reputation

Payments to injured person Damage repair
Payments non productive Replacement plant
time
Compensation
Replacement labour
Legal fees
Training
Insurance
Business interruption

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 Benefits of Good Health and
Safety Practice
1) Increased levels of compliance
2) Improved production
3) Improved staff morale
4) Improved company reputation
5) Reduced accidents
6) Reduced ill health
7) Reduced damage to equipment
8) Reduced staff complaints
9) Reduced staff turnover
10) Reduced insurance premiums
11) Reduced fines and compensation claims
© TWI Gulf WLL 2008
 Definitions
An Accident: An unwanted, unforeseen, unplanned
event which results in a loss of some kind

Near Miss (Incident): An unwanted, unforeseen,

unplanned event that has the potential to result in
a loss

Immediate/Direct Cause: The unsafe act or condition

that results in an accident or incident

Root/Underlying Cause: The failure of procedures,

management systems that have resulted in the
unsafe act or condition
© TWI Gulf WLL 2008
FLT scenario
Immediate/direct causes
Cornering to fast
Hitting obstructions
Driving on uneven ground
Driving across slopes
Turning on slopes
Moving with load elevated
Driving with unstable load/excessive load
Collision with another vehicle
Faulty truck
Poor road surface/lighting
Driving under the influence of drink or drugs © TWI Gulf WLL 2008
FLT scenario
Root/underlying causes
No or inadequate risk assessment
No safe systems of work
No defect reporting systems
Lack of management commitment
Lack of daily truck inspections
Lack of maintenance of vehicle
Lack of maintenance of workplace
Lack of supervision
Unfamiliarity with workplace
High workload
Poor selection of vehicle or driver © TWI Gulf WLL 2008
 ILO Definitions
Occupational Accident: An occurrence arising out
of or in the course of work that results in a fatal or
non-fatal occupational injury
Occupational injury: Death, any personal injury or
disease resulting from an occupational accident
Commuting (travel) Accident: An accident
resulting in occupational injury involving loss of
working time occuring on the direct way between
the place of work

© TWI Gulf WLL 2008

Other Terms in accident
Investigation
TYPES (CATEGORIES) OF ACCIDENTS
Falls from heights
Struck by moving vehicle
Slips and trips
Stuck by moving objects
TYPES (CATEGORIES) OF INJURY
Sprain, Strain, Dislocation
Cuts, Lacerations
Broken/Fractured bones
Burns
Amputation of limb(s)
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 Domino Sequence
1 2
3
4
5

1) Lack of Management control

2) Basic Causes – Personal/Job factors
3) Immediate Causes ( Unsafe Acts/conditions)
4) Accident/Incident
5) Loss/Injury © TWI Gulf WLL 2008
 Causes of Accidents
Individual and job factors
a) Unclear lines of responsibility
b) Poor supervision
c) Lack of information, instruction and training
d) Ineffective communication
Unsafe Acts
a) Misuse of equipment
b) Not following safe procedures
Unsafe Conditions
a) Poor Housekeeping
b) Poor design and construction
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 Employees attitude
Home Influence.
Education and training.
Job experience.
Personal habits.
Mentally and physically unsuited to do the job.
Works problems and grievances
Peer groups.
Management commitment

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Accident Prevention: Birds Pyramid

1 Major Injury

10 Minor Injury

30 Property Damage

Critical Incidents
600
(Near Misses)

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Benefits of Collecting
near miss data
To identify underlying causes

May allow preventative action to be taken

All failures are taken seriously

Generally accepted near misses greatly
outnumber accidents

Produce more data © TWI Gulf WLL 2008

 Principles of Prevention
Avoid Risks
Evaluate risks
Combat risks at source
Adapt to Individual
Adapt to technical progress
Replace dangerous
Coherent Policy
Priority to collective measures
Instructions to employees
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 Preventative Strategy

Safe Place
Equipment/ Access/Egress
Materials (Articles/Substances)/Environment

Safe Person
Information, Instruction and Training
Safe Behaviour
Awareness, Knowledge, Competence
Supervision
Health Surveillance
Personal Protective Equipment
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 Safe Systems
Policies and Standards
Rules
Procedures
Safe systems of work
Permits to work
Clear lines of responsibility
Accident Investigation and analysis
Emergency preparedness
Purchasing controls © TWI Gulf WLL 2008
 Health and Safety Performance
Dupont accident trend study
Number of Accidents

Technical Improvements (Hardware)

Process and Procedural Safety (Software)

Human Factors

1970s 1980s 1990s 2000s

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Influences on Behaviour at Work

