ACCIDENT INVESTIGATION

ACCIDENT INVESTIGATION

• A methodical effort to collect and interpret the facts of accident.
• An inquiry as to how and why the accident occurred in order to explore actions that should be taken to
prevent or minimize recurrence of the accident.
•Most important thing- Investigation is not intended to place blame.

Purposes of Accident Investigation

• To establish all facts
• To draw conclusion
• To make recommendations
• To prevent recurrence

Principles of Accident Investigation

The investigation of any accident event will never progress unless that event is first properly reported to the appropriate management within an organization.

Reasons Why Accidents Are Not Reported

• Natural fear many people have of being associated with an accident event.
• Idea of investigating a situation that has resulted in some degree of loss
• Reflect unfavorably on their own performance or that of their department.
• Simply do not wish to interrupt work production

Types of Accident to be Reported

• Fatal Accidents
• Accidents resulting to injuries
• Diseases/Illnesses
• Dangerous occurrences
• Near misses

Advantages of Having the Supervisor as the Accident Investigator

• More familiar with the people involved.
• Have a better understanding of the process or operation.
• Know all safe work practices/rules pertaining to his/her job
• Employees may be willing to speak more freely.

Who Should Conduct Accident Investigation?

 Safety Officer/Man
• Serves as secretary of the safety and health committee
• Coordinates all safety and health programs for the employer and employees
• Conducts safety and health inspections as member of the SH committee
• Conducts investigation of accident as member of the SH Committee
• Maintains or help in the maintenance of efficient accident record system

Advantages of Having the Supervisor as the Accident Investigator

• More familiar with the people involved.
• Have a better understanding of the process or operation.
• Know all safe work practices/rules pertaining to his/her job
• Employees may be willing to speak more freely.

Investigation is a 4 Step Process

1. Control the Scene

 • Provide medical care for injured

        > First Aid

        > On Scene Evaluation

        > Transport for Medical Care

• Control existing hazards

        > Prevent further injuries

        > Get more help if needed

• Preserve evidence

        > Barricade the area of the accident, and keep everyone out!

        > The only persons allowed inside the barricade should be rescuers, law enforcers, and investigators

        > Protect the evidence until investigation is complete

2. Gather Data 

            Ask “What Happened”

• Get a brief overview of the situation from witnesses and victims.

• Not a detailed report yet, just enough to understand the basics of what happened.

            The Interview

• Put the person at ease.

– People may be reluctant to discuss the incident, particularly if they think someone will get in trouble

• Reassure them that this is a fact-finding process only.

– Remind them that these facts will be used to prevent a recurrence of the incident

• Interview as soon as possible after the incident

– Do not interrupt medical care to interview

• Interview each person separately

• Do not allow witnesses to confer prior to interview

• Take Notes!

• Ask open-ended questions

– “What did you see?”

– “What happened?”

• Do not make suggestions

• If the person is stumbling over a word or concept, do not help them out

• Use closed-ended questions later to gain more detail.

– After the person has provided their explanation, these type of questions can be used to clarify

– “Where were you standing?”

– “What time did it happen?”

• Don’t ask leading questions

– Bad: “Why was the truck operator driving recklessly?”

– Good: “How was the truck operator driving?”

• If the witness begins to offer reasons, excuses, or explanations, politely decline that knowledge and remind them to stick with the facts

• Summarize what you have been told.

– Correct misunderstandings of the events between you and the witness

• Ask the witness/victim for recommendations to prevent recurrence

– These people will often have the best solutions to the problem

• Get a written, signed statement from the witness

– It is best if the witness writes their own statement; interview notes signed by the witness may be used if the witness refuses to write a statement

           Securing Evidence      

• Examine the accident scene. Look for things that will help you understand what happened:

– Dents, cracks, scrapes, splits, etc. in equipment

– Tire tracks, footprints, etc.

– Spills or leaks

– Scattered or broken parts  

• Diagram the scene

– Use blank paper or graph paper. Mark the location of all pertinent items; equipment, parts, spills, persons, etc.

– Note distances and sizes, pressures and temperatures

– Note direction (mark north on the map)

• Take photographs

– Photograph any items or scenes which may provide an understanding of what happened to anyone who was not there.

– Photograph any items which will not remain, or which will be cleaned up (spills, tire tracks, footprints, etc.)

• Check training records

–Was appropriate training provided?

• Check equipment maintenance records

– Is regular PM or servicing provided?

– Is there a recurring type of failure?

• Check accident records

– Have there been similar accidents or injuries

involving other employees?

3. Analyze Data

• Gather all photos, drawings, interview material and other information collected at the scene.

• Determine a clear picture of what happened

• Formally document sequence of events

Develop the Sequence of Events

It is important that the sequence of events clearly describe what occurred so that someone unfamiliar with an accident is able to “see it happen” as they read. If an event is hard to understand, it may be that the description is too vague or general.

Determine Causes

• Employee actions

> Safe behavior, at-risk behavior

> Not limited to personnel involved with the accident

• Environmental conditions

> Lighting, heat/cold, moisture/humidity, dust, vapors, etc.

• Equipment condition

> Defective/operational, guards, leaks, broken parts, etc.

• Procedures

> Existing (or not), followed (or not), appropriate (or not)

• Training

> Was employee trained - when, by whom, documentation

Find Root Causes

• When you have determined the contributing factors, dig deeper!
> If employee error, what caused that behavior?
> If defective machine, why wasn’t it fixed?
> If poor lighting, why not corrected?
> If no training, why was it?

Make Recommendations

• Determine corrective actions
> Recommendations based on key contributory factors and underlying/root causes
> Select the ones likely to be most effective, most cost beneficial and most acceptable
> Establish time table
> Recommendation(s) must be communicated clearly

4. Prepare A Report

• Accident Report should contain the following:
> Background Information
> Account of the Accident
> Analysis of the Accident and Conclusion
> Recommendations for correcting the problem(s)

Implement and Follow up

• Implement corrective actions as soon as possible
• Monitor implementation of corrective actions as to their effectiveness
• Conduct follow up and review

CONCLUSION

• An ounce of prevention is better than a pound of cure, as the saying goes, but we still can’t discount the importance of that “pound of cure”.
• The only way to prevent the recurrence of an accident/incident is to have an accurate understanding of the event.

“An accident/incident report is not the end of an accident/incident response
and investigation process, it is in fact the start of the corrective process”

Thank you!