INCIDENT REPORTING

&
INVESTIGATION
 1. What is Safety ?

It is a condition which gives you freedom from hazard,

risk, accident which may cause injury, damage and loss to
material or property damage and even death.
OR
Safety is defined as freedom from those condition that can
cause injury to persons including death or damage to
property or environment.
What is accident ?
It is an unexpected or unplanned event
which may or may not result in injury or
damage or property loss or death.

3. What is injury ?
It is defined as a harmful condition
sustained by the body as a result of an
accident.
What is hazard ?
Inherent property of a substance or an occurrence
which has potential to cause loss or damage
property, person or environment.

What is risk ?
In probability of the realization of potential for
loss or damage or injury.

What is incident?
It is an event which represents deviation from the
intended sequence of designed steps.
 OBJECTIVES

 To understand Accident Investigation

process in order to conduct more effective
accident investigations at work place.
 Understanding of various techniques in
Accident Investigation Process
 To identify root causes and recommend
preventive measures.
 WHAT IS THE NEED FOR
INVESTIGATING ACCIDENTS?

MORAL

ECONOMIC Legal

WHY
THE INVESTIGATION
 THE TEAM

Should consist of:

 The Health and Safety Officer
 The local Manager/Supervisor
 The local Safety Rep/Responsible Person
 An expert in a particular field (if needed)
 Who else – discuss!
 Aids Required
Toolkit list:
 Camera, including films etc
 Lighting/Torch
 Tape recorder/Personal dictaphone
 Mobile Telephone
 Thermometer
 Tape measure
 Clipboard/Pens etc
 Coloured chalk
 Barrier Tape
 Keep out signs
 PPE
 Protective Gloves/latex
 Absorbent Cloths/tissue
 Plastic Bags - waterproof
 Responsibilities of Team
 Take the control of the accident scene
 Prevent further injury/damage/loss
 Preserve evidence
 Log/measure facts
 Note environmental evidence
 Isolate/interview genuine witnesses/staff/persons in the vicinity
 Check relevant documentation
 Communicate/liase with other team members/mgt
 Co-ordinate ongoing investigation information
 Determine causes
 Prepare/complete accident investigation report
 Influence changes necessary to prevent recurrence
 Environment
Measurements
 Temperature
 Lighting conditions
 Noise/vibrations
 Space constraints
 Condition of flooring
 Ceiling
 Wet/slippery conditions
 Obstructions
 Traffic
 Weather
 Access/egress
RECORDS

 Reports
 MOMs
 Risk Assessments
 Training Records
 Monitoring Procedures
STRUCTURING THE
INVESTIGATION
THE INITIAL RESPONSE

Take control at the scene

 Make sure you don’t injure yourself
 Prevent secondary accidents
 Call for a first aider/emergency services
 Call for Accident Investigation team
 Preserve accident scene
 IDENTIFICATION OF
EVIDENCE

Critical in any investigation identify

 Sequence of events
 Outcome (Near misses, Major injuries or Fatal)
 Causes
 EVIDENCE

Evidence must be factual

 it may be something tangible
 it may be the environmental conditions
which prevailed at accident time
RECORDING EVIDENCE

Recording surroundings:
 Isolate the area /deal with any injured person(s) first
 Observe position of injured person(s)
 Time of day/Date
 Environment conditions
 Photographs/Film
 RECORDING EVIDENCE

Injured Person The Injury

 Name/ D.O.B  Nature of injury
 Employment details  Treatment
 Training received
 Experience/knowledge
RECORDING EVIDENCE

Four key areas:

 Witnesses
 Reports
 Equipment, Plant etc
 Documents and Procedural Manuals
RECORDING EVIDENCE

Witnesses
Care must be exercised when taking any statements
or when handling witnesses
RECORDING EVIDENCE

Site Accident Summary Reports:

Medical Department
Supervisor
Safety Advisor
RECORDING EVIDENCE
Equipment
 Model/make of
 Serial number
 Age
 Intended/actual use
 Any modifications
 Maintenance records
 Guarding
 Interlocks
 Safety Checklists
 RECORDING EVIDENCE
Documents and Procedural manuals including:
Riskassessments
Technical instructions
Permits to work
Method statements
Records of training
Records of previous problems/accidents

