Accident and Incident

Investigation
 Objectives of this Section

To define the reasons for investigating

accident and incidents.
To outline the process for effectively
investigating accidents and incidents.
To facilitate an effective investigation.
 Accident Investigation
Important part of any safety management
system. Highlights the reasons why accidents
occur and how to prevent them.
The primary purpose of accident investigations
is to improve health and safety performance
by:
Exploring the reasons for the event and identifying
both the immediate and underlying causes;
Identifying remedies to improve the health and
safety management system by improving risk
control, preventing a recurrence and reducing
financial losses.
 What to Investigate?
All accidents whether major or minor are
caused.

Serious accidents have the same root causes

as minor accidents as do incidents with a
potential for serious loss. It is these root
causes that bring about the accident, the
severity is often a matter of chance.

Accident studies have shown that there is a

consistently greater number of less serious
accidents than serious accidents and in the
same way a greater number of incidents then
accidents.
Many accident ratio studies have been
undertaken and the one shown below is based
on studies carried out by the Health & Safety
Executive.

1
Major injury
Or illness

7
Minor injuries or illnesses

189
Non Injury Accidents/Illnesses
 Accident Studies
In all cases the non injury incidents had the
potential to become events with more serious
consequences.

Such ratios clearly demonstrate that safety

effort should be aimed at all accidents
including unsafe practices at the bottom of the
pyramid, with a resulting improvement in
upper tiers.

Peterson (1978) in defining the principles of

safety management says that an unsafe act,
an unsafe condition, an accident are
symptoms of something wrong within the
 Accident Studies
All events represent a degree of failure in
control and are potential learning experiences.
It therefore follows that all accidents should be
investigated to some extent.

This extent should be determined by the loss

potential, rather then just the immediate
effect.
 Stages in an
Accident/Incident
Investigation
The stages in an accident/incident investigation
are shown in
Deal with immediate risks Dealthe following diagram.
with immediate
risks.

Select the level of investigation.

Select the level of
investigation.
Investigate the event.

Investigate the event.

Record and analyse the results.

Review the process. Record and analyse the

results.

Review the process.

 Dealing with
Immediate Risks
Deal with immediate When accidents and incidents
risks.
occur immediate action may be
necessary to:
Select the level of
investigation. Make the situation safe
and prevent further injury.
Investigate the event.
Help, treat and if
necessary rescue injured
Record and analyse the
results.
persons.

Review the process. An effective response can only

be made if it has been planned
for in advance.
 Selecting the level of
investigation
The greatest effort should be put
Deal with immediate
risks.
into:
Those involving severe injuries,
ill-health or loss.
Select the level of
investigation. Those which could have caused
much greater harm or damage.
Investigate the event. These types of accidents and
incidents demand more careful
Record and analyse the
investigation and management
results. time. This can usually be achieved
by:
Review the process. Looking more closely at the
underlying causes of significant
events.
Assigning the responsibility for
the investigation of more
significant events to more senior
 Investigating the
Event
Deal with immediate
risks.

The purpose of investigations

Select the level of
investigation. is to establish:
The way things were and how they
Investigate the event. came to be.
What happened the sequence of
Record and analyse the
events that led to the outcome.
results. Why things happened as they did
analysing both the immediate and
Review the process. underlying causes.
What needs to be done to avoid a
repetition and how this can be
achieved.
A few sources should give the investigator all
that is needed to know.
Observation
Information from physical
sources including:
Premises and place of
work
Access & egress
Plant & substances in use
Location & relationship of
physical particles
Any post event checks,
sampling or
reconstruction
Documents
Information from:
Written instructions;
Procedures, risk
assessments, policies
Records of earlier
inspections, tests,
examinations and
surveys.
Checking reliability, accuracy
Identifying conflicts and resolving differences
Identifying gaps in evidence
Interviews
Information from:
Those involved and
their line
management;
Witnesses;
Those observed or
involved prior to the
event e.g. inspection
& maintenance staff.
 Investigation Kit
Preparation
Clipboard, Pre-
Camera &
printed Forms
Video Camera PPE
Cassette Tape Containers for
Recorder Taking and Storing
Flash and Batteries Samples
Mobile Telephone / Barrier Tape
Walkie-Talkie