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 The Individual
Factors affecting Individual behaviour:
1) Age, health, Gender
2) Training and education
3) Education, Experience
4) Home life
5) Peer group pressure
6) Job satisfaction and security
7) Motivation
8) Attitude
9) Perception © TWI Gulf WLL 2008
Areas affecting the individual

a) Motivation
b) Attitude
c) Perception

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 a) Motivation
Motivation may be defined as: The drive a
person has to achieve a particular goal
Incentives/Recognition
Recognition
Job satisfaction
Personal achievement
Team spirit
Realistic goals
Committed management
Safe environment
Involvement in decisions
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 b) Attitude
Attitude may be defined as:
The tendency to behave in a particular way in a
certain situation
What affects Attitude?
Culture
Experience
Peer Groups
Management commitment
Home influence
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 c) Perception

Perception may be defined as:

The way that people interpret and make
sense of presented information e.g. in
relation to their surroundings

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Perception

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Perception

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Perception

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 Perception
Perception can be affected by:
Sensory input
PPE
The nature of the hazard
previous experience
Familiarity with the situation
Feeling of being in control
Level of training
Peer group influences
Confidence in others
Personal characteristics © TWI Gulf WLL 2008
Why employees fail to comply with safety
procedures even when competent
Lack of motivation
Unrealistic working procedures
Lack of management commitment
Over familiarisation with the task
Repetative work leading to boredom
Peer group pressure
Wilful disregard of laid down procedures/Supervision
Fatigue and stress
Lack of information, consultation
Job insecurity © TWI Gulf WLL 2008
 Human Failure
a) Human error may be defined as:
Failure on the part of the human
operator to perform an assigned
task within specified limits of
tolerance

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© TWI Gulf WLL 2008
© TWI Gulf WLL 2008
© TWI Gulf WLL 2008
© TWI Gulf WLL 2008
Factors contributing to
Human Error
1) Slips
2) Lapses of attention
3) Mistaken actions
4) Mis-perceptions
5) Mistaken priorities
6) Wilfullness
7) Inadequate design
8) Inadequate information
© TWI Gulf WLL 2008
 Slips and Lapses of attention
Slips
a) Performing an action too early/late
b) b) Omitting steps from a procedure
c) c) Reading the wrong dial

Lapse of attention
a) Forget what we set out to do
b) b) Competing demands for attention
c) c) Loss of concentration due to tiredness
© TWI Gulf WLL 2008
Mistaken Actions, Mis-perceptions,
Mistaken priorities, Wilfullness
Mistaken actions: Doing the wrong thing under
the impression it is right (Example Digger)
Mis-perceptions: Competing information
produces tunnel vision
Mistaken priorities: Organisations objectives not
clearly conveyed or understood
Wilfulness: Wilfully disregarding safety rules
Inadequate design or information © TWI Gulf WLL 2008
 Violations

Simply put: “Breaking the rules”

1) Routine
2) Situational
3) Exceptional

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 Routine and Situational
Violations
Routine: Become normal way of working
a) Desire to cut corners/save time
b) Rules perceived to be to restrictive
c) Lack of supervision and enforcement

d) New workers taught bad habits

Situational: Breaking rules due to pressure
a) Time pressure
b) Insufficient staff
c) Correct equipment not available
© TWI Gulf WLL 2008
 Violations
3) Exceptional: Rare occurrence happen when
something has gone wrong and decision is
made to put things right even if it means
taking risks that are known to be
unsuitable or inappropriate

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 Violations

Routine
Situational
Exceptional

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 The Job
Task Analysis
Decision making
Ergonomics
Procedures, information and
instructions
The working environment
Tools and Equipment
Work Patterns
Communication
Maintenance
Boredom and monotonous work
Peer pressure © TWI Gulf WLL 2008
Overall approach for Investigation

1) Develop effective reporting

procedures
2) Deal with immediate risks
3) Select level of investigation

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Reasons for failure to Report
Accidents
Ignorance of Procedures
Over complicated procedures
Peer Pressure
Management Retribution
Preserve accident record
Lack of Management Response
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Training programme for
employees
Need to prevent happening again
Aim to improve health and
safety performance
May be requirement to report to enforcing authority
For use in
accident data
How to report
Who to report
accident to
Explain the information required on form
There will be a no
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Successful Reporting procedures

1) Reporting system simple

2) No blame culture
3) Feedback given

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 Significance of Accident

A Actual/Potential 1 Minor 2 Serious 3 Major

severity

B Likelihood of 2 Seldom 2 Occasional 3 Frequent

recurrence

C Actual/potential 2 None 3 One person 3 More than

population one person

© TWI Gulf WLL 2008

 Score significance
Significance Action
score
2 or less The Supervisor/team leader records details of
the accident and recommends corrective
action
3 to 6 As above but an additional form is completed
identifying all immediate causes.
8 to 12 The line Manager investigates and completes
a form identifying the immediate and
underlying causes
13 or more A formal investigation takes place led by a
Senior Manager/Director
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 Types of Investigation
a) Supervisory Investigation

b) Formal Investigations suggested team:

1) A Senior Manager to chair the investigation

2) A Manager or Supervisor of area concerned.
3) Competent persons for technical advice.
4) A Safety Professional
5) An Employee Representative.

