You’re rushing to make your morning coffee/tea,

after face wash you grab the mug, but it slips from
your hand. It shatters on the floor

Immediate Cause: wet hand, smooth ceramic, lose grip

Root Cause: Time Pressure/ In Rush
 Accident Investigation

Occupational Health and Safety (CH161)

Ghulam Ishaq Khan Institute of Engineering Sciences & Technology 2
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What is an accident ?
An unwanted, unplanned event that causes injuries, illnesses, or property damage.

o Bad event caused by error or by chance.

o Unintentional, results in some damage or injury.
o Result of the failure of people, equipment, materials or environment to
react as expected.

For Example:
• A car crash
• Some equipment malfunctions in a factory and injures the workers
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What is an Incident ?

o Includes all ‘undesired

circumstances’ and ‘near
misses’ which could cause
accidents.
o Big or small, good or bad,
intentional or unintentional.
o A bank robbery, a funny or
controversial situation etc.
 5

• Undesired circumstance: A set of conditions or circumstances that have the potential to

cause injury or ill health, e.g., untrained operators working on heavy machinery.
• Near miss: An event that, while not causing harm, has the potential to cause injury or ill
health.

  

Undesired circumstance Near Miss Accident

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Types of Accidents
FAC (First aid case):
An accident occurring while on the job and which is treated at site by the qualified first aider
(one time treatment) or any minor industrial injury which normally do not need medical
intervention. The injured person resume his work .
MTC (Medical treatment case):
Medical treatment case an accident occurring in plant, and which required intervention of
qualified medical professional. The injured person required medication more than a day and he
may or may not resume duty on same day.

LTA or LTI (Lost time accident or incident ):

A lost time injury (LTI) is an injury sustained by an employee that will ultimately lead to the loss
of productive work time in the form of worker delays. An injury is considered a lost time injury
only when the worker is unable to perform the regular duties of the job, takes time off for
recovery, or is assigned modified work duties for the recovery period.
 Accident Ratio Study

HEINRICH’S
SAFETY
SAFETY
PYRAMID
TRIANGLE
 9
Reasons for Incident/Accident Investigation

1. Logic and Understanding

2. Legal Reasons

3. Benefits
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Reasons for Incident/Accident Investigation
1- Logic and Understanding
• All incidents/accidents have causes … eliminate the cause and eliminate
future incidents.
• The direct and indirect causes of an incident/accident can be discovered
through investigation.
• Corrective action indicated by the causation can be taken to eliminate future
incidents/accidents.
• Valuable information and understanding can be gained from carrying out
accident/incident investigations.
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Reasons for Incident/Accident Investigation
2- Legal Reasons

• To ensure that the organization is operating in compliance with legal

requirements.

• Company has a positive attitude to health and safety.

• The investigation will also provide essential information for insurers in the

event of an employer’s liability or other claim.

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Reasons for Incident/Accident Investigation
3- Benefits
• The prevention of similar events occurring again.

• The prevention of business losses due to disruption immediately after the

event, loss of production, loss of business through a lowering of reputation

or inability to deliver, and the costs of criminal and legal actions.

• Improvement in employee morale and general attitudes to HS.

• Improving management skills to improve health and safety performance

throughout the organization.

 13
When Should the Investigation Be Conducted?
Immediate information from the person suffering the accident often proves to be
most useful.

• Factors are fresh in the minds of witnesses.

• Witnesses have had less time to talk.

• Physical conditions have had less time to change.

• More people are likely to be available.

• Take immediate action to prevent a recurrence and to demonstrate management

commitment to improvement.
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INVESTIGATION PROCESS

(1). Immediate
Action (5). Analyse
Information
(2). Plan the
Investigation
(6). Recommend
(3). Collect Solution
Information
(7). Report
(4). Organize Outcomes
Information
 15
1- Immediate Action

• Does anyone require medical attention?

• How can the incident scene be secured and taken control of?

• Are there any hazards, that pose a danger to yourself or other persons, that

need removing?

• Was any equipment involved in the incident?

• Were any departmental vehicles involved in the incident?

• Does any individual or organisation need to be informed of the incident?

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2- Plan The Investigation

• What is the time frame for the investigation?

• Who do I need to speak to?

• Does anything need to be photographed?

• Do you need to draw a sketch plan of the incident scene?

• What other documents need to be collected or sighted?

• Who do I report the investigation findings to?

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2- Plan The Investigation
Preparation for investigation

 Seal the accident area.

 Interview witnesses.

 Draw and take measurements of the

accident area.

 Take samples.
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3- Collect Information

• The date, time and location of the incident.

• The people involved.

• Any known events leading up to the incident.

• What was happening at the time of the incident.

• Weather conditions.
 19
3- Collect Information (Conducting Interviews)

• Purpose for investigating the incident is to find out why it happened.

