ACCIDENT

INVESTIGATION
HEALTH & SAFETY PROJECT REPORT

GROUP:
RETISH DESHMUKH
SAYED SARWAR HUSSAIN

WHAT IS AN INCIDENT?
An incident is any unplanned event that causes injury. A dangerous occurrence is any
event that could have caused injury, but did not. The term incident will be used to
describe both incidents and dangerous occurrences.
WHAT IS AN INCIDENT INVESTIGATION?
An incident investigation is the account and analysis of an incident based on information
gathered by a thorough examination of all contributing factors and causes involved.
Please note: The term incident is used in some situations and jurisdictions to cover both an
"accident" and "incident". It is argued that the word "accident" implies that the event was related
to fate or chance. When the root cause is determined, it is usually found that many events were
predictable and could have been prevented if the right actions were taken -- making the event not
one of fate or chance (thus, the word incident is used). For simplicity, we will use the term
accident to mean all of the above events.
The information that follows is intended to be a general guide for supervisors or joint
occupational health and safety committee members. When accidents are investigated, the
emphasis should be concentrated on finding the root cause of the accident rather than the
investigation procedure itself so you can prevent it from happening again. The purpose is to find
facts that can lead to actions, not to find fault. Always look for deeper causes. Do not simply
record the steps of the event.
Reasons to investigate a workplace accident include:

most importantly, to find out the cause of accidents and to prevent similar accidents in the
future

to fulfill any legal requirements

to determine the cost of an accident

to determine compliance with applicable safety regulations

to process workers' compensation claims

Incidents that involve no injury or property damage should still be investigated to determine the
hazards that should be corrected. The same principles apply to a quick inquiry of a minor
incident and to the more formal investigation of a serious event.

Who should do the accident Investigation?

Ideally, an investigation would be conducted by someone experienced in accident causation,

experienced in investigative techniques, fully knowledgeable of the work processes, procedures,
persons, and industrial relations environment of a particular situation.
Some jurisdictions provide guidance such as requiring that it must be conducted jointly, with
both management and labor represented, or that the investigators must be knowledgeable about
the work processes involved.
In most cases, the supervisor should help investigate the event. Other members of the team can
include:

employees with knowledge of the work

safety officer

health and safety committee

union representative, if applicable

employees with experience in investigations

"outside" expert

representative from local government

Should the immediate supervisor be on the team?

The advantage is that this person is likely to know most about the work and persons involved and
the current conditions. Furthermore, the supervisor can usually take immediate remedial action.
The counter argument is that there may be an attempt to gloss over the supervisors shortcomings
in the accident. This situation should not arise if the accident is investigated by a team of people,
and if the worker representative(s) and the members review all accident investigation reports
thoroughly.

Why look for the root cause?

An investigator who believes that accidents are caused by unsafe conditions will likely try to
uncover conditions as causes. On the other hand, one who believes they are caused by unsafe
acts will attempt to find the human errors that are causes. Therefore, it is necessary to examine
some underlying factors in a chain of events that ends in an accident.
The important point is that even in the most seemingly straightforward accidents, seldom, if
ever, is there only a single cause. For example, an "investigation" which concludes that an

accident was due to worker carelessness, and goes no further, fails to seek answers to several
important questions such as:

Was the worker distracted? If yes, why was the worker distracted?

Was a safe work procedure being followed? If not, why not?

Were safety devices in order? If not, why not?

Was the worker trained? If not, why not?

An inquiry that answers these and related questions will probably reveal conditions that are more
open to correction than attempts to prevent "carelessness".

What are the steps involved in investigating an accident?

The accident investigation process involves the following steps:

Report the accident occurrence to a designated person within the organization

Provide first aid and medical care to injured person(s) and prevent further injuries or
damage

Investigate the accident

Identify the causes

Report the findings

Develop a plan for corrective action

Implement the plan

Evaluate the effectiveness of the corrective action

Make changes for continuous improvement

As little time as possible should be lost between the moment of an accident or near miss and the
beginning of the investigation. In this way, one is most likely to be able to observe the conditions
as they were at the time, prevent disturbance of evidence, and identify witnesses. The tools that

members of the investigating team may need (pencil, paper, camera, film, camera flash, tape
measure, etc.) should be immediately available so that no time is wasted.

