Module 15

Lesson 15

INCIDENT / ACCIDENT
INVESTIGATION

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 What is an Accident
• An unintended happening, mishap.
• Most often an accident is any unplanned event that
results in personal injury or in property damage.
• The failure of people, equipment, supplies or
surroundings to behave or react as expected causes
most accidents.

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 Types of Incident
• Minor Accidents
Accidents that cause minor injury/illness, requiring little or
no treatment or property damage.

• Serious Accidents
Accidents that cause lost time cases, visits to the local
emergency room, accidents where victims are hospitalized,
an accident involving a fatality, or damage to equipment
and/or property.

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 Types of Accidents
• Near Miss
An unplanned event that interrupts the completion of an
activity which directly involves the workers and does not
result in personal injury, illness or in property damage.

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 Causes and Contributing
Factors of Accidents
• Accident Causation Model

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 Causes and Contributing
Factors of Accidents
• Task
 Ergonomics
 Safety work procedures
 Condition changes
 Process
 Materials
 Workers
 Appropriate tools/materials
 Safety devices (including lockout)

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 Causes and Contributing
Factors of Accidents
• Material
 Equipment failure
 Machinery design/guarding
 Hazardous substances
 Substandard material

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 Causes and Contributing
Factors of Accidents
• Environment
 Weather conditions
 Housekeeping
 Temperature
 Lighting
 Air contaminants
 Personal protective equipment

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 Causes and Contributing
Factors of Accidents
• Human Factor
 Level of experience
 Level of training
 Physical capability
 Health
 Fatigue
 Stress

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 Causes and Contributing
Factors of Accidents
• Management/Process Failure
 Visible active senior management support for
safety
 Safety policies
 Enforcement of safety policies
 Adequate supervision
 Knowledge of hazards
 Hazard corrective action
 Preventive maintenance
 Regular audits

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 Who Should Perform the
Accident Investigation?
• Supervisor / Safety representative
 Minor accidents
 Near Misses
 Trends i.e., slip, trips, and falls
 Serious accidents
 Trends i.e., struck by

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 Purpose of Accident
Investigation
• Determine the sequences of events leading to failure.
• Identify the cause of the accident.
• Find methods to prevent accident from recurring.

Investigation is not intended to place blame.

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 Be Prepared
• Accident Investigation Kit - Preparing a kit of necessary
forms and tools will help you be more effective once your
investigation begins. Keep the kit where it is easily
accessed.
 Accident investigation forms
 Accident Statements
 Interview Question forms
 Graph Paper
 Other forms and worksheets, as applicable (or can
be accessed online when needed)

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 Be Prepared
 Barricade tape  Safety glasses
 Camera  Hearing protection
 Flashlight  Gloves
 Pens/pencils  Steel-toed shoes
 Rubber gloves (dependent upon
 Sample bags or location)
containers with labels  Hard hat (dependent
 Tape measure upon location)
 Personal protective  Coveralls
equipment

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 Initial Response
(Serious Accident)
• Get the first aid kit and assist the victim following
accepted standards of care, if trained to do so.
Otherwise, wait for emergency medical services to
arrive.
• Do not move the victim unless it is absolutely necessary
(e.g. the building is on fire, there are hazardous fumes in
the area, etc.)
• Turn off any equipment or power switches that need to
be turned off.
• Do not move anything in the area.

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 Initial Response
(Serious Accident)
• Make a note of the people involved that will need to be
interviewed later.
• Use barricade tape or other means to block off the area.
• Notify your departmental safety representative,
management.
• Employees should be directed to return to work to
reduce interference with rescue workers and to prevent
secondary accidents. Only affected area will be stop.

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 Initial Response
(Minor Accident)
• Get the first aid kit and assist the victim following accepted
standards of care, if required.
• Turn off any equipment or power switches that need to be turned off.
Do not move anything in the area.
• Make a note of the people involved that you will want to interview
later.
• Notify your departmental safety representative and management.
• Get your accident investigation kit and begin your investigation.