• If any witnesses are reluctant to speak to you, assure them that the
investigation aims to understand, not assign blame or liability.
• If possible, speak to witnesses at the scene of the incident.
• Speak to people separately.
• Always use simple language and avoid acronyms.
• End each interview on a positive and encouraging
note.
Who, what, when, where and how
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3- Collect Information (Conducting interviews)

• Open questions:
• What did you see?
• Who else was present at the scene?
• When did the incident happen?
• Closed questions:
• Are you feeling better today?
• Are you happy?
• Multiple questions:
• Did you see the staircase tread breaking and the teacher
walking down the staircase while carrying a box?
 21
3- Collect Information (Recording Statements )

• Recording oral information is essential in creating a written document,

often referred to as 'taking a statement' in investigation procedures."
• In health and safety investigations, there is no assignment of blame, and
liability is linked to the investigation's findings.
• It is important to note that the gathered information will not be presented
as evidence in a court of law.
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3- Collect Information (Recording the Scene)

• Photographs are the most useful investigation tools and

can eliminate the need to write descriptions.

• Photographs provide a permanent record of:

✓ The original scene and as things change.

✓ Any scratches, dents and perishable evidence (e.g., Tyre marks, bruises).

✓ Before and after views (e.g., Scene, equipment).

✓ Comparison between damaged and undamaged equipment

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4- Organise Information

• Put it into some order.

• Timeline chart.
 24
5- Analyse Information

• To determine the cause of the incident, analyze the timeline events by

repeatedly asking 'why' until the root cause is identified.
• Identify the possible causes and determine which are within the control of
workplace.
• Can you apply a solution to a possible cause if it is outside the control of
the workplace ?
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5- Analyse Information
 26

 Say what happened step-by-step.

 Analyze the events with the 6 key questions:

1. Who? Who saw the crash?

2. What? What happened to the brakes?

3. When? When did the brakes fail?
4. Where? Where were the replacement brakes?
5. Why?
Why wasn’t the mechanic told?
6. How?
How did the crash happen?
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5- Analyse Information
• Immediate Causes:
• Unsafe acts, Unsafe conditions
• Underlying or Root Causes: Reasons behind the immediate causes.
Often failures in the management system:
✓ No supervision
✓ No PPE provided
✓ No training
✓ No maintenance
✓ No checking or inspections
✓ Inadequate or no risk assessments
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6- Recommend Solutions
Sometimes it is easier to look for solutions by using tables or columns.
• In one column, list the possible causes you found during your analysis of the
timeline.
• In the next column, indicate whether the possible causes are within the control
of the workplace.
• In the third column, write all the possible solutions.
➢ Address hazardous conditions promptly; interim actions can be considered.
➢ Underlying causes will require more complex actions:
➢ will take time, effort, disruption and money
➢ need for prioritisation
 29
6- Recommend Solutions

• Elimination – Completely remove the risk.

• Substitution – Replace the risk with a less dangerous one.

• Engineering – Redesign work processes or equipment.

• Administration – Provide training and/or procedures.

• Personal protective equipment – Use personal protective equipment.

 30
7- Report Outcomes

• Report the investigation findings. • Say what happened.

• Include all gathered data and • Say which were the surface causes.

information. • Say which were the root causes.

• Conclude with an executive • Say what needs to be done to avoid

summary. future accidents.

“A
“Remember, having a workplace incident is regrettable, but GOOD
not learning from it is unforgivable. Take an action when you REPORT”
are aware of one.”
 31
Act as Detective

Play the role of a Home Safety

Investigator. Use what you learned in
the lecture to:

[Link] the Root Cause using the 5

Whys.

[Link] Hierarchy of
Controls measures to prevent this from
ever happening again.
 32
Word Scramble
Your Task:
Unscramble the following words related to accident investigation. The definitions are your clues!

1.T N I C D I N E (The broader umbrella term for any unwanted event) INCIDENT

2.R A E N S S I M (An event that could have caused harm but didn't) NEAR MISS
NEAR MISS

3.S U O C A T R O O (The fundamental, systemic reason something happened) ROOT

ROOTCAUSE
CAUSE

4.E R Y G O H A R H H C O T R N O L S (A ranking of safety solutions from best to worst) HIERARCHY

OF CONTROLS HIERARCHY OF CONTROLS
5.I V E D N E E C R P E S E R V O I T A N (The first step after securing an accident scene) EVIDENCE
PRESERVATION
EVIDENCE PRESERVATION
SUMMARY

Workplace Incidents:
• Are caused by unsafe acts and conditions
• Can be Prevented
• Must be reported (including serious incidents and near misses)
• Must be investigated immediately to determine root cause(s)

• Rely on fostering a positive safety culture.

 HOME WORK
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Thank you !