WORKER HEALTH AND SAFETY

Oregon OSHA
Accident Investigation
STUDENT WORKBOOK
ACCIDENT INVESTIGATION

Oregon OSHA
Accident Investigation
Presented by Oregon OSHA Public
Education — Our Mission:
We provide knowledge and tools to advance self-sufficiency in
workplace safety and health.

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 STUDENT WORKBOOK

Table of Contents

Welcome!. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Goals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

The basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

The Six-Step Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Step 1 — Securing the Scene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Step 2 — Collecting the Facts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Step 3 — Developing the Sequence of Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Step 4 — Determining the Cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Step 5 — Recommending Improvements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Step 6 — Writing the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Appendix: Reference Materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Oregon OSHA Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

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ACCIDENT INVESTIGATION

Welcome!
This workshop is part of a blended learning
program, which also includes our online Accident
Investigation course, which can be accessed at:
osha.oregon.gov/edu/courses/Pages/default.aspx.

This workshop is designed to help you gain the

basic skills necessary to conduct an effective
accident investigation at your workplace. We’ll work
through the three primary tasks of the accident
investigator; discuss employer responsibilities; and
learn how to write an accident report.

The more you contribute, the more you’ll get out of

this training. Participate and have fun!

Goals
Given the information and exercises in this
workshop, you should be better able to complete
the three primary tasks of an accident investigator:

1. Gather useful information

2. Analyze the facts surrounding the accident
3. Write the accident report

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ACCIDENT INVESTIGATION

The basics
Accident investigation definitions
Accident An unexpected incident or exposure that results in an injury or
illness to an employee or property damage.

Incident Often referred to as a near miss, this is an event that could have
resulted in personal harm or property damage.

Lost-time injury When an employee gets injured while carrying out a work task
for the employer and is unable to come in for their next shift or a
longer stretch of time.

Hazard A thing or object that has the potential to harm or cause illness.

Physical Exposure An exposure which you must come into contact with to cause an
injury or illness.

Environmental You must be in the general area to be affected (examples include

Exposure loud noises and chemical fumes).

Direct cause The result of the condition and/or behavior; the final event which
produces an accident.

Surface cause Hazardous conditions and unsafe employee/management

behaviors that produced the accident.

Root cause The underlying reason the surface cause exists.

Personal Protective Equipment worn to minimize exposure to a variety of hazards.

Equipment (PPE) Examples include gloves or hard hats.

Unsafe conditions Unsafe equipment/tools that directly cause the accident.

Unsafe actions Harmful behavior that contributed to the accident; this can include
gaps in safety training for staff members.

System weaknesses Underlying inadequate or missing programs, plans, policies,

processes, and/or procedures that contributed to the accident.

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Identify the proper steps Where do workplace injuries

for conducting an accident come from?
investigation ⚪ Unpreventable acts account for only 2
percent of all workplace accidents
Identifying the causes of accidents can include:
⚪ Hazardous conditions account for less than
⚪ A direct cause 10 percent of all workplace accidents
⚪ Surface causes ⚪ Hazardous practices account for the majority
⚪ Root causes (88 percent) of all workplace accidents

The purpose of investigating accidents is to The fact that unsafe practices and conditions
determine the following: occur should not be used to blame employees.
⚪ The cause of the accident Hazardous practices and conditions can often
⚪ What changes need to be implemented be linked to employee training, equipment
⚪ If this affects other work areas and locations issues, work volume, time crunches, etc.
Source: SAIF Loss Control Approach
⚪ What policies and procedures may need to
be changed

The responsibility for the correction of unsafe work

practices and conditions in the workplace lies with YOU.

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Group exercise: Forming investigative teams

Team leader:

Team members:

What’s the difference between an accident and an incident?

The two key conditions that must exist before an accident occurs are:

Unpreventable acts:

Only percent of all workplace accidents are unpreventable.

Heart attacks and other events that could not have been known by the employer are examples
of unpreventable events. Employers may try to place their injuries into this category. They justify
these beliefs with such comments as: “He just lifted the box wrong and strained his back. What
could we do?” This approach does not examine the root cause of the injury.

System failure:
Safety management system failures account for about percent of all workplace accidents.

System failures refer to inadequate design or performance of safety programs that provide
training, resources, enforcement, and supervision.