All documentation must be accessible, evidence used

must be recorded, numbered, cross-referenced and
signed by originators
INTERVIEWING SKILLS
INTERVIEWING SKILLS

Successful Investigative Interviews:

 A two-way process
 Need not be an interrogation
 Establishment of Trust
 INTERVIEWING SKILLS

Examples of witnesses:
 The Injured
 Witnesses to accidents / events (visual & aural)
 Managers and Supervisors
 INTERVIEWING SKILLS

Key Points
 Questioning should be open-ended to encourage
witnesses to give evidence
 Useful to have visual aids
though do not put suggestions forward to interviewee
 Statements should be written and signed with date and
time of the interview
INTERVIEWING SKILLS
Personal needs
People need to feel:
 valued
 appreciated
 listened to
 understood
 INTERVIEWING SKILLS
Practical needs
 Reasons for the interview
 Immediate & underlying causes can be established
 Facts accounted for/evaluated
 Agreement on actions to be taken
INTERVIEWING SKILLS
Improved techniques:
 Listen and respond with empathy
 Ask for help and encourage involvement
 Explain and ask for explanations
 Always be truthful
INFORMATION
PREPARATION
ROOT CAUSE ANALYSIS
 ACCIDENT CAUSATION
Accident Domino Theory

Accidents happen as a result of a sequence of events, the theory

is, that if you interfere at any stage, the accident will not occur,
and therefore there will be no loss or injury.

Loss/Injury
ACCIDENT INVESTIGATION
MODELS

 Change and Change Analysis

 Fault Tree Analysis

Change and Change Analysis

4. Set down all the

1. Consider the
differences
accident situation

3. Compare 5. Analyse differences in

Terms of effect on the
accident

2. Consider a comparable
Accident-free situation

6. Integrate the information into

The investigative process
 Change and Change Analysis
Factors Present Prior Differences? Affective Changes
Situation Comparable
Situation

Working Condition
Environmental
Normal/Overtime
Workspace
Floor condition
People
Operator?
Fellow worker?
Supervisor?
Fault Tree Analysis
(Example)

B1 B1

1 2
C1 C2

4 3
Fault Tree Accidental Starting
of the Machine

OR

AND
Short Circuit
Between 1 & 2

Accidental Contact Accidental Contact

At C1 At C2

OR OR

Mechanical Accidental Mechanical Accidental

Blocking of Pressing of Blocking of Pressing of
C1 B1 C2 B2
 Fault Tree Analysis

 Can prevent investigator bias.

 Advantages:
– Identifies possible paths from basic cause;
– Shows relationships, system deficiencies;
– Considers ‘hardware’ and human failings;
– Clear record of analytical path followed;
– Rational basis for decision making.
 REPORT WRITING

Should consider:
1. What is the purpose of the report
2. Who will need it
3. Report structure
4. Style
5. Presentation
 REPORT WRITING

3. Report Structure 4. Style 5. Presentation

 Main body first ‘Simplicity’ check layout
 Conclusions & No ambiguous check content
recommendations sentences check words used i.e
Exaggeration punctuation/grammar
 Introduction Overuse of adjectives name & date
 Final stage: etc
appendices/refs etc Conclusions - brief, to
the point
 REPORT WRITING

Once the draft report is completed

ensure that the following is
covered:
 Coherent description of the events leading
up to the accident
 Rational view of what should be done in the
way of remedial actions
 SUMMARY
A successful accident investigation process should
incorporate:
 A causal model representing a ‘system based approach
 Involvement of key, relevant individuals
 Procedures/protocols to structure and support the
investigation
 Identification of both immediate and underlying causes
 Development of recommendations that address the
latter
 Implementation of these recommendations and update
of relevant risk assessments
 Follow up to ensure, actions taken are successful
 Feedback to relevant parties to share learning
 Development of an accessible database
THANK YOU
 Case study-1
5.3mØ

Opening for Hoist

Hukchuk Arrangement

Work-Platform 0.9m
220m

A A
~300mm 5m

1.5m
~9m
Hoist

16mØ A-A
 R x 2.025 = 4000x 0.033
R = 65
Horizontal Force Required= 65 X 0.1(µ)
= 6.5 kg

4m 6mm thick
SS Diary vessel 4T
4m Weighing 4T

0.033m
R 2.025m