1 2 3 4

Preserve/ Collect Determine Implement

Document Information Root Corrective
Scene Causes Actions

UnitedStatesDepartmentofLabor
OccupationalSafetyandHealthAdministration


TABLEOFCONTENTS

PURPOSEOFTHEGUIDEWHYINVESTIGATE?...............................................................................................1
PRINCIPLESOFINCIDENTINVESTIGATIONS.....................................................................................................1
TheLanguageofIncidentInvestigations..................................................................................................1
InvestigateAllIncidents,IncludingCloseCalls......................................................................................2
InvestigatePrograms,NotBehaviors........................................................................................................3
FocusontheRootCauses,NotBlameorFault.........................................................................................4
ESTABLISHANINCIDENTINVESTIGATIONPROGRAM.........................................................................................4

CONDUCTINCIDENTINVESTIGATIONSAFOURSTEPSYSTEMSAPPROACH..........................................................6
Step1.Preserve/DocumenttheScene.....................................................................................................7
Step2.COLLECTINFORMATION......................................................................................................................8
Step3.DETERMINEROOTCAUSES..................................................................................................................9
Step4.IMPLEMENTCORRECTIVEACTIONS.....................................................................................................10
RESOURCES...........................................................................................................................................12
REFERENCES..........................................................................................................................................14

APPENDIXA:INCIDENTINVESTIGATIONFORM....................................................................................................A1
APPENDIXB:INCIDENTINVESTIGATORSKIT.......................................................................................................B1
APPENDIXC:TIPSFORVIDEO/PHOTODOCUMENTATION......................................................................................C1
APPENDIXD:SKETCHTHESCENETECHNIQUES...................................................................................................D1
APPENDIXE:COLLECTINFORMATIONCHECKLIST.................................................................................................E1
APPENDIXF:SAMPLEQUESTIONSFORIDENTIFYINGINCIDENTROOTCAUSES...........................................................F1

DISCLAIMER:
ThisguidewasdevelopedbyOSHA'sDirectorateofTrainingandEducationandisintendedtoassistemployers,workers,andothersasthey
strivetoimproveworkplacehealthandsafety.Thisguideisadvisoryinnatureandinformationalincontent.Itisnotanewstandardor
regulationanddoesnotcreateanynewlegalobligationsoralterexistingobligationscreatedbyOSHAstandardsorregulationsorthe
OccupationalSafetyandHealthActof1970(OSHAct).PursuanttotheOSHAct,employersmustcomplywithsafetyandhealthstandardsand
regulationsissuedandenforcedeitherbyOSHAorbyanOSHAapprovedstateplan.Inaddition,theOSHActsGeneralDutyClause,Section
5(a)(1),requiresemployerstoprovidetheirworkerswithaworkplacefreefromrecognizedhazardslikelytocausedeathorseriousphysical
harm.Implementationofanincidentinvestigationprograminaccordancewiththisguidecanaidemployersintheireffortstoprovideasafe
workplace.

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 Incident [Accident] Investigations: A Guide for Employers

Yourcompanyexperiencedanincidentthatresulted(oralmostresulted)inaworker
injuryorillnessNowwhat?
Asaresponsibleemployer,youneedtoreactquicklytotheincidentwithaprescribed
investigationprocedureforfindingtherootcausesandimplementingcorrectiveactions.
Quickandplannedactionsdemonstrateyourcompanyscommitmenttothesafetyand
healthofyourworkers,andyourwillingnesstoimproveyoursafetyandhealth
managementprogramtopreventfutureincidents.

PURPOSE OF THE GUIDE WHY INVESTIGATE?

ThepurposeofthisIncidentInvestigationGuideistoprovideemployersasystemsapproachtohelp
themidentifyandcontroltheunderlyingorrootcausesofallincidentsinordertopreventtheir
recurrence.
WHY INVESTIGATE?
TheBureauofLaborStatisticsreportsthatmorethanadozen Incident investigations
workersdiedeverydayinAmericanworkplacesin2013,andnearly4 help employers:
Prevent injuries and
millionAmericanssufferedaseriousworkplaceinjury.Andtensof
illnesses
thousandsaresickenedordiefromdiseasesresultingfromtheir
Save lives
chronicexposurestotoxicsubstancesorstressfulworkplace
Save money
conditions.Theseeventscausemuchsufferingandgreatfinancial
Demonstrate
losstoworkersandtheirfamilies,andalsoresultinsignificantcosts
commitment to health
toemployersandtosocietyasawhole.Manymorenearmissesor
and safety
closecallsalsohappen;theseareincidentsthatcouldhavecaused Promote positive
seriousinjuryorillnessbutdidnot,oftenbysheerluck.Practicallyall workplace morale
oftheseharmfulincidentsandclosecallsarepreventable. Improve management

Allincidentsregardlessofsizeorimpactneedtobeinvestigated.Theprocesshelpsemployerslook
beyondwhathappenedtodiscoverwhyithappened.Thisallowsemployerstoidentifyandcorrect
shortcomingsintheirsafetyandhealthmanagementprograms.

OSHAcreatedthisGuidetohelpemployersconductworkplaceincidentinvestigationsusingafourstep
systemsapproach.ThisprocessissupportedbyanIncidentInvestigationForm,foundinAppendixA,
whichemployerscanusetobesurealldetailsoftheincidentinvestigationarecovered.Additionaltools
toassistwiththeinvestigationprocessarefoundinAppendicesBthroughF.

PRINCIPLES OF INCIDENT INVESTIGATIONS

The Language of Incident Investigations

EmployerswillnoticethisGuideusesthetermincident,notaccident,todescribeaworkplaceevent.
Thisisbecausethewordaccidenthascometobeconsideredasarandomeventthatoh,well,itjust

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 Incident Investigations: A Guide for Employers

happenedandcouldnothavebeenprevented.However,thevastmajorityofharmfulworkplace
eventsdonotjusthappen.Onthecontrary,mostharmfulworkplaceincidentsarewhollypreventable.