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Principal Questions to be
Answered

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 WHO?

• Who was working with him/her?

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 WHAT?
• What was the injured employee’s explanation?
• What were they doing at the time of the accident?
• What was the position at the time of the accident?
• What is the exact nature of the injury?
• What operation was being performed?
• What materials were being used?
• What safe-work procedures were provided?

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 WHAT?
• What personal protective equipment was used?
• What PPE was required?
• What elements could have contributed?
• What guards were available but not used?
• What environmental conditions contributed?
• What related safety procedures need revision?
• What hours were the employee or student working?
• What ergonomic factors were involved?

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 WHEN?
• When did the accident occur?
• When did the employee start work?
• When did the employee begin employment?
• When was job-specific training received?
• When did the supervisor last visit the job?

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 WHY?
• Why did the accident occur?
• Why did the employee do what he/she did?
• Why did co-workers do what they did?
• Why did conditions come together at that moment?
• Why was the employee in the specific position?
• Why were the specific tool/equipment selected?

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 WHERE?
• Where did the accident occur?
• Where was the employee positioned?
• Where were eyewitnesses positioned?
• Where was the supervisor at the time?
• Where was first aid initially given?

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 HOW?
• How did the accident occur?
• How did the employee get injured (specifically)?
• How could the injury have been avoided?
• How could witnesses have prevented it?
• How could witnesses have better helped?
• HOW COULD THE ACCIDENT HAVE BEEN
PREVENTED?

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 Facts and Physical Data
• Scene
Before objects are moved, cleaned, or removed, record the
scene as it was at the time of the accident.

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 Facts and Physical Data
• Take Photos!
Take pictures of the accident area from different angles
and distances to preserve the scene for later review. Take
a shot of the general area, a closer shot of the object
involved in the accident, and a close up shot of any detail
which might be important. It may be helpful to place an
object, such as a ruler or pencil, of known size into the
picture to show proportion.

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 Facts and Physical Data
• Sketch the Layout
Using graph paper, make a sketch of the objects in the
area and their locations. Use a tape measure to note the
actual distances between objects for exact reference.
Remember to include vertical measurements as well as
horizontal. Check the entire area (ceiling, walls, equipment,
and floor) for signs of damage or disturbance, or which may
in any way be related to the accident. Be thorough!

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 Facts and Physical Data
• Document Conditions
Slips and trips are one of the most common accidents at
any work site, and therefore an accident investigation is
always recommended. As you are gathering data at the
scene, if a slip or trip hazard is suspected, use a Slip and
Trip Worksheet to record conditions and help identify
contributing and root causes.

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 Facts and Physical Data
• Sequence of Events
You will also want to begin to establish the sequence of
events leading up to the accident. Identify the key events
involved. Begin by recording the accident. Work your way
backwards to fill in events leading up to the accident based
on witness statements and interviews. This information can
be referred to later when determining contributing causes
and identifying the root cause.

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 Facts and Physical Data
• People
It will be necessary to talk to people who were involved in the accident,
a witness to the accident, or who were involved in the reporting and
response to the accident. First, identify such persons and have them
write their account of what happened as soon as possible. The more
time people have to discuss the accident, the more their account may
be influenced by other's accounts and memory retention. Interview
witnesses separately. The accident statement form is used to record
witness, supervisor, and the injured employee accounts. You will need
to have several copies on hand to accommodate all involved.

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 Facts and Physical Data
• Employee Statement
As soon as feasibly possible, have the injured/ill
employee(s) complete an accident statement regarding the
circumstances leading up to the accident and what
happened that resulted in the injury/illness. The employee
should state in his/her own words what happened. Explain
that this type of paperwork is routine in accident
investigations.

