ACCIDENT

INVESTIGATION
Accidents are CAUSED
CAUSED…they
…they
do not just happen!
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Accident Investigation Purposes of Accident Investigation

A methodical effort to collect and interpret the
To establish all facts

facts of accident.

To draw conclusion

An inquiry as to how and why the accident

To make recommendations
occurred in order to explore actions that should

To prevent recurrence
be taken to prevent or minimize recurrence of
the accident.

Most important thing-
thing- Investigation is not
intended to place blame.

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Reasons Why Accidents

Principles of Accident Investigation Are Not Reported

Natural fear many people have of being
The investigation of any accident event associated with an accident event.
will never progress unless that event is
Idea of investigating a situation that has resulted
first properly reported to the appropriate in some degree of loss
management within an organization
Reflect unfavorably on their own performance or
that of their department.

Simply do not wish to interrupt work production

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 Types of Accident Who Should Conduct Accident
to be Reported Investigation?

Supervisors

FatalAccidents
• More familiar with the people involved

Accident
Accident--causing injury or illness
• Have a better understanding of the

Diseases
operation

Dangerous occurrences
• Know all safe work practices/rules

Near misses pertaining to his/her job
• Employees may be willing to speak more
freely
• Have a personal stake in the investigation
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Advantages of Having the Supervisor as the Disadvantages of Having the Supervisor as the
Accident Investigator Accident Investigator

More familiar with the people
Possible whitewash or cover-

cover-up.
involved.
Supervisor tend to be more

Have a better understanding of sympathetic to his/her subordinate.
the process or operation.
Lack of knowledge on technical

Have a personal stake in safety.
accident investigation.
Focus may not be on the incident

Employees may be willing to but on the operation.
speak more freely.
Has tendency to create conflict
between safety and productivity.

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Who Should Conduct

Accident Investigation? Size of Investigating Team

Safety Officer/Man
• Serves as secretary of the safety and health
The extent of injury
committee
The potential for injury or damage
• Coordinates all safety and health programs for
The potential for repetitions
the employer and employees
• Conducts safety and health inspections as
The department involved
member of the SH committee
Requirement for specialized knowledge
• Conducts investigation of accident as
Legal requirement
member of the SH Committee
• Maintains or help in the maintenance of efficient
accident record system
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Investigation is a 4 Step Process Control the Scene

Accident 1. Control the Scene
Provide medical care for injured

• First Aid
• On Scene Evaluation
• Transport for Medical Care
3. Analyze Data 2. Gather DATA
Control existing hazards
• Prevent further injuries
• Get more help if needed
4. Write
Report

Preserve evidence

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Gather Information:
Interview Process
The Interview

Interview as soon as possible

When? Where?
after the incident

In group or individually?
• Do not interrupt medical
care to interview

Put the person at ease.
Interview each person

Reassure them that this separately
is a fact-
fact-finding process
Do not allow witnesses to
only. confer prior to interview

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The Interview The Interview

Use closed-ended questions later to gain more

Take Notes!
detail.

Ask open-
open-ended questions
• After the person has provided their explanation,
• “What did you see?”
these type of questions can be used to clarify
• “What happened?”
• “Where were you standing?”

Do not make suggestions
• “What time did it happen?”
• If the person is stumbling over a word or
concept, do not help them out

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 The Interview The Interview

Don’t ask leading questions
Summarize what you have been told.
• Bad: “Why was the forklift operator driving • Correct misunderstandings of the events
recklessly?” between you and the witness
• Good: “How was the forklift operator driving?”
Ask the witness/victim for recommendations to

If
the witness begins to offer reasons, excuses, prevent recurrence
or explanations, politely decline that knowledge • These people will often have the best
and remind them to stick with the facts solutions to the problem

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Gather Information:
The Interview Accident Scene

Examine the accident scene. Look for things

Get a written, signed statement from the witness
that will help you understand what happened:
• It is best if the witness writes their own
• Dents, cracks, scrapes, splits, etc. in
statement; interview notes signed by the equipment
witness may be used if the witness refuses
• Tire tracks, footprints, etc.
to write a statement • Spills or leaks
• Scattered or broken parts

Diagram the scene

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Gather Evidence Gather Information: Records

Take photographs

Check training records
• Photograph any items or scenes which may
provide an understanding of what happened to • Was appropriate training provided?
anyone who was not there.
Check equipment maintenance records
• Photograph any items which will not remain, or • Is regular PM or servicing provided?
which will be cleaned up (spills, tire tracks,
footprints, etc.) • Is there a recurring type of failure?

