Accident

Reporting
& Investigation
Training

Mr. Yahya Abdi Hassan

Environmental Health and Safety Manager
 What Is An Accident?
Unplanned, unwanted, but
controllable event which disrupts
the work process and causes
injury to people.
 What is an “Accident”?
By dictionary definition: “an unforeseen event”,
“chance..”, “unexpected happening..”, formerly
“Act of God”
• From experience and
analysis: they are
“caused occurrences” Fatalities

– Predictable - the logical Severe Injuries

outcome of hazards
Minor injuries

– Preventable and
avoidable - hazards do not Close calls

have to exist. They are

caused by things people
Hazardous conditions

do -- or fail to do.
The Four Misconceptions About Safety
FUNDAMENTAL MISCONCEPTIONS

1. Accidents cannot be prevented

2. We don’t have many accidents

3. Safety is expensive.

4. We are insured anyway.

Purpose of Investigation

 Determine sequence of
events that led to
consequence
 Offer corrective action
recommendations to
prevent recurrence of
the incident
 Never to assign blame
or assess liability
 What should be investigated?
 All
incidents that
cause
 Injury
 Illness
 Lost time
 Property damage
 Allnear-miss
incidents
 Where should the
investigation be conducted?

The
investigation
must be
conducted at
the site of
the incident
Who should conduct the
investigation?
 Team
 Supervisor of the
affected employee
 Safety committee
representative for
area
 Safety officer
 Affected
employee(s)
 When should the
investigation be conducted?

Immediately after the

incident occurred
 Memories are fresh
 Evidence is in place
 Immediate corrective
actions can be initiated
 Incident Investigation
Procedures
 Priority of incidents to be investigated
 Notification of incident occurrence
 First aid response
 Securing the area
 Gathering evidence
 Interviewing witnesses
 How program will be evaluated and
updated
 How to Conduct an
Investigation?
Focus on finding fact, not fault
 Investigate the facts
 Review the facts to find the cause
 Recommend corrective measures
 Document findings and actions
 Follow-up
 Attending the accident scene
 OBSERVE
 Look at the scene and the surrounding area

 Take measurements and produce a diagram

 Take photographs

 INTERVIEW
 The injured person and/or

witnesses (preferably separately)

 At the scene if possible(within 48 hours)

 Note down beforehand some key questions to

be answered - CHECKLIST
 Ask open-ended questions in a friendly manner

 KEEP AN OPEN MIND (be aware of your bias)

 Interviews
 Startwith initial discussions with
preferably the injured person and
peers/witnesses (Mainly what happened)
 Thenmove on to interview supervisors
and senior managers (Mainly why)
 Donot rush into statement taking, get
an overview first
 Statements
 Introduce yourself (if necessary)and
explain your role – what needs to be
done
 Invite safety rep or another person
they would like to sit in, but not
answer questions
 If trainee under 18 years, interview
with an adult, preferably a parent
 Run through your questions and what
they witnessed and make notes to help
structure a statement – ‘Each persons
summary’
 Investigate the Facts
 Look at the situation
 Record general information
 Collect evidence
 Interview witnesses
 Review records
 Investigate the Facts

Look at the situation

 Examine the big picture
 Think of the 5 W’s (who,
what, why, when, where)
 Outline your approach
 Investigate the Facts
Record General Information
 Time and exact location
 Injuries
 Medical treatment or first aid
 Anything unusual
 Investigate the Facts

Collect Evidence
 Photographs of equipment
 Samples of chemicals
 Broken parts or pieces
 Investigate the Facts
Interview Witnesses
 Individually
 At the scene of the incident
 Immediately after the
incident, if possible
 With an open mind
 Investigate the Facts
Review Records to Identify
Trends
 Inspection records
 Previous incident reports
 Maintenance records
 Workers’ compensation
insurance forms
Review the Facts to Find the
Cause
 Review all information
 Clarify the facts
 Analyze information
 Examine contributing
factors
 List possible causes
 Identify the cause
 Examining Contributing Factors

Employ a process called branching to

find root causes

Person slips on oil on floor

Why?

Oil was spilled on floor Person stepped in oil

 Examining Contributing Factors

Oil was spilled on floor Person stepped in oil

Why? Why?

Machine was being Person walked through

serviced and oil spilled work area
 Examining Contributing Factors

Machine was being Person walked through

serviced and oil spilled work area

Why? Why?

Spill not Oil spill Person worked in

prevented not cleaned department
 Recommend Corrective Actions
 Look at each step in the chain of
events
 Suggest attainable actions
 Assign responsibility for
implementation
 Coordinate a schedule for
implementation
 Start with simple solutions; move on
to those that will be more complex
Recommend Corrective Actions

Causes: Action:

Spill was not prevented ?

Oil spill not cleaned ?

Person worked in department ?

 Document Findings and Actions

Incident investigation reports usually

contain
 General information
 Description of injury or illness
 Description of the incident
 Analysis
 Corrective actions
 Dates for completion
and follow-up
 Follow-Up

Ensure that recommended

corrective actions
 Have been implemented
properly
 Are effective in
eliminating or reducing
future incidents
 Do not create an
unforeseen hazard
 Do you investigate incidents &
accidents in your company?