Copyright@NIOSH 2005/1 13
 Interviews
Interviewing the person(s) involved and
witnesses to the accident is of prime
importance, ideally in familiar
surroundings so as not to make the
person uncomfortable.
The interview style is important with
emphasis on prevention rather than
blame.
The person(s) should give an account of
what happened in their terms rather
than the investigators.
 Interviews

Interviews should be separate to stop

people from influencing each other.
Questions when asked should not be
intimidating as the investigator will be
seen as aggressive and reflecting a
blame culture.
 Observation
The accident site should be inspected
as soon as possible after the accident.
Particular attention should/must be
given to:

Positions of people.
Personnel protective equipment (PPE).
Tools and equipment, plant or
substances in use.
Orderliness/Tidiness.
 Documents
Documentation to be looked at includes:
Written instructions, procedures and risk
assessments which should have been in
operation and followed. The validity of these
documents may need to be checked by
interview. The main points to look for are:
Are they adequate/satisfactory?
Were they followed on this occasion?
Were people trained/competent to follow it?
Records of inspections, tests, examination and
surveys undertaken before the event. These
provide information on how and why the
circumstances leading to the event arose.
 Determining Causes
Collect all information and facts which
surround the accident.
Immediate causes are obvious and easy to
find. They are brought about by unsafe acts
and conditions and are the ACTIVE
FAILURES. Unsafe acts show poor safety
attitudes and indicate a lack of proper training.
These unsafe acts and conditions are brought
about by the so called root causes. These are
the LATENT FAILURES and are brought about
by failures in organisation and the
managements safety system.
Determine what changes are
needed
The investigation should determine what control
measures were absent, inadequate or not
implemented and so generate remedial action
for implementation to correct this.

 Generally, remedial actions should

follow the hierarchy of risk control:

Eliminate Risks by substituting the dangerous

by the inherently less dangerous.
Combat risks at source by engineering controls
and giving collective protective measures
priority.
Minimise risk by designing suitable systems of
working.
Use PPE as a last resort.
 Recording & Analysing
the Results
Recorded in a similar and systematic
manner.
Deal with immediate
risks. Provides a historical record of the
accident.
Select the level of Analysis of the causes and
investigation.
recommended preventative protective
measures should be listed.
Investigate the event. Completed as soon after the accident
as possible.
Information on the accident and
Record and analyse the
results. remedial actions should be passed to
all supervisors.
Review the process.
Appropriate preventative measures
may also have to be implemented by
such supervisors.
Investigation reports and accident
statistics should be analysed from time to
time to identify common causes, features
and trends not be apparent from looking at
 Reviewing the Process
Reviewing the
Deal with immediate accident/incident investigation
risks.
process should consider:
The results of investigations and
Select the level of
investigation. analysis.
The operation of the investigation
Investigate the event. system (in terms of quality and
effectiveness).

Record and analyse the

Line managers should follow
results. through and action the
findings of investigations and
Review the process.
analysis. Follow up systems
should be established where
necessary to keep progress
under control.
 The investigation system should be
examined from time to time to check
that it consistently delivers information
in accordance with the stated objectives
and standards. This usually requires:
Checking samples of investigation forms to
verify the standard of investigation and the
judgements made about causation and
prioritisation of remedial actions.
Checking the numbers of incidents, near
misses, injury and ill-health events;
Checking that all events are being reported.
CASE STUDY AT MALAYSIA
(REFER TO ATTACHMENT)
 CASE STUDY
CASE STUDY - Ladder