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 Facts and Physical Data
• Witnesses
It is important to have all witnesses to the accident
complete an accident Statement so that information can be
reviewed later for consistencies in each account. The
witnesses should state in their own words what they
witnessed, and be encouraged to include as much detail as
possible, whether they feel it is relevant or not. Explain that
this type of paperwork is routine in accident investigations.

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 Facts and Physical Data
• Supervisor
Often the supervisor is the first person notified of an
accident. He or she should complete an accident
Statement regarding details of notification and actions
taken. The supervisor may also be able to provide
information regarding earlier behavior, activities of the
person(s) involved in the accident, or related personnel
issues.

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 Facts and Physical Data
After all statements have been taken, the investigator (Safety
Supervisor as applicable) should review them for
consistencies/inconsistencies and common themes or unique
information. This will help the investigator determine who will
need a follow up interview and what questions will need to be
asked. Use an Interview Questions form to write down what
questions will be asked for the face-to-face interview. Not all
questions must be written down since many will arise based on
what information is provided at the time of the interview;
however, all responses should be documented.

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 Facts and Physical Data
• Paperwork - There may be existing documentation that you may
need to review to determine what policies, practices, protocols,
training, and assessments are already in place. Review the
following, as appropriate.
 Written policies related to the activities of personnel
 Related health and safety programs
 Hazard assessment forms or monitoring results
 Training records
 Disciplinary action or counseling of the employee or student
injured
 Operator's manual if machinery or equipment was involved
 Written standard operating procedures (SOP)

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 Facts and Physical Data
• Parts
Parts involved in an accident can be any material, machine,
equipment, or structure involved. Identify "parts" to be
further investigated to identify areas of concern. For
complicated systems, technical experts, manufacturer
representatives, or inspectors may need to be involved in
the review.

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 Facts and Physical Data
The first priority is to preserve the evidence. Do not move
objects or remove components until interviews and pictures
have been taken and all parties that will be involved in the
investigation are present and agree to proceed. In serious
incidences involving manufactured products, parts or
components may be taken as evidence for legal purposes,
and a chain of custody may be required to prove that parts
and components have not been tampered with. You must
notify RMS of investigations involving outside
manufacturers, inspectors, or other representatives.

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 Data Analysis
The purpose of analyzing the data is to identify all of the causes
for which a corrective action is possible. Management must
review and select the corrective action(s) most likely to be
effective (i.e. the root cause), beneficial (i.e. contributing
causes), cost-effective, and acceptable, and implement them.
There are a variety of accident investigation and analysis
techniques available, some of which are more complicated than
others and may require specialized training. There are benefits
and limitations associated with every method. This program
provides techniques that most investigators can use
immediately.

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 Data Analysis
• Sequence of Events and Contributing Causes
You will need to consider the event and ask if there was some reason
(i.e. contributing cause) which caused the event to be present or to
occur. you will begin to see where you need more information and what
questions will need to be answered during interviews and analysis.
Once all of the events and conditions have been filled in, review it to
identify the event or condition which could have prevented the accident
had it been controlled or did not occur. There may be more than one
causal factor. Further investigation of events or conditions may be
necessary.

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 Data Analysis
• Fishbone Diagram
For more complicated accidents involving various elements, it may be
helpful to use the Fishbone Diagram to identify ideas regarding
contributing causes. Both tools guide you through the process of
considering various aspects and causes by providing categories to
brainstorm on or common questions to ask.
To use the Fishbone Diagram, first state the problem in the form of a
"why" question to help stimulate ideas. The investigator or team should
agree on the statement of the problem. The "bones" or branches of the
diagram are categories that can be changed or modified to suit your
subject matter.

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 Data Analysis
Suggested categories include:
 People
 Policies
 Procedures
 Processes
 Machinery
 Materials
 Environment (facilities, weather, noise, lighting, etc.)
 Technology

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 Data Analysis
Consider each category when brainstorming causes for the
problem statement. Write the cause along the vertical line
connected to the related category. The investigator or team
should review the causes to determine which one(s)
warrant further investigation.

