Accident Investigation

East Carolina University

SAF ETY
Environmental Health & Safety
210 East Fourth Street
(252) 328-6166
http://www.ecu.edu/oehs
safety@ecu.edu
EH&S Web Page
 Objectives
• Explain the meaning and impact of
accidents.
• Identify different types of accident causes.
• Know the purpose of accident
investigation.
• Explain how to conduct an accident
investigation.
• Know how to document accident
investigations.
 What is an Accident?
• Unplanned event results in mishap
(personal injury or property damage).
• Accidents are the result of the failure of
people, equipment, materials, or
environment to react as expected.
• All accidents have consequences or
outcomes.
 Purpose of Accident
Investigation

• Determine the sequences of events

leading to failure.
• Identify the cause of the accident.
• Find methods to prevent accident from
recurring.
 Be Prepared
• Develop a policy for accident investigation
• Routinely audit your policy to:
- ensure personnel understand their role
- system is driving corrective actions

Assign responsibilities to personnel:

- employee must be trained to investigate
- investigator should know process
Leading Causes of Workplace Deaths

Miscellaneous
11%
Caught Between
Object/Equipment
Motor Vehicles
5%
32%
Airplanes
5%
Gunshot Wounds
8%

Slips and Falls

8%
Struck by Moving,
Falling or Stationary
Objects
Heart Attacks/Strokes 18%
13%
8
 PROGRAM REQUIREMENTS
ALL EMPLOYERS MUST: ACCIDENT
INVESTIGATION


PROGRAM
Review job specific hazards ACC IDENT INVESTIGATION

 Implement corrective actions

 Conduct hazard assessments
 Conduct accident investigations
 Provide training to all required employees
 Install engineering controls where possible
 Institute administrative controls where possible
 Control workplace hazards using PPE as a last resort
 ACCIDENT INVESTIGATION
IS IMPORTANT
A GOOD PROGRAM WILL HELP: SAFETY
STATISTICS
 Improve quality.
 Improve absenteeism.
 Maintain a healthier work force.
 Reduce injury and illness rates.
 Acceptance of high-turnover jobs.
 Workers feel good about their work.
 Reduce workers’ compensation costs.
 Elevate SAFETY to a higher level of
awareness.
 PROGRAM IMPLEMENTATION

IMPLEMENTATION OF AN ACCIDENT
INVESTIGATION PROGRAM REQUIRES:

 DEDICATION
 PERSONAL INTEREST
 MANAGEMENT COMMITMENT
NOTE:
UNDERSTANDING AND SUPPORT FROM THE WORK FORCE
IS ESSENTIAL, WITHOUT IT THE PROGRAM WILL FAIL!
 MANAGEMENT’S ROLE

 CONSIDERATIONS:
1. SUPPORT THE PROCESS.
2. ENSURE YOUR SUPPORT IS VISIBLE.
3. GET INVOLVED.
4. ATTEND THE SAME TRAINING AS YOUR WORKERS.
5. INSIST ON PERIODIC FOLLOW-UP & PROGRAM REVIEW.
6. IMPLEMENT WAYS TO MEASURE EFFECTIVENESS.
 THE SUPERVISOR’S ROLE
 CONSIDERATIONS:
1. TREAT ALL “NEAR-MISSES” AS AN ACCIDENT.
2. GET INVOLVED IN THE INVESTIGATION.
3. COMPLETE THE PAPERWORK (WORK ORDERS, POLICY
CHANGES, ETC.) TO MAKE CORRECTIVE ACTIONS.
4. GET YOUR WORKERS INVOLVED.
5. NEVER RIDICULE ANY INJURY.
6. BE PROFESSIONAL - YOU COULD SAVE A LIFE TODAY.
7. ATTEND THE SAME TRAINING AS YOUR WORKERS.
8. FOLLOW-UP ON THE ACTIONS YOU TOOK.

•Most important-Investigation is not intended to place blame!

 THE EMPLOYEE’S ROLE

 CONSIDERATIONS:

1. REPORT ALL ACCIDENTS AND NEAR-MISSES IMMEDIATELY.

2. CONTRIBUTE TO MAKE CORRECTIVE ACTIONS.
3. ALWAYS PROVIDE COMPLETE AND ACCURATE INFORMATION.
4. FOLLOW-UP WITH ANY ADDITIONAL INFORMATION.
 INDUSTRIAL HYGIENE & SAFETY
CONTROLS

ENGINEERING CONTROLS FIRST CHOICE

 Work Station Design  Tool Selection and Design
 Process Modification  Mechanical Assist

 ADMINISTRATIVE CONTROLS SECOND CHOICE

 Training Programs  Job Rotation/Enlargement
 Pacing  Policy and Procedures

PERSONNEL PROTECTIVE
EQUIPMENT  LAST CHOICE
 Gloves  Wraps
 Shields  Eye Protection
 Non-Slip Shoes  Aprons
 Types of Causes