© TWI Gulf WLL 2008

Five Steps to Investigation

1) Gather the information

2) Analyse the information
3) Identify the risk control measures
4) Report and recommendations
5) Take action

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Dealing with immediate risks

Treatment for the injured person

Make area safe
Implement emergency plan

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Five Steps to Investigation

1) Gather the information

2) Analyse the information
3) Identify the risk control measures
4) Report and recommendations
5) Take action

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 Investigation General points

1) Investigate as soon as possible

2) Keep and open mind
3) Do not dismiss contradictory evidence
4) Do not apportion blame

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Investigation Major elements

1) The scene
2) Documentation
3) The people
4) Interviewing witnesses
5) Specialist test/examinations

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 The Scene (1)
What activities were being carried out?

Was there anything unusual?

Were there adequate safe working

procedures?
Were they being followed?

Was the risk known? If so why not

controlled?
Did the organisation and arrangement of the
wok influence the accident? © TWI Gulf WLL 2008
 The Scene (2)
Materials
-- Materials or substance
Equipment
--Tools, vehicles, machinery etc.
Environment
--Lighting, temperature etc
People
--Human error, inexperience, training:

© TWI Gulf WLL 2008

 Documentation
Risk assessments
Training records and programmes

Maintenance records and inspection records

Audit records
Test certificates

Previous accident records

© TWI Gulf WLL 2008
People, Interviewing,
Specialist Tests
THE PEOPLE
Questions that can be asked regarding the
people may be:
Were those involved authorised, competent
Were the following the procedures
Did they have all the appropriate information
Were they adequately supervised
Was human error a contributory factor

INTERVIEWING WITNESSES
SPECIALIST TESTS
© TWI Gulf WLL 2008
 Recording Findings

Name Address etc, of injured Employee

Time, date of accident
Department where accident happened
Exact location
Type of accident
Part of body injured
Brief description of accident

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 Analyse the Information

Analysis should determine:

Cause of the injury
Immediate/direct causes
Root/underlying causes
Identify possible failures in systems

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Fault Tree Analysis

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Identify the risk control
measures

There may be:

No control measures in place
Control measures in place that were not used
Control measures in place that failed

Combinations of the above

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Identify the risk control
measures
Measures should be evaluated for:
Their ability to prevent recurrences
Whether they are practical
Whether they will be used

Whether they will remain effective

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 Questions to be answered
The immediate/direct causes
The underlying/root causes
Physical control measures in place
Why were the causes unrecognised and uncorrected
Human error
Review the risk assessments
Organisational arrangements in place
What if anything prevented a more serious outcome
Immediate response as effective as it could have been

© TWI Gulf WLL 2008

Report and Recommendations
Who – The injured person
When – Date and time
Where – Location
What – Accident/injury
How – Detail of events
Why – Analysis of cause
Recommendations
Documentation
Possible breaches of law
© TWI Gulf WLL 2008
 Take Action
Involve Senior Management
Highest priority risks control measures
implemented first
Lower risks control measure in order of
priority
Specific Senior Manager in charge of
implementation

© TWI Gulf WLL 2008

Reporting of accidents accidents
ILO require each government to nominate:
Competent authority who should implement a
policy for:
The recording, notification and investigation of
occupational accidents and diseases
The recording, notification and investigation of
commuting accidents, dangerous occurrences and
incidents
Compilation, analysis and publication of statistics on
such accidents, diseases and dangerous occurrences
Establish procedures for employers to ensure
information on accidents is maintained
Also many Countries require reporting of certain
types of injury, diseases, dangerous occurrences and
commuting accidents
© TWI Gulf WLL 2008
Examples of reportable events
Injuries: Death, fracture, amputations etc.
Diseases: Dermatitis, Asthma, lung diseases
Dangerous occurrences: Collapse of cranes,
contact with overhead power lines, etc
Commuting accidents

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 Type of data collected
Incidents/Accidents
Incident /accident or near miss reports
Reports to enforcing authorities
Reports to insurers
RIDDOR reports

Work related ill health

Sickness absence reports
Health surveillance
Medical diagnosis from outside organisation
© TWI Gulf WLL 2008
Categorising accident data
Category of person affected
Injury type
Part of body injured
Severity of injury
Age/sex of person
Work activity
Shift/time of day
Location of accident
© TWI Gulf WLL 2008
Frequency & Incidence Rates

No of Accidents in Period x 100,000

Frequency rate =
Total hours worked in period

Incidence rate = No of Accidents in Period x 1,000

Av. No.of Employees in Period

Severity rate: The average length of time taken off

work as the result of accidents

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 Communicating Data

Safety committees
Team briefings
Company magazines
Board meetings
Performance reviews for managers
Annual reports
© TWI Gulf WLL 2008
Benefit of using accident data
a) Shows patterns and trends
Pattern: Repeated events
Trend: A line of general direction

b) Identify weaknesses in procedures

c) Prioritise safety measures
d) Identify areas for improvement
e) Set targets for reduction
© TWI Gulf WLL 2008