What should be looked at as the cause of an accident?

Accident Causation Models

Many models of accident causation have been proposed, ranging from Heinrich's domino theory
to the sophisticated Management Oversight and Risk Tree (MORT).
The simple model shown in Figure 1 attempts to illustrate that the causes of any accident can be
grouped into five categories - task, material, environment, personnel, and management. When
this model is used, possible causes in each category should be investigated. Each category is
examined more closely below. Remember that these are sample questions only: no attempt has
been made to develop a comprehensive checklist.

Figure 1: Accident Causation

Task
Here the actual work procedure being used at the time of the accident is explored. Members of
the accident investigation team will look for answers to questions such as:

Was a safe work procedure used?

Had conditions changed to make the normal procedure unsafe?

Were the appropriate tools and materials available?

Were they used?

Were safety devices working properly?

Was lockout used when necessary?

For most of these questions, an important follow-up question is "If not, why not?"

Material
To seek out possible causes resulting from the equipment and materials used, investigators might
ask:

Was there an equipment failure?

What caused it to fail?

Was the machinery poorly designed?

Were hazardous substances involved?

Were they clearly identified?

Was a less hazardous alternative substance possible and available?

Was the raw material substandard in some way?

Should personal protective equipment (PPE) have been used?

Was the PPE used?

Were users of PPE properly trained?

Again, each time the answer reveals an unsafe condition, the investigator must ask why this
situation was allowed to exist.

Environment

The physical environment, and especially sudden changes to that environment, are factors that
need to be identified. The situation at the time of the accident is what is important, not what the
"usual" conditions were. For example, accident investigators may want to know:

What were the weather conditions?

Was poor housekeeping a problem?

Was it too hot or too cold?

Was noise a problem?

Was there adequate light?

Were toxic or hazardous gases, dusts, or fumes present?

Personnel
The physical and mental condition of those individuals directly involved in the event must be
explored. The purpose for investigating the accident is not to establish blame against someone
but the inquiry will not be complete unless personal characteristics are considered. Some factors
will remain essentially constant while others may vary from day to day:

Were workers experienced in the work being done?

Had they been adequately trained?

Can they physically do the work?

What was the status of their health?

Were they tired?

Were they under stress (work or personal)?

Management
Management holds the legal responsibility for the safety of the workplace and therefore the role
of supervisors and higher management and the role or presence of management systems must
always be considered in an accident investigation. Failures of management systems are often
found to be direct or indirect factors in accidents. Ask questions such as:

Were safety rules communicated to and understood by all employees?

Were written procedures and orientation available?

Were they being enforced?

Was there adequate supervision?

Were workers trained to do the work?

Had hazards been previously identified?

Had procedures been developed to overcome them?

Were unsafe conditions corrected?

Was regular maintenance of equipment carried out?

Were regular safety inspections carried out?

This model of accident investigations provides a guide for uncovering all possible causes and
reduces the likelihood of looking at facts in isolation. Some investigators may prefer to place
some of the sample questions in different categories; however, the categories are not important,
as long as each pertinent question is asked. Obviously there is considerable overlap between
categories; this reflects the situation in real life. Again it should be emphasized that the above
sample questions do not make up a complete checklist, but are examples only.

How are the facts collected?

The steps in accident investigation are simple: the accident investigators gather information,
analyze it, draw conclusions, and make recommendations. Although the procedures are
straightforward, each step can have its pitfalls. As mentioned above, an open mind is necessary
in accident investigation: preconceived notions may result in some wrong paths being followed
while leaving some significant facts uncovered. All possible causes should be considered.
Making notes of ideas as they occur is a good practice but conclusions should not be drawn until
all the information is gathered.

Injured workers(s)
The most important immediate tasks--rescue operations, medical treatment of the injured, and
prevention of further injuries--have priority and others must not interfere with these activities.
When these matters are under control, the investigators can start their work.