Inshort,thebasicprincipleisthatincidentsdonothavetooccur;theycanbepreventedbyaddressing
theshortcomingsintheprogramsthatmanagehealthandsafetyintheworkplace.

Thefollowingarethekeytermsthatareusedthroughoutthisguide:
Incident:Aworkrelatedeventinwhichaninjuryorillhealth(regardlessofseverity)orfatality
occurred,orcouldhaveoccurred.
RootCauses:Theunderlyingreasonswhyunsafeconditionsexistorifaprocedureorsafetyrule
wasnotfollowedinaworkplace.Rootcausesgenerallyreflectmanagement,design,planning,
organizationaloroperationalfailings(e.g.,adamagedguardhadnotbeenrepaired;failureto
usetheguardwasroutinelyoverlookedbysupervisorstoensurethespeedofproduction).
CloseCall:Anincidentthatcouldhavecausedseriousinjuryorillnessbutdidnot;alsocalleda
nearmiss.
Investigatingaworksiteincidentafatality,injury,illness,orclosecallprovidesemployersand
workerstheopportunitytoidentifyhazardsintheiroperationsandshortcomingsintheirsafetyand
healthprograms.Mostimportantly,itenablesemployersandworkerstoidentifyandimplementthe
correctiveactionsnecessarytopreventfutureincidents.
Incidentinvestigationsthatfocusonidentifyingandcorrectingrootcauses,notonfindingfaultor
blame,alsoimproveworkplacemoraleandincreaseproductivity,bydemonstratinganemployers
commitmenttoasafeandhealthfulworkplace.

Investigate All Incidents, Including Close Calls

OSHAstronglyencouragesemployerstoinvestigateallworkplaceincidentsboththosethatcause
harmandtheclosecallsthatcouldhavecausedharmunderslightlydifferentcircumstances.
Investigationsareincidentpreventiontoolsandshouldbeanintegralpartofanoccupationalsafetyand
healthmanagementprograminaworkplace.Suchaprogramisastructuredwaytoidentifyandcontrol
thehazardsinaworkplace,andshouldemphasizecontinualimprovementinhealthandsafety
performance.Whendonecorrectly,aneffectiveincidentinvestigationuncoverstherootcausesofthe
incidentorclosecallthatweretheunderlyingfactors.Mostimportant,investigationscanprevent
futureincidentsifappropriateactionsaretakentocorrecttherootcausesdiscoveredbythe
investigation.

Effectiveincidentinvestigationsaretherightthingtodo,notonlybecausetheyhelpemployersprevent
futureincidents,butbecausetheyhelpemployerstoidentifyhazardsintheirworkplacesand
shortcomingsintheirsafetyandhealthmanagementprograms.Investigationsalsosaveemployers
money,becauseincidentsarefarmorecostlythanmostpeoplerealize.TheNationalSafetyCouncil
estimatesthat,ontheaverage,preventingaworkplaceinjurycansave$39,000,andpreventinga
fatalitymorethan$1.4million,nottomentionthesufferingoftheworkersandtheirfamilies.Themore
obviousfinancialcostsarethoserelatedtoworkers'compensationclaims,buttheseareonlythedirect

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 Incident Investigations: A Guide for Employers

costsofincidents.Theindirectcostsarelessobvious,butverycommonlygreater,andincludelost
production,scheduledelays,increasedadministrativetime(foremergencyresponse,investigations,
claimprocessingandothers),lowermorale,trainingofnewortemporarypersonnel,increased
absenteeism,anddamagedcustomerrelationsandcorporatereputation.

Investigate Programs, Not Behaviors

Asstatedpreviously,incidentinvestigationsthatfollowasystemsapproacharebasedontheprinciple
thattherootcausesofanincidentcanbetracedbacktofailuresoftheprogramsthatmanagesafety
andhealthintheworkplace.Thisapproachisfundamentallydifferentfromabehavioralsafety
approach,whichincorrectlyassumesthatthemajorityofworkplaceincidentsaresimplytheresultof
humanerrororbehavioralfailures.Underasystemsapproach,onewouldnotconcludethat
carelessnessorfailuretofollowaprocedurealonewasthecauseofanincident.Todosofailsto
discovertheunderlyingorrootcausesoftheincident,andthereforefailstoidentifythesystemic
changesandmeasuresneededtopreventfutureincidents.Whenashortcomingisidentified,itis
importanttoaskwhyitexistedandwhyitwasnotpreviouslyaddressed.

For example:

Ifaprocedureorsafetyrulewasnotfollowed,whywasthe
procedureorrulenotfollowed? Onecentralprincipleisthe
Didproductionpressuresplayarole,and,ifso,whywere needtoconsiderthe
productionpressurespermittedtojeopardizesafety? organizationalfactorsthat
Wastheprocedureoutofdateorsafetytraininginadequate? createthepreconditionsfor
Ifso,whyhadtheproblemnotbeenpreviouslyidentified,or,if errorsaswellasthe
ithadbeenidentified,whyhaditnotbeenaddressed? immediatecauses.
SidneyDekker(2006)

Asystemsapproachalwayslooksbeyondtheimmediatecausesoftheincident.Ifaworkersuffersan
amputationonatablesaw,theinvestigatorwouldaskquestionssuchas:
Wasthemachineadequatelyguarded?Ifnot,whynot?
Wastheguarddamagedornonfunctional?Ifso,whyhadntitbeenfixed?
Didtheguarddesigngetinthewayofthework?
Hadtheemployeebeentrainedproperlyintheprocedurestodothejobsafely?