Accident Description:
I was going to clean gutters.
I set up the ladder and when
I stepped on the fourth rung
up, it broke. I fell to the
ground and felt extreme pain
in my leg.
QUESTIONS TO UNCOVER
CAUSES
What kind of ladder was used? Load rating?
What was the condition of the ladder?
Where did the ladder break?
Was the ladder inspected for damage prior to use?
What kind of training has the employee had to use and inspect
ladders prior to use?
What was the employee carrying? How much did it weigh?
Did the load on the ladder exceed the load rating?
How was the ladder stored? Where?
Has the ladder ever been dropped or damaged? If so, how?
How did the ladder rung break?
What is the procedure for cleaning gutters?
Is there a fall protection plan in place?
What was the weather?
What was going on around the work location at the time?
Investigation Findings -
Ladder
Ladder is a Type II, metal, load capacity of 225 pounds.
The ladder is kept on a rack on the truck and the truck is
parked outside.
The ladder was placed up against a wall at a 1:4 ratio.
Employee was wearing tool belt which weighed
approximately 30 pounds. The total load was above
maximum load capacity.
Three days ago the ladder fell off the truck while
transporting because it was not secured properly.
The employee says he inspected the ladder after and did
not note any deficiencies. It had not been inspected since.
Employee received training on ladder safety when first
employed seven years ago.
Procedures are in place for ladder inspections but not
followed or enforced.
No procedures in place for cleaning gutters.
Accident Causes Ladder
Direct causes
Rung Failed

Indirect causes
Ladder overloaded
Improper storage caused ladder damage (not tied down)
Not inspected prior to each use
Improper selection of equipment
Using defective equipment

Basic causes
Supervisor not enforcing procedures
Inadequate training
 CAUSATION SUMMARY
POSSIBLE CAUSES CORRECTIVE ACTIONS FOLLOW UP
Rung failed Take ladder out of service Immediately
(Destroyed) K. Colby
Ladder overloaded Provide equipment that is suitable for 5/17/07
the task K. Gregg
Improper storage caused ladder Provide proper means and equipment 5/17/07
damage (not tied down) for storage and provide training on T. Kinman
ladder storage
Not inspected prior to each use Develop, carry out and enforce policy 6/15/07
for inspection of ladders B. Dorris
Improper selection of Provide training on proper ladder 5/16/07
equipment selection J. Collins
Using defective equipment Provide training on ladder inspection 5/15/07
G. Jacobson
Supervisor not enforcing Enforce safety rules/discipline policy Immediately
procedures R. Nunamaker
Inadequate training Provide training on ladder use, 5/17/07
selection, inspection and storage L. Schneider
GROUP WORK
 DIRECTIONS
Divide into small work groups (not more than 6).
Each group will be given a case study to work on.
From the accident description, come up with
questions to ask to uncover the causes.
Once questions are complete we will give each group
the findings of the case study they are working on.
From the findings determine all causes (direct,
indirect and basic) and corrective actions to be taken
for each cause.
List causes and corrective actions on causation
summary sheet.
 CASE STUDY- Meat Slicer
Accident Description:

I was slicing roast beef with a meat

slicer. My hand slipped into the
rotating blade cutting my thumb and
forefinger.
QUESTIONS TO UNCOVER CAUSES
How was the employee cutting the meat?
What was she doing before she cut meat?
How long had she been using the meat cutter?
Who taught her how to use it?
Are there procedures for using it correctly?
Does the blade have a protective guard? Was it
functional?
Have there been other injuries on this cutter?
Is there any protective equipment available?
Who was around before, after?
Investigation Findings Meat Slicer
Meat being sliced is slippery.
There is a guard on the meat cutter. The configuration of the
meat cutter would have prevented a cut if the guard were used.
Procedures required the use of the guard.
The employee was not trained in the safe use of the meat cutter,
although she was an experienced kitchen worker.
The employee says guard was used, but the person who cleaned
the cutter after the accident said the guard was NOT engaged.
There have been no other accidents on this equipment.
However, there have been several employee injuries in this
kitchen.
Employee was talking to another employee and looked away just
before the accident.
There were cut-resistant gloves available but not used. No
procedures mandated their use.
 Accident Causes Meat Slicer
Direct causes
Unguarded rotating blade