Physical Evidence

Before attempting to gather information, examine the site for a quick overview, take steps to
preserve evidence, and identify all witnesses. In some jurisdictions, an accident site must not be
disturbed without prior approval from appropriate government officials such as the coroner,
inspector, or police. Physical evidence is probably the most non-controversial information
available. It is also subject to rapid change or obliteration; therefore, it should be the first to be
recorded. Based on your knowledge of the work process, you may want to check items such as:

positions of injured workers

equipment being used

materials or chemicals being used

safety devices in use

position of appropriate guards

position of controls of machinery

damage to equipment

housekeeping of area

weather conditions

lighting levels

noise levels

time of day

You may want to take photographs before anything is moved, both of the general area and
specific items. Later careful study of these may reveal conditions or observations missed
previously. Sketches of the accident scene based on measurements taken may also help in
subsequent analysis and will clarify any written reports. Broken equipment, debris, and samples
of materials involved may be removed for further analysis by appropriate experts. Even if
photographs are taken, written notes about the location of these items at the accident scene
should be prepared.

Eyewitness Accounts
Although there may be occasions when you are unable to do so, every effort should be made to
interview witnesses. In some situations, witnesses may be your primary source of information
because you may be called upon to investigate an accident without being able to examine the
scene immediately after the event. Because witnesses may be under severe emotional stress or

afraid to be completely open for fear of recrimination, interviewing witnesses is probably the
hardest task facing an investigator.
Witnesses should be kept apart and interviewed as soon as possible after the accident. If
witnesses have an opportunity to discuss the event among themselves, individual perceptions
may be lost in the normal process of accepting a consensus view where doubt exists about the
facts.
Witnesses should be interviewed alone, rather than in a group. You may decide to interview a
witness at the scene of the accident where it is easier to establish the positions of each person
involved and to obtain a description of the events. On the other hand, it may be preferable to
carry out interviews in a quiet office where there will be fewer distractions. The decision may
depend in part on the nature of the accident and the mental state of the witnesses.

Interviewing
Interviewing is an art that cannot be given justice in a brief document such as this, but a few do's
and don'ts can be mentioned. The purpose of the interview is to establish an understanding with
the witness and to obtain his or her own words describing the event:

DO...

put the witness, who is probably upset, at ease

emphasize the real reason for the investigation, to determine what happened and why

let the witness talk, listen

confirm that you have the statement correct

try to sense any underlying feelings of the witness

make short notes or ask someone else on the team to take them during the interview

ask if it is okay to record the interview, if you are doing so

close on a positive note

DO NOT...

intimidate the witness

interrupt

prompt

ask leading questions

show your own emotions

jump to conclusions

Ask open-ended questions that cannot be answered by simply "yes" or "no". The actual questions
you ask the witness will naturally vary with each accident, but there are some general questions
that should be asked each time:

Where were you at the time of the accident?

What were you doing at the time?

What did you see, hear?

What were the environmental conditions (weather, light, noise, etc.) at the time?

What was (were) the injured worker(s) doing at the time?

In your opinion, what caused the accident?

How might similar accidents be prevented in the future?

If you were not at the scene at the time, asking questions is a straightforward approach to
establishing what happened. Obviously, care must be taken to assess the credibility of any
statements made in the interviews. Answers to a first few questions will generally show how well
the witness could actually observe what happened.
Another technique sometimes used to determine the sequence of events is to re-enact or replay
them as they happened. Obviously, great care must be taken so that further injury or damage does
not occur. A witness (usually the injured worker) is asked to reenact in slow motion the actions
that preceded the accident.

Background Information
A third, and often an overlooked source of information, can be found in documents such as
technical data sheets, health and safety committee minutes, inspection reports, company policies,
maintenance reports, past accident reports, formalized safe-work procedures, and training
reports. Any pertinent information should be studied to see what might have happened, and what
changes might be recommended to prevent recurrence of similar accidents.

What should I know when making the analysis and conclusions?