Inasystemsapproach,investigationsdonotfocusprimarilyonthebehaviorsoftheworkersclosestto
theincidents,butonthefactors[programdeficiencies]thatpromptedsuchbehaviors.Thegoalisto
changetheconditionsunderwhichpeopleworkbyeliminatingorreducingthefactorsthatcreate
unsafeconditions.Thisistypicallydonebyimplementingadequatebarriersandsafeguardsagainstthe
factorsthatcauseunsafeconditionsoractions.

Rootcausesofteninvolvemultipledeficienciesinthesafetyandhealthmanagementprograms.These
deficienciesmayexist,forexample,inareassuchasworkplacedesign,culturalandorganizational
factors,equipmentmaintenanceandothertechnicalmatters,operatingsystemsandprocedures,

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 Incident Investigations: A Guide for Employers

staffing,supervision,training,andothers.Eliminatingtheimmediatecausesislikecuttingweeds,while
eliminatingtherootcausesisequivalenttopullingouttherootssothattheweedcannotgrowback.

Focus on the Root Causes, Not Blame or Fault

Asuccessfulincidentinvestigationmustalwaysfocusondiscovering Eliminatingtheimmediate
therootcauses.Ifaninvestigationisfocusedonfindingfault,itwill causesislikecuttingweeds,
alwaysstopshortofdiscoveringtherootcauses.Itisessentialto whileeliminatingtheroot
discoverandcorrectallthefactorscontributingtoanincident,which causesisequivalenttopulling
nearlyalwaysinvolveequipment,procedural,training,andothersafety outtherootssothattheweed
andhealthprogramdeficiencies. cannotgrowback.

Addressingunderlyingorrootcausesisnecessarytotrulyunderstand
whyanincidentoccurred,todeveloptrulyeffectivecorrectiveactions,andtominimizeoreliminate
seriousconsequencesfromsimilarfutureincidents.
Moreover,ifaninvestigationisunderstoodtobeasearchforsomeonetoblame,bothmanagement
andlaborwillbereluctanttoparticipateinanopenandforthrightmanner.Workerswillbeafraidof
retaliationandmanagementwillbeconcernedaboutrecognizingsystemflawsbecauseofpotential
legalandfinancialliabilities.
Effective Incident
Investigations that focus on identifying and correcting the real Investigation Programs:
underlying causes not only prevent future incidents, but can also Clearly state easyto follow
improve workplace morale and productivity, by demonstrating an written procedures
employers commitment to a safe and healthful workplace. Provide for personnel to be
trained on incident
investigation and company
ESTABLISH AN INCIDENT INVESTIGATION PROGRAM procedures
Offer collaboration
Whenaseriousincidentoccursintheworkplace,everyonewillbebusy between workers, worker
representatives, and
dealingwiththeemergencyathand.Therefore,itisimportanttobe management
preparedtoinvestigateincidentsbeforetheyoccur.Anincident Focus on identifying root
investigationprogramshouldincludeaclearlystated,easytofollow cause(s), not on
establishing fault
writtenplantoincludeguidelinesfor: Emphasize correcting root
Howandwhenmanagementistobenotifiedoftheincident cause(s)
NotifyingOSHA,whichmustcomplywithreporting Implement timely
corrective actions based on
requirementsthatare:
investigation findings
o Allworkrelatedfatalitieswithin8hours Provide for an annual
o Allworkrelatedinpatienthospitalizations,all program review to identify
and correct program
amputations,andalllossesofaneyewithin24hours
deficiencies and identify
Whoisauthorizedtonotifyoutsideagencies(i.e.,fire,police, incident trends
etc.)
Whowillconductinvestigationsandwhattrainingtheyshouldhavereceived
Timetablesforcompletingtheinvestigationanddeveloping/implementingrecommendations
Whowillreceiveinvestigationrecommendations

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 Incident Investigations: A Guide for Employers

Whowillberesponsibleforimplementingcorrectiveactions

Althoughasupervisorsometimesconductsincidentinvestigations,tobemosteffectiveinvestigations
shouldbeconductedbyateaminwhichmanagersandemployeesworktogether,sinceeachbrings
differentknowledge,understanding,andperspectivestoaninvestigation.Workingtogetherwillalso
encourageallpartiestoowntheconclusionsandrecommendationsandtojointlyensurethat
correctiveactionsareimplementedinatimelymanner.

Wheretheincidentinvolvesatemporaryworkerprovidedbyastaffingagency,boththestaffingagency
andthehostemployershouldconductanincidentinvestigation.Wheretheincidentinvolvesamulti
employerworksite,theincidentinvestigationshouldbesharedwitheachemployerattheworksite.Itis
afundamentalprincipalthattemporaryworkersareentitledtothesameprotectionsundertheOSHAct
asallothercoveredworkers.Therefore,ifatemporaryworkerisinjuredandthehostemployerknows
aboutit,thestaffingagencyshouldbeinformedpromptly,sothestaffingagencyknowsaboutthe
hazardsfacingitsworkers.Equally,ifastaffingagencylearnsofaninjury,itshouldinformthehost
employerpromptlysothatfutureinjuriesmightbeprevented,andthecaseisrecordedappropriately.
Boththehostemployerandstaffingagencyshouldtrackandwherepossible,investigatethecauseof
workplaceinjuries.

Aswenowknow,investigationsaretofocusonidentifyingrootcauses,notestablishingfault.Employers
canreinforceasystemsapproachbystressingitintheirwrittenprogramaswellastheirinvestigation
procedures.Identifyingandcorrectingrootcausesshouldalwaysbethekeyobjective.