Check accident records
• 35mm cameras, Polaroids,
Polaroids, and video cameras
are all acceptable. • Have there been similar accidents or injuries
 Digital cameras are not recommended - digital involving other employees?
images can be easily altered
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 Analyze Data Data Analysis List

Gather all photos, drawings, interview
Accident Title
material and other information collected at
Date, Time, Location
the scene.
Persons involved

Determine a clear picture of what happened
Witnesses

Formally document sequence of events
Work & Environmental Conditions at time
of accident

Immediate actions taken at scene

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Determine Causes Determine Causes

Employee actions

Procedures
• Safe behavior, at-
at-risk behavior
• Existing (or not), followed (or not),

Environmental conditions
appropriate (or not)
• Lighting, heat/cold,

Training
moisture/humidity, dust, vapors,
etc. • Was employee trained - when, by whom,
documentation

Equipment condition
• Defective/operational, guards,
leaks, broken parts, etc.
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Change Analysis Find Root Causes

When you have determined the
contributing factors, dig

What was not normal before the accident deeper!

Where the abnormality occurred • If employee error, what

When was it first noted caused that behavior?

How it occurred • If defective machine, why
wasn’t it fixed?
• If poor lighting, why not
corrected?
• If no training, why was it?

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 Make Recommendations Prepare A Report

Accident Reports should contain the

Determine corrective actions following:
• Recommendations based on key contributory
• Description of the incident and injuries
factors and underlying/root causes
• Select the ones likely to be most effective, • Sequence of events
most cost beneficial and most acceptable • Pertinent facts discovered during the
• Establish time table investigation
• Recommendation(s) must be communicated • Conclusions of the investigator(s)
clearly
• Recommendations for correcting the
problem(s)

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RULE No. 1050 – Notification & Keeping of Accidents

and/or Occupational Illnesses

OSH RULE REPORT/FORM WHEN TO WHERE TO

REPORT REPORT

Rule No. Work Accident On or before the 2 copies, to

RULE 1050 1050 – Illness Report 20th day of the be submitted
Notification (WAIR) – month following to concerned
& Keeping of DOLE/BWC/IP--6)
DOLE/BWC/IP the date of RO & copy
Accidents occurrence of the furnished the
NOTIFICATION AND KEEPING and/or accident Bureau

OF RECORDS OF Occupational
Illnesses
Annual Exposure
Data Report (AEDR)
On or before Jan
30 of the
ACCIDENTS AND / OR – (DOLE/BWC/IP-
(DOLE/BWC/IP-6b) following year

OCCUPATIONAL ILLNESSES Fatal/major Within 24 hours

accident

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 Implement and Follow up

“An accident/incident report is not
Implement corrective actions as soon as

the end of an accident/incident possible

Monitor implementation of corrective actions
response and investigation as to their effectiveness
process, it is in fact the start of
Conduct follow up and review

the corrective process”

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Investigation Traps CONCLUSION

Put your emotions aside!
• Don’t let your feelings interfere - stick to the
An ounce of prevention is better than a pound of
facts! cure, as the saying goes, but we still can’t
• Don’t be subjective. discount the importance of that “pound of cure”.

Do not pre-
pre-judge.
• Find out the what really happened.
The only way to prevent the recurrence of an
accident/incident is to have an accurate
• Do not let your beliefs cloud the facts.
understanding of the event.

Never assume anything.

Assign cause, not blame.

Do not use names in recommendations if

referring to an individual’s actions.
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