At this stage of the investigation most of the facts about what happened and how it happened
should be known. This has taken considerable effort to accomplish but it represents only the first
half of the objective. Now comes the key question--why did it happen? To prevent recurrences of
similar accidents, the investigators must find all possible answers to this question.
You have kept an open mind to all possibilities and looked for all pertinent facts. There may still
be gaps in your understanding of the sequence of events that resulted in the accident. You may
need to reinterview some witnesses to fill these gaps in your knowledge.

When your analysis is complete, write down a step-by-step account of what happened
(your conclusions) working back from the moment of the accident, listing all possible
causes at each step. This is not extra work: it is a draft for part of the final report. Each
conclusion should be checked to see if:

it is supported by evidence

the evidence is direct (physical or documentary) or based on eyewitness accounts, or

the evidence is based on assumption.

This list serves as a final check on discrepancies that should be explained or eliminated.

Why should recommendations be made?

The most important final step is to come up with a set of well-considered recommendations
designed to prevent recurrences of similar accidents. Once you are knowledgeable about the
work processes involved and the overall situation in your organization, it should not be too
difficult to come up with realistic recommendations. Recommendations should:

be specific

be constructive

get at root causes

identify contributing factors

Resist the temptation to make only general recommendations to save time and effort.
For example, you have determined that a blind corner contributed to an accident. Rather than just
recommending "eliminate blind corners" it would be better to suggest:

install mirrors at the northwest corner of building X (specific to this accident)

install mirrors at blind corners where required throughout the worksite (general)

Never make recommendations about disciplining a person or persons who may have been at
fault. This would not only be counter to the real purpose of the investigation, but it would
jeopardize the chances for a free flow of information in future accident investigations.
In the unlikely event that you have not been able to determine the causes of an accident with any
certainty, you probably still have uncovered safety weaknesses in the operation. It is appropriate
that recommendations be made to correct these deficiencies.

The Written Report

If your organization has a standard form that must be used, you will have little choice in the form
that your written report is to be presented. Nevertheless, you should be aware of, and try to
overcome, shortcomings such as:

If a limited space is provided for an answer, the tendency will be to answer in that space despite
recommendations to "use back of form if necessary."

If a checklist of causes is included, possible causes not listed may be overlooked.

Headings such as "unsafe condition" will usually elicit a single response even when more than
one unsafe condition exists.

Differentiating between "primary cause" and "contributing factors" can be misleading. All
accident causes are important and warrant consideration for possible corrective action.

Your previously prepared draft of the sequence of events can now be used to describe what
happened. Remember that readers of your report do not have the intimate knowledge of the
accident that you have so include all pertinent detail. Photographs and diagrams may save many
words of description. Identify clearly where evidence is based on certain facts, eyewitness
accounts, or your assumptions.
If doubt exists about any particular part, say so. The reasons for your conclusions should be
stated and followed by your recommendations. Weed out extra material that is not required for a
full understanding of the accident and its causes such as photographs that are not relevant and
parts of the investigation that led you nowhere. The measure of a good accident report is quality,
not quantity.
Always communicate your findings with workers, supervisors and management. Present your
information 'in context' so everyone understands how the accident occurred and the actions in
place to prevent it from happening again.

What should be done if the investigation reveals human error?

A difficulty that has bothered many investigators is the idea that one does not want to lay blame.
However, when a thorough worksite accident investigation reveals that some person or persons
among management, supervisor, and the workers were apparently at fault, then this fact should
be pointed out. The intention here is to remedy the situation, not to discipline an individual.
Failing to point out human failings that contributed to an accident will not only downgrade the
quality of the investigation. Furthermore, it will also allow future accidents to happen from
similar causes because they have not been addressed.
However never make recommendations about disciplining anyone who may be at fault. Any
disciplinary steps should be done within the normal personnel procedures.

How should follow-up be handled?

Management is responsible for acting on the recommendations in the accident investigation
report. The health and safety committee, if you have one, can monitor the progress of these
actions.
Follow-up actions include:

Respond to the recommendations in the report by explaining what can and cannot be
done (and why or why not).

Develop a timetable for corrective actions.

Monitor that the scheduled actions have been completed.

Check the condition of injured worker(s).

Inform and train other workers at risk.

Re-orient worker(s) on their return to work.

REFERENCES:
[Link]

[Link]