Accident / Incident
Investigation
What is an Incident?
an instance of something
happening
an event or occurrence
Dictionary
any situation that
unexpectedly arises in
the workplace which has
the potential to cause
injury, damage or harm
Dictionary
a near-miss or an
actual injury-related
event
usual results to minor
injury
for Safety Officers &
Safety Practitioners
?
to your company
Why define?
avoid being misconstrued (a
hazard)
OSHS book did not provide
a meaning
for common understanding
esp. in writing policies &
procedures
Incident versus
Accident is . . . .
What is an Accident?
an undesired event
that results in
physical harm or
damage to property
Dictionary
the result of a contact of
man with a source of
energy above the
threshold limit of the body
or structure.
for Safety Officers & Safety Practitioners
An unplanned or unexpected
occurrence that may or may not
result in 1 personal injury, 2
property damage, 3 work stoppage
or 4 interference or 5 any
combination thereof, which arises
out of and in the course of
employment.
for Safety Officers & Safety Practitioners
OSHS, Occupational Safety & Health Standards
Accident Investigation
methodical effort 1collect
and 2interpret the facts of
an accident.
Inquiry
Accident Investigation
answers
how & why
Accident Investigation
prevention
Accident Investigation
minimization
Accident Investigation
An inquiry as to how and why the
accident occurred in order to
explore actions that should be
taken to prevent or minimize
recurrence of the accident.
Reasons for Failure to Report Accidents
Fear of discipline
Concern about the record
Concern about reputation
Fear of medical treatment
Dislike of medical personnel
Desire to prevent work interruption
Reasons for Failure to Report Accidents
Desire to keep personal record clear
Avoidance of red tape
Concern about attitude of others
Poor understanding of importance
Why Investigate?
To serve as bases for Safety
and Health programs, projects,
and activities
To establish all facts To make recommendations
To draw conclusions To prevent recurrence
Attributes of an Effective Investigation
Describe what happened
Determine the real causes
Decide the risks
Develop controls
Define trends
Demonstrate Concern
What to Investigate?
Injury
Occupational illness
Damage to property
Near-misses
Chemical spill
Fire
Theft
Who Should Investigate?
Supervisors
Managers
Employees
Why the Supervisor?
They have a personal interest
The Line
They know the people and conditions
Supervisors
They know best how and where to
get the information.
They will start or take the actions
They benefit from investigating.
Middle Managers Participation
There is a major loss or high potential
incident.
The circumstances cross into other
supervisor’s areas.
The remedial actions have a broad
scope or significant costs.
Middle
Managers
Steps in Investigation
Respond Respond to the
emergency promptly
and positively.
Collect Collect pertinent
information about the
incident.
Analyze Analyze all significant
causes
Steps in Investigation
Respond
Respond to
the
emergency
promptly and
positively.
Steps in Investigation
Develop Develop and take
remedial actions.
Review Review findings and
recommendations.
Follow Follow through on the
effectiveness of the
actions.
Supervisor’s Initial Actions
Take control at the scene.
Ensure first aid and call for emergency
services.
Control potential secondary accidents.
Identify sources of evidence at the scene.
Preserve alteration from alteration.
Investigate to determine the loss potential.
Notify appropriate managers.
Sources of Information
Number?
Locations of Preventive
Collaboration? Sketches
equipment, Equipment
Witnesses Maintenance
and Maps
machine, Examination
Corroboration? Ask the 5W
people
Where?
•Education Preserve the Quality check
•Employment original conditionAppropriate
Material
Records
•Training Accident materials
of the Site of the Failure
Check
•Safety Photography Correct Parts
Accident (SOA) Analysis
•Accident (P/N, SN)
Accident Photography
Photograph the scene
from all sides.
Use a long/medium/close-
up sequence.
Get the correct exposure.
Training
Records
Previous
Accident
Records Maintenance
Logs/Records
Reports
Check Schedules
Job Procedures
and Practices
Help people
visualize what
happened.
Sketches
Label clearly. and Make it simple.
Maps
Sketch location
of people
involved; key
facilities &
equipment
Check If Things Don’t Look Right For:
Tools
Equipment
Materials Examination
Equipment
Material Failure Analysis
• High Loss Potential:
• Failure of Equipment
• Failure of Structures
• Overloading
• Material Defects
• Improper Construction
• Inadequate Servicing
Interviewing Witnesses
• Interview separately.
• Interview at an appropriate place.
• Put the person at ease.
• Get the individual’s version.
• Ask the necessary question at the
right time.
• Give the witness some feedback.
Interviewing Witnesses
• Record critical information quickly.
• Use visual aids.
• End on a positive note.
• Keep the line open.
Interviewing Procedures
• Reassure the witness
• Let the witness tell the story
• begin with open-ended questions
• Don’t ask leading questions
Interviewing Procedures
• Summarize
• Ask for recommendations
• Get written statements
• Close on a positive note
Accident Investigation should not be delayed
1. Operations are disrupted.
• Management should give immediate
attention and conduct thorough
investigation the soonest possible time
to incidents or accidents arising in the
workplace.
• Do not wait for another accident to
happen before conducting the
investigation of a preceding event.
Accident Investigation should not be delayed
2. Memories fade
• Facts from investigations are usually
supplied by witnesses.
• Memories deteriorate proportionately
with time, thus, witnesses’ accounts
would seem to be more accurate and
reliable at the closest possible time to
the occurrence of the accident.
Accident Investigation should not be delayed
Employees / workers are at risk
• Investigations are always done
to find out and look for the
cause of the accident.
• Simply, to avoid recurrence of
the accident.
Techniques in Root Cause Analysis
The BUT WHY or 5 WHY technique
Analyze Cause
Write down each loss (cost of the accident).
Under each loss, write all the contacts with forms or
energy or substance that were responsible for the
loss.
Under each contact factor, list the substandard
actions and conditions that created it.
Under each substandard action or condition list all
basic causes which prompted it.
Review of programs, its standards and compliance
with standards.
Take Remedial Actions
1. Temporary Actions
2. Permanent Actions
Temporary Actions:
Correct the symptoms of accidents:
Substandard Acts
Substandard Conditions
Permanent Actions:
Remedy or treat:
Personal and job factors
Oversights and omissions in programs, standards and
compliance.
Writing a Good Report
Evaluation
Action Plan Identifying Description
Informations
Cause
Analysis
Report Reviews
Allows objective look at findings
and recommendations.
Prompts thoroughness and
accuracy.
Prompts sharing of the
report information.
Case Problem
You, as a Safety Manager, have received a report that Juan dela Cruz has lost the
tips of his two fingers in an accident on the milling machine he operates. His
foreman states that it was a clear case of carelessness that Juan is accident prone
anyway, and that he thinks that the man ought to be discharged from his job or
moved to another department at least. The records show that Juan has been in his
present assignment just for 3 weeks but he has been with this company for 3 years.
Two months ago, he was absent for 3 days with a badly lacerated hand as a result
of an accident with the knife he was using. A year earlier he suffered a badly
sprained ankle in a fall; and shortly after he was hired, he suffered a minor injury
on a drill press.
Questions
1. Do you agree with the foreman?
2. What things would you want to investigate relative to possible causes of the
sequence of accidents Juan has encountered?
3. Discuss some of the possibilities in this case.
4. Discuss the distribution of accidents among specific individuals and between
age groups.