Indirect causes
Employees hand slipped
Employee was distracted
Meat cutter could be operated without guards in place
Cut-resistant gloves were available but not used

Basic causes
Supervisor not enforcing procedures for equipment
Procedures not in place for use of gloves (PPE)
Employee was not aware that guard use was mandatory
 CAUSATION SUMMARY

CAUSES CORRECTIVE ACTIONS FOLLOW UP

Unguarded rotating blade Ensure guard is in place Immediately by all

Employees hand slipped Ensure guard is in place 1/15/07

Jo Donahoe
Employee was distracted Develop, implement and enforce 1/15/07
safety procedures Charlotte Harper
Meat cutter could be operated Retrofit guard so it cannot be Immediate -
without guards in place disabled Lance Wells
Cut-resistance gloves were Develop, implement, and enforce 5/15/07
available but not used procedure for glove use Pam Milleson
Supervisor not enforcing Enforce safety rules/discipline Immediate
procedures for equipment policy Louise Matzner
Procedures not in place for use Develop, implement and enforce 5/15/07
of gloves (PPE) procedures for glove use Shirley Schaeffer
Employee was not aware that Train staff on use of equipment Immediate -
guard use was mandatory and procedures Amy Kimberling
 CASE STUDY - Bus
Accident Description:

I was checking the steering fluid in

bus engine. I had to climb up on the
front tire and when I was getting
down, I felt my left knee pop.
 QUESTIONS TO UNCOVER CAUSES
Why did employee have to stand on the tire?
Are there other ways of checking fluids?
What is the process for getting down?
What type of training did you receive for checking fluids? By
who?
What is the distance between tire and first step to get
down?
Each additional step?
Tell me what you did from the time you arrived at work?
What was going on/happening around you at the time you
were
getting down?
What type of shoes were you wearing?
Have there been similar incidents? Explain.
What was the weather?
 Investigation Findings Bus
Driver was not trained how to check fluids on this type of
bus.
There are two step ladders available, but none close by.
No process or procedures in place for checking fluids.
Ladder use is covered in Accident Prevention Program but
there was no training specific to ladder use provided to
drivers.
Distance from tire to the peg step is 34 inches, step to
ground is 20 inches.
Driver had washed bus prior to checking fluids and area
around the bus was still wet.
Shoes being worn did not have good tread on soles to
prevent slipping. ($3 slip-ons)
Another driver came up and started talking as driver was
getting down.
 Accident Causes Bus
Direct causes
Improper body movement

Indirect causes
Failure to use proper equipment - step ladder
Wearing inappropriate footwear
Lack of step ladders available and not close by
Employee was distracted

Basic causes
Inadequate training in pre-trip procedures for all types of
buses
No designated bus wash area
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP
Improper body movement Develop procedures and train 12/15/05
drivers on procedures R Nicholson
Failure to use proper Enforce safety rules/discipline Immediately
equipment step ladder policy T Head
Wearing inappropriate Develop, implement and 12/15/05
footwear enforce safety procedures P Pocinich
Lack of step ladders Ensure adequate number of 11/30/05
available and not close by step ladders and ensure they B Petersen
are readily available
Employee was distracted Safety awareness training Immediate,
Ongoing
T Kinman
Inadequate training in pre- Train staff on use of all 3/16/07
trip inspections for all types equipment and procedures J Peterson
of buses

No designated bus wash area Designate bus wash area 6/30/07

J Mills
 CASE STUDY - Student
Accident Description:

A severely Autistic high school

student struck me in the back
while I was walking him to the
time out room.
 QUESTIONS TO UNCOVER
CAUSES
What training has employee had in dealing
with autistic students? And this student?
Has the child ever acted out in this way
before? When and under what circumstances
Is there a behavior plan in place for this
student? Was employee following it?
How did employee take student to time out
room?
What was going on prior to the
misbehavior?
Is there any personal protective equipment?
Investigation Findings
Student
Teacher was a substitute. Has a Special Ed
endorsement but has only taught in a Special Ed
classroom twice before.
Student is not familiar with substitute teacher.
Substitute teacher was informed of the students
behavior.
Substitute teacher was not informed of how to
handle the situation.
Teacher was holding students hand and leading
him to the room, she was in front of him.
Teacher put her arm around student.
 Accident Causes Student
Direct causes
Student hit teacher

Indirect causes
Teacher was walking in front of student (unsafe act) and
touched student (behavioral plan identifies the child is
uncomfortable with being touched)
Teacher was not able to de-escalate the student

Basic causes
Inadequate practices regarding staff selection
Inadequate training
Inadequate experience/skills
 CAUSATION SUMMARY

CAUSES CORRECTIVE ACTIONS FOLLOW UP

Student hit teacher Evaluate and make necessary 03/01/07

changes to remove trigger(s) L. Wallis
Teacher was walking in Develop, implement and enforce 6/30/07
front of student and safety procedures E. Rudeen
touched student
Teacher was not able to Provide other personnel trained in Immediately
de-escalate the student de-escalation to assist sub when L Muchlinski
needed

Inadequate practices Evaluate sub selection process 06/30/07

regarding staff selection C. Bailey
Inadequate training Evaluate and modify sub training 06/30/07
policies L. Bush
Inadequate Evaluate sub selection process 06/30/07
experience/skills C. Bailey
 CASE STUDY - Chair
Accident Description:

I was standing on student desk to

hang art work from the ceiling. When
I stepped back on to the chair to get
down, it collapsed.
 QUESTIONS TO UNCOVER
CAUSE
Why was employee standing on desk?
Is there a step ladder available? Where are they located?
What is the age, style and condition of desk & chair?
What type of shoes were they wearing?
Have there been similar incidents?
What was employee doing prior to getting on the desk?
What was going on at the time employee got off the desk?
What other ways do employees have for hanging items?
What training have employees received for hanging items?
What are the procedures for hanging items from the
ceiling?
 Investigation Findings Chair

Desks are for kindergarten students.

Desks and chairs are new this year.
Current practice is to use desks for hanging
items.
Teacher changes items hanging from ceiling once
a month.
Stepladders are available in every wing.
There are no procedures in place for using
stepladders. Ladder use is covered in Accident
Prevention Program.
There has been no training on stepladder use.
 Accident Causes Chair
Direct causes
Chair broke

Indirect causes
Improper use of equipment
Failure to use proper equipment

Basic causes
Safety procedures not in place
Inadequate training
 CAUSATION SUMMARY

CAUSES CORRECTIVE ACTIONS FOLLOW UP

Chair broke Take out of service (tag or destroy) Immediately

J Cornaggia

Improper use of Train staff on use of equipment 4/15/06

equipment J Klundt

Failure to use proper Enforce safety rules/discipline Immediately

equipment policy R Johnson

Safety procedures not in Develop, implement and enforce 3/17/06

place safety procedures D Heider

Inadequate training Train staff on use of equipment 4/15/06

and procedures M Mayberry
CASE STUDY - Groundsperson

I was unloading 50
pound bags of
fertilizer from
truck, twisted
wrong and hurt my
back.
QUESTIONS TO UNCOVER
CAUSE
What are the procedures for unloading fertilizer from a truck?
What type of truck were the bags on?
Where were the bags on the truck?
How were the bags stacked?
Where was the employee unloading bags from?
Where was the employee moving the bags to?
Where were you located?
How often do you perform this type of lifting?
What were you doing before the incident?
Have you been trained in lifting?
Did you have help? Did you ask for help?
What were the conditions at the time?
How was the employee dressed?
 Investigation Findings - Groundsperson

Employee had been trained in lifting properly.

