Accident /Incident

Investigation

Overview
Purpose of Investigation
Managing the Accident Scene
Steps in Conducting Investigation

Investigations are conducted

to:

Prevent recurrence
Comply with policies and
regulatory requirements
Maintain employee awareness

ACCIDENT
An undesired event that results
in harm to people, damage to
property, or loss to process

ILO Accident Report

Accidents - 250 M/year or 685 T/day or
475/minute or 8/second
Working children - 12 M (recorded),
12,000 are fatal
Working Adults - 3,000/day = 2/min.

Types of Accident
1. Personal injury or illness
2. Property damage
3. Combination of items 1 & 2
4. Near-miss (actually an
incident)

INCIDENT
An undesired event which,
under
slightly
different
circumstances,
could
have
resulted in harm to people,
damage to property, or loss to
process

Accidents are the result of: :

Unsafe Acts
Unsafe Conditions

UNSAFE ACTS
Behaviors which could permit
the occurrence of an accident or
incident
Deviation from standard
procedures or practices

UNSAFE CONDITIONS
Circumstances which could
permit the occurrence of an
accident or incident
Deviation
from
standard conditions
(equipment,
materials,
or
environment)

Prevention is the reason for

conducting an Accident
Investigation
Unless the unsafe acts/conditions are :

Identified and
Eliminated or controlled

similar mishaps will occur

All accidents must be

investigated:

LTI
Non-LTI
Near Miss
Chemical Spill
Property Damage
Fire and Explosion

Accident Investigations are

usually considered a
Supervisors responsibility

Advantages of Supervisors
over other investigators:
More familiar with the people
involved
Better understanding of the
operations
Personal interest in investigations

Team Effort
All employees should
understand :

What to report
How to report

What to Report

LTI
Non-LTI
Near Misses
Property Damage
Chemical Spill
Fire or Explosion

Whom to Report to:

Medical
Safety
Environmental Control
Management

Managing the Accident

Scene
Two Priorities:
Care & treatment of the
injured
Elimination or control of
remaining hazards

Care & Treatment of

Injured
Supervisors can increase their
ability to respond to Medical
Emergencies by:
Training in First Aid
Drills under normal and
abnormal conditions
Liaison with hospitals

Controlling Remaining
Hazards
If a hazardous environment or
toxic materials exist:
Notify necessary personnel
Provide PPE to potentially
exposed
Refer to MSDS

Isolate the site

To protect people from further
injury
To preserve evidence and
valuable clues

Successful investigation is
done ...
Immediately
Completely
Thoroughly

Investigate
immediately, because:
Operations are disrupted
Memories fade
Employees are at risk

Conducting the
Investigation
Gather information
Analyze the facts
Make recommendations

ACCIDENT INVESTIGATION
Guidelines:
1. Investigate immediately
2. Ensure immediate treatment
3. Secure the area
4. Record details of event (photo, sketch, etc.)
5. Collect physical evidence
6. Review other sources (victims record, friends, etc.)
7. Interview witnesses (5Ws + 1H)
8. Write causal factors (man, machine, material, method)
9. Make recommendations (effective/reliable results)

Gathering Information
Preliminary Facts:
NOI, POI, DOI, TOI
personnel involved
property damage
environmental harm

Accident Investigation
Equipment
Report form
Notebook or pad of
paper
Tape recorder
Camera (instant or
digital)
Measuring equipment

Sources of Information

Witnesses
Physical evidence at the
scene
Existing records

Witnesses

Victim and onlookers

Those who heard what happened
Saw area prior to incident
Others with info about involved
individuals, equipment or
circumstances

Interviewing Witnesses

1.
2.
3.
4.

Reassure the witness

Let the witness tell the story
Begin with open-ended questions
Dont ask leading questions

Interviewing Witnesses

5.
6.
7.
8.

Summarize
Ask for recommendations
Get written statements
Close on a positive note

ACCIDENT INVESTIGATION
Questions for reporting: WHO
- was injured?
- saw the accident?
- was working with the injured?
- had instructed/assigned the job to the injured?
- else was involved?
- has the information of events prior to the accidents?

ACCIDENT INVESTIGATION
Questions for reporting: WHAT
- is the injury?

- training had been given?

- is the damage or loss?

- were the contributory causes

of the accident?

- was the injured doing?

- had the injured been
instructed to do?
- tools/equipment/machinery
were being used?
- did the injured & any
witnesses saw?

- communication system was

used?
- is the state of health of the
injured?
- safety rules were violated?
- safety system and procedures
were there?

ACCIDENT INVESTIGATION
Questions for reporting: WHEN
- did the accident occur?
- did the damage become evident?
- did the injured start the job?
- was the explanation of hazard given?
- did the supervisor last see the injured?
- did the persons involved last have food & rest?