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 Incident Investigations: A Guide for Employers

CONDUCT INCIDENT INVESTIGATIONS A FOURSTEP SYSTEMS APPROACH

Oneofthebiggestchallengesfacingtheinvestigatorsisto Humanerrorisnotthe
determinewhatisrelevanttowhathappened,howithappened, conclusionofaninvestigation.
andespeciallywhyithappened.Thisinvolvesconductingasystems Itisthestartingpoint.
approachincidentinvestigation SidneyDekker(2006)
Errorsareseenas thatfocusesontherootcauses
consequencesratherthan oftheincidenttoreallyhelppreventthemfromhappeningagain.
causes
JamesReason(2000) Thissectionoftheguideassiststheemployertoimplementafour
stepapproachtoconductasuccessfulincidentinvestigation.Included
isasetofappendicesthatcanserveastoolsforemployerstousewhenconductinginvestigations.They
are:
AppendixA:IncidentInvestigationFormpreviouslyintroduced;willbeusedtowalkthe
employerthroughthefourincidentinvestigationsteps
AppendixB:IncidentInvestigatorsKitliststheequipmentrecommendedtohavereadyatall
timestobepreparedtoconducttheinvestigation
AppendixC:TipsforVideo/PhotoDocumentation
AppendixD:SketchtheSceneTechniques
AppendixE:CollectInformationChecklist
AppendixF:SampleQuestionsforIdentifyingIncidentRootCausesSamplequestionstoaskin
asystemsapproachprocess

Thefourstepsystemsapproachinthisguideissupportedby
theIncidentInvestigationForm[AppendixA]andothertools.
Thisapproachwillassistemployersthroughtheincident
investigationandhelptoensuretheimplementationof
correctivemeasuresbasedonthefindings.

Thestepsare:
1. PRESERVE/DOCUMENTTHESCENE[seeAppendicesA,B,C
andD]
2. COLLECTINFORMATION[seeAppendixE]
3. DETERMINETHEROOTCAUSESAlltheWhystheincidentoccurred[seeAppendixF]
4. IMPLEMENTCORRECTIVEACTIONSPreventFutureIncidents

SafetyFirst
Beforeinvestigating,allemergencyresponseneedsmustbecompletedandtheincidentsitemustbe
safeandsecureforentryandinvestigation.

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Withaneffectivesafetyandhealthmanagementprograminplace,alltheinvolvedpartiesareawareof
therolestheyplayduringtheinvestigation.Thishelpsthetransitionfromemergencyresponseandsite
safetytopreservingthesceneanddocumentingtheincident.
Nowisthetimeanemployersincidentinvestigationprogramswrittenplangoesintoeffectandthe
incidentinvestigationbegins.

Step 1. Preserve/Document the Scene

PreservetheScene:
Preservethescenetopreventmaterialevidencefrombeingremovedoraltered;investigatorscanuse
cones,tape,and/orguards.

DocumenttheScene:
Documenttheincidentfactssuchasthedateoftheinvestigationandwhoisinvestigating.Essentialto
documentingthesceneiscapturingtheinjuredemployeesname,injurydescription,whethertheyare
temporaryorpermanent,andthedateandlocationoftheincident.Investigatorscanalsodocumentthe
scenebyvideorecording,photogaphingandsketching.

ToolsprovidedtohelpwithStep1are:
AppendixA:IncidentInvestigationForm[applicablesectionspicturedatallsteps]
AppendixB:IncidentInvestigatorsKit
AppendixC:TipsforVideo/PhotoDocumentation
AppendixD:SketchtheSceneTechniques

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 Incident Investigations: A Guide for Employers

Step 2. COLLECT INFORMATION

Incidentinformationiscollectedthroughinterviews,documentreviewsandothermeans.AppendixE
providesachecklisttousetohelpensureallinformationpertinenttotheincidentiscollected.

Inadditiontointerviews,investigatorsmayfindothersourcesofusefulinformation.Theseinclude:
Equipmentmanuals
Industryguidancedocuments
Companypoliciesandrecords
Maintenanceschedules,recordsandlogs
Trainingrecords(includingcommunicationtoemployees)
Auditandfollowupreports
Enforcementpoliciesandrecords
Previouscorrectiveactionrecommendations

Interviewscanoftenyielddetailed,useful
informationaboutanincident.Sincememoriesfade,
interviewsmustbeconductedaspromptlyas
possible:preferablyassoonasthingshavesettled
downabitandthesiteisbothsecureandsafe.The
soonerawitnessisinterviewed,themoreaccurate
andcandidhis/herstatementwillbe.

Anincidentinvestigationalwaysinvolvesinterviewing
andpossiblyreinterviewingsomeofthesameor
newwitnessesasmoreinformationbecomesavailable,uptoandincludingthehighestlevelsof
management.Carefullyquestionwitnessestosolicitasmuchinformationaspossiblerelatedtothe
incident.

Sincesomequestionswillneedtobedesignedaroundtheinterviewee,eachinterviewwillbeaunique
experience.Wheninterviewinginjuredworkersandwitnessesitiscrucialtoreducetheirpossiblefear
andanxiety,andtodevelopagoodrapport.Whenconductinginterviews,investigatorsshould:
Conducttheinterviewinthelanguageoftheemployee/interviewee;useatranslatorifneeded
Clearlystatethatthepurposeoftheinvestigationandinterviewisfactfinding,notfaultfinding
Emphasizethatthegoalistolearnhowtopreventfutureincidentsbydiscoveringtheroot
causesofwhatoccurred
Establishaclimateofcooperation,andavoidanythingthatmaybeperceivedasintimidatingor
insearchofsomeonetoblamefortheincident
Letemployeeknowthattheycanhaveanemployeerepresentative(e.g.,laborrepresentative),
ifavailable/appropriate
Asktheindividualstorecounttheirversionofwhathappened
Notinterrupttheinterviewee

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 Incident Investigations: A Guide for Employers

Takenotesand/orrecordtheresponses;intervieweemustgivepermissionpriortobeing
recorded
Haveblankpaperandorsketchavailableforintervieweetouseforreference
Askclarifyingquestionstofillinmissinginformation
Reflectbacktotheintervieweesthefactualinformationobtained;correctanyinconsistencies
Asktheindividualswhattheythinkcouldhavepreventedtheincident,focusingonthe
conditionsandeventsprecedingtheinjury

Step 3. DETERMINE ROOT CAUSES

Therootcausesofanincidentareexactlywhatthe
termimplies:Theunderlyingreasonswhythe
incidentoccurredinaworkplace.Rootcauses
generallyreflectmanagement,design,planning,
organizationaland/oroperationalfailings(e.g.,
employeeswerenottrainedadequately;a
damagedguardhadnotbeenrepaired).