This unloading requires two people in its current
configuration.
Employee did not seek a lifting partner.
The bags were being removed from inside the
bed of the truck and swung to landing them on
the ground beside him.
Employee was performing an unsafe act by
twisting his body while lifting.
This employee has had previous on the job
injuries due to lifting.
Location for unloading puts employees in
awkward positions for lifting.
 Accident Causes
Groundsperson
Direct causes
Twisted back bodily motion

Indirect causes
Failure to seek assistance
Lifting improperly swinging, too heavy, no help
Loading, placing supplies improperly

Basic causes
Injury repeater
Insufficient supervision/enforcement policies
Unsafe layout for loading/unloading
 CAUSATION SUMMARY
CAUSES CORRECTIVE ACTIONS FOLLOW UP

Twisted back bodily motion Enforce safety rules/discipline Immediately

policy D Glaser
Failure to seek assistance Enforce safety rules/discipline Immediately
policy D Schell
Lifting improperly - Retrain in proper lifting 3/1/07
swinging, too heavy, no help techniques T Triplett
Loading/placing supplies Develop proper loading/storage 2/29/07
improperly procedures, train employees R Nunamaker
Injury repeater Enforce safety rules/discipline Immediately
policy D Schell
Insufficient Enforce safety rules/discipline Immediately
supervision/enforcement policy D Schell
policies
Unsafe layout for Relocate storage area 6/30/06
loading/unloading M Wallace
 SUMMARY

Purpose of Investigation
Establish the facts
Ensure similar incidents do not occur
Reduce the number and severity of losses

Five Step Investigation Process

Gather the facts
Review the facts to find causes
Document findings and actions
Take preventative action
Follow up
 Questions?
Contact Info:

Suzanne Reister
Program Manager
Workers Compensation/Unemployment Cooperative
North Central ESD
509-667-7100
suzanner@ncesd.org

Paula Vanderpool
Program Assistant
Workers Compensation/Unemployment Cooperative
North Central ESD
509-667-7110
paulav@ncesd.org
THE END
REVIEWS
 Certified Safety Construction
Business CB106
Presented By:
Construction Compliance
Training Center

This material was developed by Compacion Foundation Inc and The Hispanic Contractors Association de Tejas under Susan Harwood Grant Number
SH-20-843-SH0 Occupational Safety and Health Administration, U.S. Department of Labor. It does not necessarily reflect the views or policies of the
U.S. Department of Labor, nor does mention of trade names, commercial products, or organizations imply endorsements by the U.S. Government.
Provide participants with the basic skills necessary to conduct
an effective accident investigation in your workplace.

You will identify;

Primary Reasons, Benefits, and
Employer Responsibilities to
conducting an accident
investigation
Three Steps for an
Effective Investigation
Investigate and Analysis

CB106 Accident Investigation

The most important things in an accident are:
When an accident happens, the most important
thing is taking care of the victim or victims.
After that, the most important thing is
finding the causes of the accident.

All of us, including employers, need help

and advice to identify the causes of
accidents.

CB106 Accident Investigation

Accidents also cause great economic losses
Lost efficiency due to break-up of crew.

Damage to tools and equipment.

Damage from accident due to fire, water,

chemicals, spills, crashes, etc.
Loss of customers because products and
services are not provided.
Training costs for replacement worker.

CB106 Accident Investigation

What is an accident ?

An unwanted, unplanned
event that causes injuries,
illnesses, or property
damage.
What is an incident ?

An unwanted, unplanned event

that ALMOST causes injuries,
illnesses, or property damage.

CB106 Accident Investigation

 For each accident,
1
ACCIDENT 300 incidents
occurred, or
300 INCIDENTS you lost 300 chances
to
prevent the accident!
If we are going to
prevent accidents,
we have to investigate the
accidents and the incidents!

CB106 Accident Investigation

 Causes of Accidents
Unsafe Conditions

Poorly maintained machinery or equipment.

Defective or missing personal protective
equipment.
Unguarded machinery or equipment.
Missing or inadequate
warnings or safety and health
signs.
Lack of housekeeping.