ACCIDENT INVESTIGATION
Questions for reporting: WHY
- did the injury occur?

- was PPE not used?

- did the communication fail?

- was there no safe system of

work?

- was the training not given?

- were the unsafe condition
permitted?

- was there no safety

instruction given?

- was the supervisor not

- was the hazard not spotted at
consulted when things
previous inspection?
started go wrong?
- was PPE not provided?
- was the supervisor not there
at the time?

ACCIDENT INVESTIGATION

Questions for reporting: WHERE

- did the accident occur?
- did the damage occur?
- was the supervisor at that time?
- was the witnesses at that time?

ACCIDENT INVESTIGATION

Questions for reporting: HOW

- did the injury occur?
- could the accident have been avoided?
- could have been the injury avoided?
- could the supervisor have prevented the
accident?
- could better design help?

Physical Evidence
Provides information about an
accident that witnesses may
overlook or take for granted

Sketches
To record important details at the
accident site for later study

Comfort Room

Electrocution
victim

Include everything that

could be important:
Floor plan from overhead view
Location of involved man,
machine, tool
Size and location of transient
evidences (spills, dust,
footprints, skid marks)

AHU

Photographs

detail
color differences
complex shapes
difficult to recall

Photographs

General area
Detailed shots
Show scale on small objects
Indicate reference point
Better to take too many than
too few

Examining Physical Evidence

Machines

EXAMINING

Tools

Materials

Machines & Tools

Physical condition
Position of switches/levers
Reading of gauges
Safeguards
Warning devices

Material

Position and condition can indicat

Misuse
Abuse
Disuse
Improper handling
Damage

Material - Chemical
If chemicals are involved:
correct item used
correct concentration
expired
contaminated
MSDS availability

If items have to be
removed from the
scene for detailed
examination:

Log and label

Secure storage & transport
Avoid contamination
Guard against tampering and loss
Appropriate HSE warnings

Environment (Work)

Weather condition
Illumination
Noise
Housekeeping

Existing Records
Employee records
Equipment records
Job or Task records
Previous Accident Investigation
reports

Workshop I - Gathering of Facts

I. Actual Accident or Simulated Accident
- Nature of Accident
- Parties involved/responsible person(s)
- Place of Accident
- Time and Date of Accident
II. Interview witnesses/victims
- 5Ws and 1 H develop at least 20 questions
III. Collected evidences, photographs, records review
15 minutes
IV. Presentation: Dramatization
10 minutes

Analyzing the Facts

Cause Analysis (root)
Change analysis

Immediate and Basic

Causes
A C C ID E N T / IL L N E S S

H A ZA R D O U S
A C TS

H A ZA R D O U S
C O N D IT IO N S

U N A W A R E
U N A B LE
U N M O T IV A T E D

U N N O T IC E D
U N C O R R E C TE D

 Look beyond the direct causes of

the accident
Find out what can be done to
eliminate the underlying reason for
the hazardous behaviors and
conditions that led to the mishap

Direct
Causes

Basic
(root)Cause
s

Direct Causes

caught in, between, or under

struck against or struck by
fall from or fall on
overexertion or stress

Basic (Root) Causes

inadequate maintenance of equipment

inadequate codes and standards
insufficient employee safety training
safe work practices inadequately followed
faulty design of work area
supervisors not performing duties

Change Analysis
Compares how a job was
actually performed with the way
it should have been performed

Change Analysis
ACTUAL
BEHAVIORS or
CONDITIONS

STANDARD
BEHAVIORS or
CONDITIONS

ACTUAL
BEHAVIORS or
CONDITIONS

STANDARD
BEHAVIORS or
CONDITIONS

SAFE
BEHAVIORS or
CONDITIONS

UNSAFE
BEHAVIORS or
CONDITIONS

Recommending Corrective
Actions

Specific
Measurable
Attainable
Realistic
Time-bound

Follow-up
Its the best way to ensure that
recommendations are carried out

Report forms require

four basic types of
information

General information
A Summary
An Analysis
Recommendations

Reports should be

Clear
Detailed
Neat
Legible

Management Approach

Training
Inspections
Hazard analysis
Safety Meetings

Accident Investigation...

Not just for incidents involving

serious injury, its for ANY
occurrence that has the
POTENTIAL of causing harm

Review
Purpose of Investigation
Managing the Accident Scene
Steps in Conducting Investigation

ACCIDENT INVESTIGATION
(General Process Flow)
Ensure
immediate
medical
treatment

Followup

Corrective
action

Secure
the area

Identify
the root
cause
(causal
factors)

Gather
facts
about the
accident:
witnesses

Document
the facts:
hard
evidence,
witness