Accident Reporting &

Investigation
Paul Craythorne
Health, Safety & Environmental Advisor

Accident Reporting &

Investigation

Course Objectives

to understand:
accident definition
accident causation
accident costs
accident prevention
accident reporting/notification
accident investigation

Accident Reporting &

Investigation

Common Uninformed Comments

accidents just happen
we dont have many accidents
safety is expensive
the insurance will pay
safety is just common sense

Accident Reporting &

Investigation

Accident Definition
what

is an accident?

unplanned & uncontrolled event

that led to, or could have led to:
injury to persons, damage to
property/plant/equipment, impairment
to the environment or some other loss
to the company

Accident Reporting &

Investigation

Accident Definition

accident types

minor dangerous occurrence

near miss
plant/equipment damage
minor injury
lost time injury
disablement/fatality

Accident Reporting &

Investigation

Accident Definition

Frank Bird (Accident Triangle)

600 near misses

30 property damage
10 minor injuries
1 serious injury (lost time or fatal)

Accident Reporting &

Investigation

Accident Causation
environment
personal fault
unsafe act
unsafe condition
accident
injury/damage

Accident Reporting &

Investigation

Accident Causation

causal factors
individual
job
organisation

Accident Reporting &

Investigation

Accident Causation

causal factors
individual
knowledge
skills
training
experience
personality
attitude
risk perception

Accident Reporting &

Investigation

Accident Causation

causal factors
job

task
workload
equipment
controls
procedures
environment

Accident Reporting &

Investigation

Accident Causation

causal factors
organisation
culture
leadership
resources
work patterns
communications

Accident Reporting &

Investigation

Accident Causation

Kings Cross Fire (1987) - 31died

discarded cigarette
accumulation of rubbish
poor cleaning regime
wooden escalator
failure of fire fighting equipment
lack of emergency training
poor safety culture

Accident Reporting &

Investigation

Accident Causation

Herald of Free Enterprise (1987) 189 died

failure to close bow doors

no checking/reporting system
commercial pressures
internal friction
disease of sloppiness

Accident Reporting &

Investigation

Accident Causation

Clapham Junction (1988) - 35 died & 500

injured

signal failure
incorrect maintenance
degradation of working practices
training problems
communication problems
poor supervision
excessive working hours
failure to learn lessons

Accident Reporting &

Investigation

Accident Causation

Piper Alpha (1988) - 167 died

maintenance error
inexperience
poor maintenance procedures
communications breakdown
permit to work system fault
safety procedures not practised

Accident Reporting &

Investigation

Accident Causation

Automotive Supplier (1999) - 1 died

poor safety culture

lack of guarding
lack of training
poor perception of risk
no safe systems of work
no risk assessment programme
no effective accident system
no communication

Accident Reporting &

Investigation

Accident Costs
insured costs
uninsured costs

Accident Reporting &

Investigation

Accident Prevention

reasons
humane
economic
legal

Accident Reporting &

Investigation

Accident Prevention

control measures

safety procedures/work instructions

adequate training
effective communications
good housekeeping
guards/safety devices/warning signs
adequate working environment
regular safety inspections
risk assessment

Accident Reporting &

Investigation

Accident Reporting/Notification
internal report form
HSE RIDDOR report
injury claim requirement

Accident Reporting &

Investigation

Accident Investigation

reasons

identify root causes

identify faults
identify corrective/preventative action
prevent recurrence

Accident Reporting &

Investigation

Accident Investigation

investigation team

supervisor
safety rep
engineer
manager
safety officer

Accident Reporting &

Investigation

Accident Investigation

investigation objectives

establish chain of events

identify root causes
identify faults
identify corrective/preventative action

Accident Reporting &

Investigation

Accident Investigation

investigation techniques

attend promptly
ensure medical attention
leave scene undisturbed
take photographs/sketches
take measurements
take samples
gather documentation
interview witnesses

Accident Reporting &

Investigation

Accident Investigation

investigation techniques
interviewing witnesses
explain purpose
their version of events
do not listen to hear say
ask open questions
avoiding leading or implying
do not apportion blame
express appreciation

Accident Reporting &

Investigation

Accident Investigation

investigation report

identify team
summarise consequential events
identify root causes
describe other weaknesses
identify corrective/preventative action
allocate responsibility & timescale