CB106 Accident Investigation

 Causes of Accidents
Unsafe Acts
Conduct work operations
without prior training
Block or remove safety
devices.
Clean, lubricate, or repair
equipment while its in
operation.
Working without
protection in hazardous
places.

CB106 Accident Investigation

 Investigate
Analyze
Report

CB106 Accident Investigation

 Seal the accident area.

Interview witnesses.

Draw and take

measurements of the
accident area.

Take samples.

CB106 Accident Investigation

 Say what happened step-by-step.
Analyze the events with the 6 key questions:
Who saw the crash?
Who?
What happened to the
brakes?
What?
When did the brakes fail?
Where were the
When? replacement brakes?

Where? Why wasnt the mechanic

told?

Why? How did the crash happen?

How?

. CB106 Accident Investigation

 Say what happened.

Say which were the surface

causes.

Say which were the root

causes.

Say what needs to be done

so the accident doesnt
happen again.

CB106 Accident Investigation

 Accidents must be investigated and
analyzed from three different points of
view:
1 . Direct cause of injury
2. Surface causes of
accident
3. Root causes of the
accident

CB106 Accident Investigation

A harmful transfer of energy that
produces injury or illness.
The worker suffered two
broken legs when the truck
crashed into the wall.

CB106 Accident Investigation

Specific unsafe conditions or unsafe behaviors
that result in an accident.
The truck crashed into the wall because the
brakes failed.

CB106 Accident Investigation

Common conditions and behaviors that
ultimately result in an accident.

The company did not have a maintenance

program for its vehicles.

CB106 Accident Investigation

 Weed out the causes of injuries and
illnesses Strains
Burns
Direct Causes of
Un
gu
Cuts Injury/Illness
ar
de
d
m
ac y
hi
ne se pla
r
Ho
Bro
rd
ken
too te a haza Surface
ls Crea
Chem
ical s e a ha
zard Causes of the
pill or
Ign
Defe
ctive r t inju
ry Accident
po
PPE
s t o re
l
Untraine Fai
t
d worker Fails to inspec
Conditions Behaviors
Lack of time Fails to enforce

Fails to
h work train
To muc

Inadequate training No recognition

No discipline procedures Inadequate labeling procedures

No orientation process Outdated Procedures

Inadequate training plan No recognition plan

No accountability policy No inspection policy

- Accident Weed
Root Causes of the
Accident
CB106 Accident Investigation
 Summary
Secure the accident scene
Collect facts about what happened
Develop the sequence of events
Determine the causes
Recommend
improvements
Write the report

CB106 Accident Investigation

 Summary
Be ready when accidents happen
1. Write a clear policy statement.

2. Identify those authorized to notify

outside agencies (fire, police, etc.)

3. Designate those responsible to

investigate accidents.

4. Train all accident investigators.

5. Establish timetables for conducting

the investigation and taking
corrective action.
6. Identify those who will receive the
report and take corrective action. CB106 Accident Investigation
CB106 Accident Investigation
 Photos shown in this presentation may depict situations that are not in compliance with applicable OSHA
requirements.

It is not the intent of the content developers to provide compliance-based training in this presentation, the intent
is more to address hazard awareness in the construction industry, and to recognize the overlapping hazards
present in many construction workplaces.

It should NOT be assumed that the suggestions, comments, or recommendations contained herein constitute a
thorough review of the applicable standards, nor should discussion of issues or concerns be construed as a
prioritization of hazards or possible controls. Where opinions (best practices) have been expressed, it is
important to remember that safety issues in general and construction jobsites specifically will require a great
deal of site - or hazard-specificity - a one size fits all approach is not recommended, nor will it likely be very
effective.

It is assumed that individuals using this presentation, or content, to augment their training programs will be
qualified to do so, and that said presenters will be otherwise prepared to answer questions, solve problems,
and discuss issues with their audiences.