Determiningtherootcauseistheresultofpersistentlyaskingwhy
Determiningtherootcauseisthemosteffectivewaytoensuretheincidentdoesnothappenagain

Findingtherootcausesgoesbeyondtheobviousproximateorimmediatefactors;itisadeeper
evaluationoftheincident.Thisrequirespersistentdigging,typicallybyaskingWhyrepeatedly.
Conclusionssuchasworkerwascarelessoremployeedidnotfollowsafetyproceduresdontgetat
therootcausesoftheincident.Toavoidtheseincompleteandmisleadingconclusionsinthe
investigativeprocess,investigatorsneedtocontinuetoaskwhy?asin,Whydidtheemployeenot
followsafetyprocedures?Iftheansweristheemployeewasinahurrytocompletethetaskandthe
safetyproceduressloweddownthework,thanaskWhywastheemployeeinahurry?Themoreand
deeperwhy?questionsasked,themorecontributingfactorsarediscoveredandthecloserthe
investigatorgetstotherootcauses.Ifaprocedureorsafetyrulewasnotfollowed,whywasthe
procedureorrulenotfollowed?Didproductionpressuresplayarole,and,ifso,whywereproduction
pressurespermittedtojeopardizesafety?Wastheprocedureoutofdateorsafetytraininginadequate?
Ifso,whyhadtheproblemnotbeenpreviouslyidentified,or,ifithadbeenidentified,whyhaditnot
beenaddressed?

Itcannotbestressedenoughthatasuccessfulincidentinvestigationmustalwaysfocusondiscovering
therootcauses.Investigationsarenoteffectiveiftheyarefocusedonfindingfaultorblame.Ifan
investigationisfocusedonfindingfault,itwillalwaysstopshortofdiscoveringtherootcauses,because
itwillstopattheinitialincidentwithoutdiscoveringtheirunderlyingcauses.Themaingoalmustalways
betounderstandhowandwhytheexistingbarriersagainstthehazardsfailedorprovedinsufficient,not
tofindsomeonetoblame.

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 Incident Investigations: A Guide for Employers

Thequestionslistedbelowareexamplesofinquiriesthataninvestigatormaypursuetoidentify
contributingfactorsthat,inturn,canleadtorootcauses:
Ifaprocedureorsafetyrulewasnotfollowed,whywastheprocedureorrulenotfollowed?
Wastheprocedureoutofdateorsafetytraininginadequate?Wasthereanythingencouraging
deviationfromjobproceduressuchasincentivesorspeedofcompletion?Ifso,whyhadthe
problemnotbeenidentifiedoraddressedbefore?
Wasthemachineryorequipmentdamagedorfailtooperateproperly?Ifso,why?
Wasahazardousconditionacontributingfactor?Ifso,whywasitpresent?(e.g.,defectsin
equipment/tools/materials,unsafeconditionpreviouslyidentifiedbutnotcorrected,
inadequateequipmentinspections,incorrectequipmentusedorprovided,impropersubstitute
equipmentused,poordesignorqualityofworkenvironmentorequipment)
Wasthelocationofequipment/materials/worker(s)acontributingfactor?Ifso,why?(e.g.,
employeenotsupposedtobethere,insufficientworkspace,errorproneproceduresor
workspacedesign)
Waslackofpersonalprotectiveequipment(PPE)oremergencyequipmentacontributing
factor?Ifsowhy?(e.g.,PPEincorrectlyspecifiedforjob/task,inadequatePPE,PPEnotusedat
allorusedincorrectly,emergencyequipmentnotspecified,available,properlyused,ordidnot
functionasintended)
Wasamanagementprogramdefectacontributingfactor?Ifso,why?(e.g.,acultureof
improvisationtosustainproductiongoals,failureofsupervisortodetectorreporthazardous
conditionordeviationfromjobprocedure,supervisoraccountabilitynotunderstood,supervisor
orworkerinadequatelytrained,failurestoinitiatecorrectiveactionsrecommendedearlier)

AdditionalexamplesofquestionstoasktogettotherootcausesarelistedinAppendixF.

Step 4. IMPLEMENT CORRECTIVE ACTIONS

Theinvestigationisnotcompleteuntilcorrectiveactionsareimplementedthataddresstherootcauses
oftheincident.Implementationshouldentail
programlevelimprovementsandshouldbe
supportedbyseniormanagement.

Notethatcorrectiveactionsmaybeoflimited
preventivevalueiftheydonotaddressthe
rootcausesoftheincident.Throughoutthe
workplace,thefindingsandhowtheyare
presentedwillshapeperceptionsand
subsequentcorrectiveactions.Superficial
conclusionssuchas"Bobshouldhaveused
commonsense,"andweakcorrectiveactionssuchasEmployeesmustremembertowearPPE,are
unlikelytoimprovethesafetycultureortopreventfutureincidents.

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 Incident Investigations: A Guide for Employers

Inplanningcorrectiveactionsandhowbesttoimplementthem,employersmayfindthatsomeroot
causeswilltaketimeandperseverancetofix.Persistinginimplementingsubstantivecorrectiveactions,
however,willnotonlyreducetheriskoffutureincidentsbutalsoimprovethecompanyssafety,morale
anditsbottomline.