 Do you do it well?
 Do you find the underlying causes?
 Do you take corrective action?
 Do you review your risk assessments as
a result?
Do you do it?
 Most accidents are not
investigated

 safety specialists lead

rather than line managers
 effort determined by severity of the
injury rather than potential of the event
 little employee involvement
 if line managers do investigate, little
training in investigation skills and
techniques
 immediate technical causes only cont’d
30
 often stops when someone is found to
blame
 fails to get to underlying causes

Even if there is an investigation:

 failure to monitor full implementation of

investigation findings
 failure to systematically record findings so
that lessons can be learnt throughout the
organisation
Most firms don’t know why accidents occur 31!
Integrated approach to accident investigation and risk
assessment
i.e. it should be integrated but usually isn’t!!

from HSE CD169/2001

 Near misses are important
Powerful advantages

 why not take the “free lessons”?

 equivalent learning opportunity…
 …but, without the legal and
liability implications
 Team based investigation

RoSPA study - best practice

 led by senior managers

 involving employees, including
safety representatives
 supported by OS&H professionals
acting as facilitators
 Team based investigation
 Local knowledge, especially operational
 Building of trust;
 Creates workforce 'champions' for H&S;
 Check on safety management standards
 Investigation of lower risk safety issues
is important in creating a positive
climate for more structured investigation
when major safety failures occur.
 Some common causes
of accidents

 Not knowing or not using safe work

methods
 Lack of testing, inspection
and maintenance
 Unsafe manual handling
 Working too fast or cutting corners
 Overloading equipment cont’d
 Some common causes
of accidents
Not using:
 guards, scaffolds, platforms, etc.

Ignoring or disregarding:
 warning signs
 statutory notices
 Untidiness or carelessness

Horseplay
 Safety in the workplace requires
 Safesystems of work and good
organisation
 Gooddefect reporting and maintenance
arrangements
 Careful, safety-based work planning
 The correct tools and equipment for
the job in hand
cont’d
 Safety in the workplace requires

 Knowledge of, and compliance with,

safety law
 Adequate information, training,
instruction and supervision
 Common sense and a mature attitude
 ACCIDENT CAUSATION SEQUENCE
Top Level
decision markers

HUMAN INVOLVEMENT

Line management,
Fallible designers, planners etc.
decisions

Latent Line management

Failures

CASUAL
SEQUENCE
Pre-conditions

Unsafe
acts

Systems
defenses
Local triggers
Technical faults
Atypical conditions
Environmental
Conditions, etc.

Limited windows of
Accident opportunity
ACCIDENT
 Accident Reporting &
Investigation
 Accident Causation
• causal factors
 individual
• knowledge
• skills
• training
• experience
• personality
• attitude
• risk perception
 Accident Reporting &
Investigation
 Accident Causation

• causal factors
 job
• task
• workload
• equipment
• controls
• procedures
• environment
 Accident Reporting &
Investigation
 Accident Causation
• causal factors
 organisation
• culture
• leadership
• resources
• work patterns
• communications
ACCIDENT CAUSATION MODELS - 1

ACCIDENT

INVESTIGATE – PROCESS AND OUTCOME

STEERED BY INVESTIGATORS’ PRE-CONCEPTIONS
OF CAUSATION

CONCLUDE PRIMARY CAUSE IS EITHER:

UNSAFE ACT, or; UNSAFE CONDITION

DEVISE A RULE DEVISE A TECHNICAL

FORBIDDING SOLUTION
BEHAVIOUR
 OUTCOMES OF ACCIDENTS
 NEGATIVE ASPECTS

 Injury & possible death

 Disease
 Damage to equipment & property
 Litigation costs, possible citations
 Lost productivity
 Morale
 OUTCOMES OF ACCIDENTS
 POSITIVE ASPECTS

 Accident investigation
 Prevent recurrence
 Change to safety programs
 Change to procedures
 Change to equipment design
 Accident Reporting &
Investigation
 Accident Prevention
• control measures
 safety procedures/work instructions

 adequate training

 effective communications

 good housekeeping

 guards/safety devices/warning signs

 adequate working environment

 regular safety inspections

 risk assessment
 Acts and Conditions
UNSAFE ACT UNSAFE
CONDITIONS
 Human errors  No guarding
 Failure to follow  Trip hazards
procedures  Poor maintenance
 Violations  Poor design
 mistakes
Immediate causes (what) “4
Ps”

 Premises
 Plant/Substances
 Procedures
 People
 Premises
 Physical layout
 Condition of building
 Environment (weather)
 Tripping & slipping hazards
 PLANT/SUBSTANCES
 Machinery guarding
 Substance in use –toxic, harmful
 Mobile plant
 Item of work equipment – hand
tools, chairs
 PROCEDURE
 Written system of work/operating
procedure to be followed
 Safety Policy
 Work instruction
 Quality standard
 Custom and Practice – does not have to
be a document
 People
 Human factors
 State of health (eye sight)
 Abilities
 Errors – skill based (slip or lapse), rule
based, knowledge based or violations
 Behaviour – pressures, culture
 Underlying causes
‘Root causes’ (Why)
 Planning  Communication

 Risk  Competence
Assessment  Monitoring
 Control  Reviewing
(Supervision)
 Co-operation