No representation is made as to the thoroughness of the presentation, nor to the exact methods of
recommendation to be taken. It is understood that site conditions vary constantly, and that the developers of this
content cannot be held responsible for safety problems they did not address or could not anticipate, nor those
which have been discussed herein or during physical presentation. It is the responsibility of each employer
contractor and their employees to comply with all pertinent rules and regulations in the jurisdiction in which they
work. Copies of all OSHA regulations are available form your local OSHA office. This presentation is intended to
discuss Federal Regulations only your individual State requirements may be more stringent.

As a presenter, you should be prepared to discuss all of the potential issues/concerns, or problems inherent in
those photos particularly.

CB106 Accident Investigation

EMPLOYEE ACCIDENT
INVESTIGATION
FOR
SUPERVISORS
TRAINING OBJECTIVE

To provide
supervisors
information and
tools to investigate
employee accidents
thoroughly to
prevent them from
happening again.
 TOPICS TO BE COVERED
Definition of an Accident
Purpose of Investigation
Five Step Investigation Process
Case Studies
 WHAT IS AN ACCIDENT?

An unplanned, unwanted, but

controllable event which
disrupts the work process and
causes injury to people.
Source Labor and Industries
Accident Investigation Basics PPT
2006
Once An Accident
Happens
Ensure Safety of
Get Emergency
Others
Services 911, If
Preserve and Secure Needed
Scene

Assist Employee
Investigate As Soon with Completion of
As Possible Incident Report
 PURPOSE OF INVESTIGATING

Why do we investigate employee accidents?

* To establish the facts of the incident (exactly what

happened).

* To help ensure that a similar type of accident

doesn't happen again - people don't get hurt and
property doesn't get damaged.

* It is a DOSH requirement for all serious injuries

(WAC 296-800-320).

How do we investigate employee accidents?

 FIVE STEPS TO BASIC
ACCIDENT INVESTIGATION

GATHER THE FACTS

REVIEW THE FACTS TO FIND
CAUSES
DOCUMENT FINDINGS AND
ACTIONS
TAKE PREVENTATIVE ACTION
FOLLOW UP
 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION

1. GATHER THE FACTS

Answers what happened

Look at the accident scene

Record information: who, what, when, and
where
Preserve the accident scene and any
evidence
Interview witnesses independently
Ask open ended questions
 THINGS TO CONSIDER
WHEN FACT FINDING

Environment/facility
Equipment, clothing, personal
protective equipment (PPE)
Procedures/practices
Training - in procedures and safety
Employee readiness mental and
physical
 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION
2. REVIEW THE FACTS TO FIND
CAUSES
Answers why it happened

Review all the information you

gathered
List all possible causes (direct, indirect,
basic)
Identify all the contributing factor(s)
 CAUSES
Direct Cause the actual energy
(movement or source) that caused
injury to employee. If this energy wasnt
present, the injury would not have
occurred.
Indirect Causes any unsafe acts or
conditions that contribute to the injury
occurring.
Basic Causes policies, procedures,
environment or personal factors that
contribute to the injury occurring.
 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION

3. DOCUMENT FINDINGS AND ACTIONS

Complete the INCIDENT REPORT

State only the facts in the incident
report (no opinions)
 FIVE STEPS TO BASIC ACCIDENT INVESTIGATION

4. TAKE PREVENTATIVE
ACTION(S)
Corrective actions must address the
cause(s) of the accident
Look for both short-term and long-term
solutions
Include dates for completion of the
corrective actions and identify those
responsible
Report corrective actions to the safety
committee
 DOSHs
SOLUTION TO HAZARDS

Eliminate the hazard or use less

hazardous processes or materials
Use operational controls - SOPs
Use administrative controls (policies,
rules, training, signage)
Use engineering controls (mechanical
means substitution, ventilation, isolation)
Use personal protective equipment
and/or safety equipment
FIVE STEPS TO BASIC ACCIDENT INVESTIGATION

5. FOLLOW-UP

Follow-up to ensure that corrective

action has been taken and is
effective at reducing accidents
Monitor the progress of both short-
term and long-term corrective
actions.