Specificcorrectiveactionsaddressrootcausesdirectly;however,somecorrectiveactionscanbe
general,acrosstheboardimprovementstotheworkplacesafetyenvironment.Sampleglobalcorrective
actionstoconsiderare:
Strengthening/developingawrittencomprehensivesafetyandhealthmanagementprogram
Revisingsafetypoliciestoclearlyestablishresponsibilityandaccountability
Revisingpurchasingand/orcontractingpoliciestoincludesafetyconsiderations
Changingsafetyinspectionprocesstoincludelineemployeesalongwithmanagement
representatives

Implementingasystemsapproachwillhelpensureallincidentinvestigationsaresuccessful.
ThankyouforyourcommitmenttothesafetyandhealthoftheAmericanworkforce!

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 Incident [Accident] Investigations: A Guide for Employers

RESOURCES

OSHATrainingInstituteEducationCenters:http://www.osha.gov/otiec
TheOSHATrainingInstitute(OTI)EducationCentersareanational
networkofnonprofitorganizationsauthorizedbyOSHAtodeliver
occupationalsafetyandhealthtrainingtopublicandprivatesector
workers,supervisorsandemployersonbehalfofOSHA.Relevant
coursesare:

OSHA#7500IntroductiontoSafetyandHealthManagement
Description:Thiscoursecoverstheeffectiveimplementationofacompanyssafetyandhealth
managementsystem.Thecourseaddressesthefourcoreelementsofaneffectivesafetyandhealth
managementsystemandthosecentralissuesthatarecriticaltoeachelementspropermanagement.
Thiscourseisaninteractivetrainingsessionfocusingonclassdiscussionandworkshops.Uponcourse
completionstudentswillhavetheabilitytoevaluate,develop,andimplementaneffectivesafetyand
healthmanagementsystemfortheircompany.Minimumstudentcontacthours:5.5

OSHA#7505IntroductiontoIncident[Accident]Investigation
Description:Thiscoursecoversanintroductiontobasicincidentinvestigationproceduresanddescribes
analysistechniques.Coursetopicsincludereasonsforconductingincidentinvestigations,employer
responsibilitiesrelatedtoworkplaceincidentinvestigations,andafourstepincidentinvestigation
procedure.Thetargetaudienceistheemployer,manager,employeeoremployeerepresentativewhois
involvedinconductingincidentand/ornearmissorclosecallinvestigations.Uponcoursecompletion
studentswillhavethebasicskillsnecessarytoconductaneffectiveincidentinvestigationatthe
workplace.Minimumstudentcontacthours:7.5

OSHAWebsite:www.osha.gov

IncidentInvestigationWebpage
http://www.osha.gov/dcsp/products/topics/incidentinvesti
gation/index.html

InjuryandIllnessPreventionProgramsWebpage
http://www.osha.gov/dsg/topics/safetyhealth/index.html
ThiswebpageprovidesinformationrelevanttoInjuryandIllnessPreventionProgramsinthe
workplace.TolearnmoreaboutInjuryandIllnessPreventionPrograms,referto:
http://www.osha.gov/Publications/OSHA3665.pdfand
http://www.osha.gov/dsg/topics/safetyhealth/OSHAwhitepaperjanuary2012sm.pdf

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 Incident Investigations: A Guide for Employers

OSHAs"$afetyPays"program
Thisonlinetoolcanhelpemployersassesstheimpactof
occupationalinjuriesandillnessesontheirprofitability.To
learnmoreaboutOSHAs"$afetyPays"program,visit
http://www.osha.gov/dcsp/smallbusiness/safetypays/

Other:UKHealthandSafetyExecutive
InvestigatingAccidentsandIncidents:AWorkbookforemployers,unions,safetyrepresentatives,
andsafetyprofessionals.2004.http://www.hse.gov.uk/pubns/hsg245.pdf

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 Incident Investigations: A Guide for Employers

REFERENCES

CenterforChemicalProcessSafetypublication,GuidelinesforPreventingHumanErrorin
ProcessSafety,CenterforChemicalProcessSafety(CCPS),1994.
Conklin,T.,PreAccidentInvestigations:AnIntroductiontoOrganizationalSafety,Ashgate
PublishingCompany;1edition(September28,2012),ISBN10:1409447820,ISBN13:978
1409447825
Dekker,S.,TheFieldGuidetoUnderstandingHumanError,AshgatePublishingCompany;1
edition(June30,2006),English,ISBN10:0754648265;ISBN13:9780754648260
NationalSafetyCouncil,http://www.nsc.org/pages/home.aspx
Reason,J.,Humanerror:modelsandmanagement,BMJ2000;320:768

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 Incident Investigations: A Guide for Employers

APPENDIX A: INCIDENT INVESTIGATION FORM

FormSection SystemsApproach
SectionA:Information Step1
CompanyName:_______________________________________ Date:____________
Investigator(or)TeamName(s)andTitles:
Name Title
_________________________________ _____________________________________
_________________________________ _____________________________________
_________________________________ _____________________________________
_________________________________ _____________________________________

SectionB:IncidentDescription/InjuryInformation Step1andStep2
1) NameandAgeofInjuredEmployee: _______________________________________________
Employeesfirstlanguage:________________________________________________________
EmployeesJobTitle:_____________________________________________________________
Jobattimeofinjury: ____________________________________________________________
Typeofemployment:FulltimeParttimeTemporarySeasonalOther: ________
LengthoftimewithCompany: ____________________________________________________
Lengthincurrentpositionatthetimeoftheincident: _________________________________
Descriptionandseverityofinjury: _________________________________________________
2) Dateandtimeofincident: _______________________________________________________
3) LocationofIncident:____________________________________________________________

NOTE:Items4,5,and6areusedforbothStep1andStep2

4) Detaileddescriptionofincident:Includerelevanteventsleadingupto,during,andafterthe
incident.(Itispreferredthattheinformationisprovidedbytheinjuredemployee.)