No-fault accident analysis:

Often accident investigators confuse accident investigation with criminal investigation, where
blame is the end result. When this occurs, it obstructs the investigative process because
witnesses may fear punishment. A no-fault analysis looks for deeper causes within the safety
management system of an organization.

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Laying the foundation Reporting to Oregon OSHA

Accidents can be a time of confusion and high
emotions. Having a written accident analysis
All employers are required to report:
plan that establishes what to do and when to Within 8 hours: Within 24 hours:
do it can reduce decision-making time. All work-related Any work-related:
fatalities and ⚪ Inpatient
Include in your plan:
catastrophes hospitalization
⚪ Who should be notified of an accident ⚪ Amputation or
⚪ Who is authorized to notify outside avulsion
agencies (police, fire, etc.) ⚪ Loss of an eye
⚪ Who is assigned to conduct investigations
(include training they will need)
How to report an incident:
⚪ Who receives and acts on investigation Call 800-922-2689 (toll-free)
reports
⚪ Expectation of time frames for conducting the or call your nearest Oregon OSHA office:
investigation and follow-up actions such as
Bend Pendleton
correction of the unsafe condition or action
541-388-6066 541-276-9175

Always make sure the scene is Eugene Portland

safe before you enter. 541-686-7562 503-229-5910
Medford Salem
If you have to wait to secure the scene due to
541-776-6030 503-378-3274
emergency responders providing aid, begin
making initial observations.
It is important to act quickly and start taking When does the clock start? As soon as the
pictures or video, as material evidence can be employer knows one or more of the above
displaced while emergency responders tend to conditions have occurred.
the injured. Also, witnesses’ memories as well as A catastrophe is defined as two or more
details of what happened may change over time. fatalities or three or more employees
Finally, securing the scene also includes hospitalized from the same event.
making the area safe until the root cause
To better understand the Oregon OSHA
can be determined and safety controls are
reporting rules, take our online class.
implemented.

The object of every investigation is to prevent the incident from

happening again. Therefore, an accident investigation is not about
placing blame, but about finding facts.

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Step 1 Securing the scene

GATHER
INFORMATION Step 2 Collecting facts about what happened

Step 3 Developing the sequence of events

ANALYZE
THE FACTS Step 4 Determining the cause

Step 5 Recommending improvements

IMPLEMENT
SOLUTIONS
Step 6 Writing the report

The Six-Step Process ⚪ Survey the scene for:

Throughout this workbook we’ll look into each – Accident victims

of these six sections more closely, breaking – Witnesses and their locations at the time

down the process within each step. – Objects broken, damaged, or struck
– Tracks or skid marks from equipment
The rules behind accident investigation
– Time of day, lighting, and weather
can be found on Oregon OSHA’s website at:
– Fluid spills/stains
osha.oregon.gov/OSHARules/div1/437-001- – Surface defects
0760.pdf – Involved machines, vehicles, and
Step 1 — Securing the Scene equipment
– Distractions
Securing the scene is one of the most
– Safety devices used, not used, or failed
important aspects of accident investigation. It
– Position of equipment
ensures others won’t get injured and helps you
– Terrain (rocky, wet, slippery, frozen,
investigate what caused the accident.
cluttered, etc.)
After all injured people have been cared for, it’s – Contaminated materials, debris
time to secure the scene. Follow these steps: Documenting a scene should also involve
⚪ Cordon off the area taking note of anything to collect and submit
⚪ Turn off or block equipment for sampling.
⚪ Notify affected people Your primary goal in this step is to secure the
accident scene to prevent further harm, then,
secondarily, to safeguard the evidence.

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When is it appropriate to begin the investigation?

What are effective methods to secure an accident scene?

Securing an accident scene is critically The investigator’s kit

important, however, the victim is always the first
Time is of the essence when an accident
consideration. If you have to wait to secure the
occurs. Don’t lose an opportunity to gather
scene until medical attention has been provided,
important facts because you don’t have
you can still begin noting initial observations.
a pencil or camera at hand. Create an
Step 2 — Collecting the Facts investigator’s kit and have it ready.
We’ll cover the methods for Your kit may include:
collecting and documenting: ⚪ Camera
⚪ Direct cause of injury ⚪ Tape measure
⚪ The result of the condition ⚪ Clipboard, paper, pencil
⚪ Hazardous conditions and unsafe ⚪ First aid kit
employee/management behaviors (surface
⚪ Flashlight
causes) that produced the accident
⚪ PPE appropriate to your business
⚪ System weaknesses (root causes) that
⚪ Report forms
produced surface causes for the accident
⚪ Plastic bags with ties
We’ll also cover: ⚪ Sketching/drawing template
⚪ Putting together your investigator’s kit ⚪ Warning/barricade tape
⚪ Obtaining initial statements ⚪ A bag for storing these items
⚪ Reviewing documents ⚪ Video equipment (optional)
⚪ Capturing the scene