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 Data Analysis
• Change Analysis
 This technique emphasizes change to correct the
problem.
 Examination of deviations from the norm are
scrutinized.
 Consider all problems to result from some
unanticipated change.
 Analyze the changes to determine its cause.

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 Data Analysis
• Use the following steps in this method:
 Define the problem (What happened?).
 Establish the norm (What should have happened?).
 Identify, locate, and describe the change (What,
where, when, to what extent).
 Specify what was and what was not affected.
 Identify the distinctive features of the change.
 List the possible causes.
 Select the most likely causes.

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 Data Analysis
• Behavior Analysis
Studies indicate that 90-95% of all accidents have a human
performance causal factor. This is not to say that the
person is at fault 90-95% of the time! It simply means that a
person's behavior and attitudes, along with the culture of
the workplace, are common elements which can influence
or contribute to the cause of an accident. Where human
performance is suspected as a contributing or causal
factor, further investigation is warranted.

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 Data Analysis
This evaluation will involve three factors:
 Significance - whether the person perceives the
consequence as positive (+) or negative (-).
 Timing - whether the person believes that the
consequence will occur sooner (s) rather than later
(l).
 Consistency - whether the person perceives the
consequence as certain (c) or uncertain (u).

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 Root Cause(s)
• 5 Why
Once you've identified contributing causes and/or causal
factors using one of the methods above, the next step
involves investigating why they occurred and determining
the root cause(s). (Note: It is now generally accepted that
there may be more than one root cause to a problem.)
Again, there are many methods for determining the root
cause, and all have their limitations; however, one of the
simplest methods is the "5 Why" technique. By repeatedly
asking the question "why?" you can sort through the layers
of symptoms that lead to the root cause.

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 Root Cause(s)
To complete the "5 Why" method, write down the specific
problem on the form (i.e. contributing cause, causal factor,
or the accident itself) to help formalize and describe it.
Next, ask why the problem happens and write the answer
below the question. If the answer just provided doesn't
adequately identify the root problem, ask why again and
write down that answer. Repeat this process until you have
identified the root cause and the team is in agreement.
Asking why five times is a good rule of thumb; however,
you may only need to ask why three or four times (or six or
seven) to get to the root of the problem.

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 Corrective and Preventative
Action(s)
Depending on the situation, there may only be one corrective action
identified to address the root cause, or there may be several corrective
actions that need to be taken to address other root or contributing
causes. A Corrective and Preventative Actions form can be used to list
those causes which require additional action. Once the corrective or
preventative action has been identified, it should be assigned a due
date and a responsible person to coordinate completion. This form
should be reviewed periodically to ensure progress and eventually
close out the action item by filling in the completion date. At this point,
the accident is considered "closed".

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 Investigation Report
• An accident investigation is not complete until a report is
prepared and submitted to the proper authorities.
• Suggestion of items to include in your report.

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 Investigation Report
• Background Information
 Where and when the accident occurred
 Who and what were involved
 Operating personnel and other witnesses
• Account of the Accident (What happened?)
 Sequence of events
 Extent of damage
 Accident type
 Agency or source (of energy or hazardous material)

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 Investigation Report
• Discussion (Analysis of the Accident - HOW; WHY)
 Direct causes (energy sources; hazardous
materials)
 Indirect causes (unsafe acts and conditions)
 Basic causes (management policies; personal or
environmental factors)

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 Investigation Report
• Recommendations (to prevent a recurrence) for
immediate and long-range action to remedy:
 Basic causes
 Indirect causes
 Direct causes (such as reduced quantities or
protective equipment or structures)

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Follow-Up

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 Summary
• Get help for the injured.
• Survey the scene.
• Secure the scene (initiate interim controls).
• Collect evidence.
• Analyze data (review past investigations).
• Determine causes (scientific methods).
• Follow up (eliminate hazards).

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