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Useadditionalpagesifneeded

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5) Descriptionofincidentfromeyewitnesses,includingrelevanteventsleadingupto,duringand
aftertheincident.Includenamesofpersonsinterviewed,jobtitlesanddate/timeofinterviews.

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Useadditionalpagesifneeded

6) Descriptionofincidentfromadditionalemployeeswithknowledge,includingrelevantevents
leadingupto,duringandaftertheincident.Includenamesofpersonsinterviewed,jobtitlesand
date/timeofinterviews.

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Useadditionalpagesifneeded

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SectionC:IdentifytheRootCauses:WhatCausedorAllowedtheIncidenttoHappen?Step3
TheRootCausesaretheunderlyingreasonstheincidentoccurred,andarethefactorsthatneedto
beaddressedtopreventfutureincidents.Ifsafetyprocedureswerenotbeingfollowed,whywere
theynotbeingfollowed?Ifamachinewasfaultyorasafetydevicefailed,whydiditfail?Itis
commontofindfactorsthatcontributedtotheincidentinseveraloftheseareas:
equipment/machinery,tools,procedures,trainingorlackoftraining,andworkenvironment.If
thesefactorsareidentified,youmustdeterminewhythesefactorswerenotaddressedbeforethe
incident.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Useadditionalpagesifneeded
SectionD:RecommendedCorrectiveActionstoPreventFutureIncidents Step4

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Useadditionalpagesifneeded
SectionE:CorrectiveActionsTaken/RootCausesAddressed Step4

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Useadditionalpagesifneeded

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APPENDIX B: INCIDENT INVESTIGATORS KIT

Samplelistofitemstousetoconducttheinvestigation:
Camera
ChargedBatteries(forphones,cameras,equipment,etc.)
Video/Audiorecorder
Measuringdevicesinvarioussizes
Levelingrod
Clipboardandwritingpad
Pens,pencils,markers
Graphpaper
Straightedgeruler(Canbeusedasascalereferenceinphotos)
Incidentinvestigationforms
Flashlight
Strings,stakes,warningtape
Photomarkingcones
Personalprotectiveequipment:Gloves,hat,eyewear,earplugs,facemask,etc.
Magnifyingglass
Highvisibilityplastictapestomarkoffarea
Firstaidkit
Latexgloves
Sampling[holding]containerswithseals(Varioustypes:bags,jars,containers,etc.)
Identificationtags
Varietyoftape:Scotch,masking,duct
Compass
Carpentersruler
Hammer
Paintstick(yellow/black)
Chalk(yellow/white)
Protractor
Clinometer

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APPENDIX C: TIPS FOR VIDEO/PHOTO DOCUMENTATION

Note:Intervieweesmustbeawarethattheyarebeingvideorecordedand/orphotographed.It
isrecommendedthatinvestigatorsobtainpermissionfromtheintervieweepriortothe
interview.

TipsforVideoDocumentation:

Videothesceneassoonaspossible;doingthisearlyonwillpickupdetailsthatmay
lateraddvaluableinformationtotheinvestigation
Scanslowly360degreesleftandrighttoestablishlocation
Narratewhatisbeingtaped,anddescribeobjects,size,direction,location,etc.
Ifvehicleswereinvolved,recorddirectionoftravel,goingandcoming


TipsforPhotographDocumentation:

Alwaysmakenotesaboutthephotostaken
Startbytakingdistanceshotsfirstthenmoveintotakecloserphotosofthescene
Takephotosatdifferentangles(fromabove,360degreesofscene,left,right,rear)
toshowtherelationshipofobjectsandminuteand/ortransientdetailssuchasends
ofbrokenrope,defectivetools,drugs,wetareas,orcontainers
Takepanoramicphotostohelppresenttheentirescene,toptobottomsidetoside
Takenotesoneachphoto;theseshouldbeincludedintheincidentinvestigationfile
withthephotos
Identifyanddocumentthephototype,date/time/locationtaken,subject,weather
conditions,measurements,etc.
Placeanitemofknowndimensionsinthephototoaddaframeofreferenceand
scale(e.g.,apenny,apackofcards)
Identifythepersontakingthephoto
Indicatethelocationswherephotosweretakenonsketches(SeeAppendixD)

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 Incident Investigations: A Guide for Employers

APPENDIX D: SKETCH THE SCENE TECHNIQUES

1. Makesketcheslarge;atleast8x10andclear,besuretoprintlegibly
2. IncludeIncidentDetails(i.e.,time,date,injured,location,conditions,etc.)
3. Includemeasurements(i.e.distances,heights,lengths,etc.)andusepermanentpoints(e.g.,
telephonepole,building)toclearlypresentthemeasurements
4. IndicatedirectionsN=North;E=East;W=West;S=South
5. Makenotesonsketchtoprovideadditionalinformationsuchasthephotolocationand/or
wherepeoplewereatthetimeoftheincident
Note:Thesketchcanbeusedduringinterviewstohelpintervieweesidentifytheirlocationbefore,
duringoraftertheincident

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 Incident Investigations: A Guide for Employers

APPENDIX E: COLLECT INFORMATION CHECKLIST

Investigatorsshouldbesuretheirinvestigationanswersthefollowingquestions:
WHO? WHERE?
Whowasinjured? Wheredidtheincident occur?
Whosawtheincident? Wherewastheemployeeatthetime?
Whowasworkingwiththeemployee? Wherewasthesupervisoratthetime?
Whohadinstructed/assignedtheemployee? Wherewerefellowworkersatthetime?
Whoelsewasinvolved? Wherewereotherpeoplewhowereinvolvedat
Whoelsecanhelppreventrecurrence? thetime?
Wherewerewitnesseswhenincidentoccurred?