Basic Causes
Poor Management Safety Policy & Decisions
Personal Factors/Environmental Factors

Unsafe Act Conditions

Indirect Causes
Performance

Unplanned release of energy ACCIDENT

(Direct Cause) Personal Injury
Property Damage
 ACCIDENT CAUSATION
 Domino Theory.
 Multiple Causation
Theory.
 ACCIDENT CAUSATION
 Domino Theory.
The occurrence of an injury invariably
results from a completed sequence of
factors, the last one of these being the
injury itself. The accident which
caused the injury is in turn invariably
caused or permitted directly by the
unsafe act of a person and/or a
mechanical or physical hazard.
 ACCIDENT CAUSATION
 Domino Theory.
(One act or condition)

 The unsafe act: Climbing a defective

ladder.
 The unsafe condition: A defective
ladder.
 The corrective action 1: Replace the
ladder.
 The corrective action 2: Forbid use of
ladder.
 ACCIDENT CAUSATION
 Multiple Causation Theory.
Factors combined in random fashion
to cause accidents.
 ACCIDENT CAUSATION
 Multiple Causation Theory.
(Contributing factors)
 Was he or she properly trained?
 Was he or she reminded not to use
it?
 Did the employee know not to use it?
 Why did the supervisor allow its use?
 Did the supervisor examine the job
first?
 Why was the defective ladder not
found?
 ACCIDENT CAUSATION
 Unsafe Acts
 Horseplay.
 Defeating safety devices.
 Failure to secure or warn.
 Operating without authority.
 Working on moving equipment.
 Taking an unsafe position or posture.
 Operating or working at an unsafe
speed.
 Unsafe loading, placing, mixing,
combining.
 Failure to use personal protective
equipment.
 ACCIDENT CAUSATION
 Unsafe Conditions (Environmental)

 Improper PPE.
 Improper tools.
 Improper guarding.
 Poor housekeeping.
 Improper ventilation.
 Defective equipment.
 Improper illumination.
 Unsafe dress or apparel.
 Hazardous arrangement.
 ACCIDENT CAUSATION
 Unsafe Personal Factors

 Fatigue.
 Unclassified
 Improper attitude.
 Defective hearing.
 Defective eyesight.
 Muscular weakness.
 Lack of required skill.
 Intoxication (alcohol,
drugs).
 Lack of required
knowledge.
 ACCIDENT CAUSATION
 Behavioristic Causes
 Improper attitude.
 Lack of knowledge or skill.
 Physical or mental impairment
 CONTRIBUTING FACTORS

• HUMAN
BEHAVIOR
– Common
to all
accidents
– Not limited
to the
person
involved in
the
accident
 Consequences of Accidents
Direct Consequences Indirect Consequences

1. Personal injury 1. Lost income

2. Property loss 2. Medical expenses
3. Time to retrain
another person
4. Decreased
employee moral
 Examples of Accident Causes
Direct Causes Indirect Basic Causes
Causes
Struck Failure to No oversight
by/against secure
Falls Guarding Poor
maintenance.
Caught Improper use Training
in/between
Exertion Unsafe position Policies
Contact with…. Environmental Stress
Impact Defect Engineering
(vehicle)
 ACCIDENT REPORTING

WHAT SHOULD BE REPORTED:

 All injuries or job-related illnesses.

 Near-miss incidents.
 Vehicular, structural or equipment damage.
 Procedural deficiencies.
 Potentially unsafe conditions.
 Potentially unsafe behaviors.
 Provide Care to the Injured
• Ensure that medical care is provided to the
injured people before proceeding with the
investigation.
 CONDUCTING THE INVESTIGATION
 Purpose of the Investigation:
 Determine principal
causes.
 Determine
contributing causes.
 Develop strategies
for corrective action.
 Establish a timetable
for corrective action.
 Assign responsibility
for corrective actions.
CONDUCTING THE INVESTIGATION
Continued

 Collecting the data:

 JHA assessment forms.
 Direct observation.
 Video Tape.
 Action photographs.
 Documentary accounts.
 Accident statistics.
 Employee interviews.
 Employee surveys.
 Interview Victims & Witnesses
• Interview as soon as
possible after the incident
– Do not interrupt medical
care to interview
• Interview each person
separately
• Do not allow witnesses to
confer prior to interview
 CONDUCTING THE INVESTIGATION
Continued

INTERVIEWING WITNESSES:
 Select a comfortable, private location.
 Set the person at ease.
 Explain that the situation, not them is the focus.
 Solicit ideas to prevent future recurrence.
 Consider diagrams or drawings.
 Remain neutral in your demeanor.
 Take notes or record the discussion (facts).
 Review the statements before terminating.
CONDUCTING THE INVESTIGATION
Continued

PRINCIPAL QUESTIONS TO BE ANSWERED:

 WHO?
 WHAT?
 WHY?
 WHEN?
 WHERE?
 HOW?
CONDUCTING THE INVESTIGATION
Continued

WHO?
 Who was injured?
 Who was working with him/her?
 Who else witnessed the accident?
 Who else was involved in the accident?
 Who is the employee's immediate supervisor?
 Who rendered first aid or medical treatment?
 CONDUCTING THE INVESTIGATION
Continued

WHAT?
 What was the injured employee’s explanation?
 What were they doing at the time of the accident?
 What was the position at the time of the accident?
 What is the exact nature of the injury?
 What operation was being performed?
 What materials were being used?
 What safe-work procedures were provided?
 CONDUCTING THE INVESTIGATION
Continued

WHAT?
 What personal protective equipment was used?
 What PPE was required?
 What elements could have contributed?
 What guards were available but not used?
 What environmental conditions contributed?
 What related safety procedures need revision?
 What shift was the employee working?
 What ergonomic factors were involved?
 CONDUCTING THE INVESTIGATION
Continued

WHEN?
 When did the accident occur?
 When did the employee start his/her shift?
 When did the employee begin employment?
 When was job-specific training received?
 When did the supervisor last visit the job?
 CONDUCTING THE INVESTIGATION
Continued

WHY?
 Why did the accident occur?
 Why did the employee do what he/she did?
 Why did co-workers do what they did?
 Why did conditions come together at that moment?
 Why was the employee in the specific position?
 Why were the specific tool/equipment selected?
 CONDUCTING THE INVESTIGATION
Continued

WHERE?
 Where did the accident occur?
 Where was the employee positioned?
 Where were eyewitnesses positioned?
 Where was the supervisor at the time?
 Where was first aid initially given?
 CONDUCTING THE INVESTIGATION
Continued

HOW?
 How did the accident occur?
 How many hours had the employee worked?
 How did the employee get injured (specifically)?
 How could the injury have been avoided?
 How could witnesses have prevented it?
 How could witnesses have better helped?
 HOW COULD THE ACCIDENT HAVE BEEN PREVENTED?
 Conducting the Investigation
• Interview witnesses.
• Document the accident scene before any
changes are made.
• Review all information (procedures,
equipment manuals).
 Conducting the Investigation
• Make documented observations on:
– Pre-accident conditions
– Accident sequence
– Post-accident conditions
• Document the facts (i.e.: location, witness
remarks, and contributing factors).
• Determine sequence of events leading to
accident.
CONDUCTING THE INVESTIGATION
Continued

WHAT'S NEXT?
 Instruct employee in proper behavior?
 Warn employee of potential hazard?
 Supply appropriate safeguard?
 Supply appropriate PPE?
 Eliminate the unsafe condition?
 Repair or modify the unsafe condition?
 Implement procedural changes?
Common Problem Solving
Methods

• Job Hazard Analysis

• Sequence diagrams
• Change analysis
 Job Hazard Analysis
Steps Hazards Causes Control
Measures
 Change Analysis
• A change analysis consists of:
– Defining the problem.
– Establishing the norm.
– Identifying, locating, and describing the
change.
– Identify what was affected and not affected
– List features of change.
– Pick likely causes.
 WRITING THE REPORT
REPRESENTING THE DATA:
 Condense into the EH&S accident form.
 Compile statistical data for representation.
 Assign responsibility and prioritize.
 Make recommendations for correction.
 Recommend a timetable for correction.
 Consider funding for corrective actions.
 Forward copies to EH&S/OSHA as required.
 Distribute internally as required.
 Follow-up at periodic intervals.
 WRITING THE REPORT
Continued

FORMULATING CONTROL MEASURES

 TRAINING INITIATION OR ENHANCEMENT
 ELIMINATE OR REDUCE EXPOSURE
 ENGINEERING CONTROL MEASURES
 ADMINISTRATIVE CONTROL MEASURES
 APPLICATION OF SAFE WORK PRACTICES
 PERSONAL PROTECTIVE EQUIPMENT
 Documentation
• Complete an accident investigation form to
collect:
– Personnel information.
– Accident information (location, events leading
to accident, machines involved).
– Causes of the accident.
– Recommendation to prevent accident.
– Follow up information.
 Documentation
• From the accident investigation form and
witness statements write an accident
investigation report. The report should
include:
– Background information (where, who).
– Summary (sequence, extent, type, source).
– Analysis (causes).
– Recommendations.
FOLLOW-UP

THE GREATEST
DEFICIENCY IN
ACCIDENT
INVESTIGATION IS
LACK OF COMPETENT
FOLLOW-UP!
 “Summary”
Steps to Accident Investigation
• Survey the scene.
• Secure the scene (initiate interim controls).
• Get help for the injured.
• Who talks to the Media?
• Collect evidence.
• Analyze data (review past investigations).
• Determine causes (scientific methods).
• Disciplinary action, last resort.
• Follow up (eliminate hazards).
QUESTIONS?