WHAT? WHY?
Whatwastheincident? Whywastheemployeeinjured?
Whatwastheinjury? Whyandwhatdidtheemployeedo?
Whatwastheemployeedoing? Whyandwhatdidtheotherpersondo?
Whathadtheemployeebeentoldtodo? Whywasntprotectiveequipmentused?
Whattoolswastheemployeeusing? Whywerentspecificinstructionsgiventothe
Whatmachinewasinvolved? employee?
Whatoperationwastheemployeeperforming? Whywastheemployeeintheposition?
Whatinstructionshadtheemployeebeengiven? Whywastheemployeeusingthetoolsormachine?
Whatspecificprecautionswerenecessary? Whydidnttheemployeecheckwiththesupervisor
Whatspecificprecautionswastheemployeegiven? whentheemployeenotedthingswerentasthey
Whatprotectiveequipmentshouldhavebeen shouldbe?
used? Whydidtheemployeecontinueworkingunderthe
Whatprotectiveequipmentwastheemployee circumstances?
using? Whywasntthesupervisorthereatthetime?
Whathadotherpersonsdonethatcontributedto
theincident?
Whatproblemorquestionsdidtheemployee
encounter?
Whatdidtheemployeeorwitnessesdowhenthe
incidentoccurred?
Whatextenuatingcircumstanceswereinvolved?
Whatdidtheemployeeorwitnessessee?
Whatwillbedonetopreventrecurrence?
Whatsafetyruleswereviolated?
Whatnewrulesareneeded?

WHEN? HOW?
Whendidtheincidentoccur? Howdidtheemployeegetinjured?
Whendidtheemployeestartonthatjob? Howcouldtheemployeehaveavoidedit?
Whenwastheemployeeassignedonthejob? Howcouldfellowworkershaveavoidedit?
Whenwerethehazardspointedouttothe Howcouldsupervisorhavepreventeditcouldit
employee? beprevented?
Whenwastheemployeessupervisorlastcheckon
jobprogress?
Whendidtheemployeefirstsensesomethingwas
wrong?

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 Incident Investigations: A Guide for Employers

APPENDIX F: SAMPLE QUESTIONS FOR IDENTIFYING INCIDENT ROOT CAUSES

QUESTIONS
1. Didawrittenorwellestablishedprocedureexistforemployeestofollow?
2. Didjobproceduresorstandardsproperlyidentifythepotentialhazardsofjobperformance?
3. Werethereanyhazardousenvironmentalconditionsthatmayhavecontributedtotheincident?
4. Werethehazardousenvironmentalconditionsintheworkarearecognizedbyemployeesor
supervisors?
5. Wereanyactionstakenbyemployees,supervisors,orbothtoeliminateorcontrolenvironmental
hazards?
6. Wereemployeestrainedtodealwithanyhazardousenvironmentalconditionsthatcouldarise?
7. Wassufficientspaceprovidedtoaccomplishthejobtask?
8. Wasthereadequatelightingtoproperlyperformalltheassignedtasksassociatedwiththejob?
9. Wereemployeesfamiliarwithjobprocedures?
10. Wasthereanydeviationfromtheestablishedjobprocedures?
11. Weretheproperequipmentandtoolsavailableandbeingusedforthejob?
12. Didanymentalorphysicalconditionspreventtheemployee(s)fromproperlyperformingtheirjobs?
13. Werethereanytasksinthejobconsideredmoredemandingordifficultthanusual(e.g.,strenuous
activities,excessiveconcentrationrequired,etc.)?
14. Wasthereanythingdifferentorunusualfromnormaloperations?(e.g.,differentparts,newor
differentchemicalsused,recentadjustments/maintenance/cleaningonequipment)
15. Wastheproperpersonalprotectiveequipmentspecifiedforthejobortask?
16. Wereemployeestrainedintheproperuseofanypersonalprotectiveequipment?
17. Didtheemployeesusetheprescribedpersonalprotectiveequipment?
18. Waspersonalprotectiveequipmentdamagedornotproperlyfunctioning?
19. Wereemployeestrainedandfamiliarwiththeproperemergencyprocedures,includingtheuseof
anyspecialemergencyequipmentandwasitavailable?
20. Wasthereanyindicationofmisuseorabuseofequipmentand/ormaterialsattheincidentsite?
21. Isthereanyhistoryofequipmentfailure,wereallsafetyalertsandsafeguardsoperationalandwas
theequipmentfunctioningproperly?
22. Ifapplicable,areallemployeecertificationandtrainingrecordscurrentanduptodate?
23. Wasthereanyshortageofpersonnelonthedayoftheincident?
24. Didsupervisorsdetect,anticipate,orreportanunsafeorhazardouscondition?
25. Didsupervisorsrecognizedeviationsfromthenormaljobprocedure?
26. Didsupervisorsandemployeesparticipateinjobreviewsessions,especiallyforthosejobs
performedonaninfrequentbasis?
27. Weresupervisorsmadeawareoftheirresponsibilitiesforthesafetyoftheirworkareasand
employees?
28. Weresupervisorsproperlytrainedintheprinciplesofincidentprevention?
29. Wasthereanyhistoryofpersonnelproblemsoranyconflictswithorbetweensupervisorsand
employeesorbetweenemployeesthemselves?
30. Didsupervisorsconductregularsafetymeetingswiththeiremployees?
31. Werethetopicsdiscussedandactionstakenduringthesafetymeetingsrecordedintheminutes?
32. Weretheproperresources(i.e.,equipment,tools,materials,etc.)requiredtoperformthejobor
taskreadilyavailableandinpropercondition?

33. Didsupervisorsensureemployeesweretrainedandproficientbeforeassigningthemtotheirjobs?

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