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Be sure to test your equipment on a regular ⚪ For close pictures, place an item of known
basis and make sure to have extra batteries on dimensions in the photo to show scale, such
hand. Your smartphone can be a handy tool for as a ruler or dollar bill.
photos and video. Take notes for each photo. Identify the type of
photo, date, time, location, subject, weather
Documenting and gathering conditions, measurements, and importance of
information the photo. Your notes should be included in the
The most effective strategy is to document appendix of the report along with your photos.
as much as possible, even if you question Finally, identify the person taking the photo.
relevancy. It’s easy to discard clues or leads if
Optional: You can video the scene after
they prove not useful to the investigation.
providing help for injured persons.
While at the scene, note all your observations.
With clipboard in hand, take notes involving all Sketching the scene
the senses. What do you see? What equipment,
Accident scene sketches are crucial because
tools, materials, machines, and/or structures
they complement the information in photos
appear to be broken, damaged, struck or
and indicate distances between the elements
otherwise involved in the accident? Look for
of the scene.
gouges, scratches, dents, and smears.
If vehicles are involved, check for tracks and It’s important to be as precise and inclusive

skid marks. Look for irregularities on surfaces. as possible when making sketches. Sketching
Are there any fluid spills, stains, contaminated templates, for example, have several common
materials, or debris? figures available to trace.

What about the environment? Were there Each sketch should include:
any distractions or adverse conditions ⚪ Basic scene information: date, time,
caused by weather? location, identity of objects, victims, etc.
⚪ Positions: measurements that establish
Photographing the scene position of evidence, equipment, and where
Workshop attendees have commented that people were standing

they often wish they had taken more pictures. ⚪ Location: where each photo was shot in
relationship to the scene
Here are a few things to keep in mind as you
⚪ Direction: indicate north, south, east, west
visually document the scene:
⚪ The words “not to scale”
⚪ Start with distance shots, then move in
Sketch in every element of the scene; be sure to:
closer.
⚪ Take photos at different angles to show the ⚪ Make sketches large and clear
relationship of objects and details. ⚪ Include measurements and establish
⚪ Take panoramic photos to help present the precise, fixed, identifiable reference points
entire scene. ⚪ Print legibly

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⚪ Tie measurements to a permanent point, ⚪ Narrate what is being filmed: describe

such as a telephone pole or building objects, size, direction, location, etc.
⚪ Mark where people and equipment ⚪ If a vehicle was involved, record the
were located direction of travel both coming and going.
⚪ Include a key to explain any acronyms, ⚪ Discuss with company management the
symbols, or any special indicators, option of capturing witness descriptions on
such as color camera; staff may need to sign a waiver.
⚪ Review the video when possible to note any
Taking video at the scene information you may have missed.
If you have access to video, begin recording
the scene as soon as emergency responders
Additional video tips:
⚪ Be careful with the zoom function; upon
are providing care. Don’t impede their
later review, it can be difficult to tell what is
work. The video will pick up details and
being captured if you’re too close.
conversations that can add valuable
⚪ Shoot from a few different angles to capture
information to your investigation. Check with different aspects of the scene.
your supervisor to see what your company ⚪ If you’re going to be recording for long
policy is regarding video recording. stretches, consider using a tripod to reduce
Some important points to remember when shaking and fatigue.
video recording the scene include: ⚪ Transfer the digital video to your work
computer for storage so it remains on file
⚪ Get the lay of the land by standing back and for further review.
zooming into the scene. ⚪ When recording, make sure the autofocus
⚪ Capture the entire scene to establish function has been turned on to increase the
location by panning the camera 360 clarity of video.
degrees.

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Reviewing documents
You can obtain information by reviewing
documents and records, including:

⚪ Oregon OSHA Form 300 and DCBS Form 801

⚪ Maintenance records – to determine the
maintenance history of the tools,
equipment or machinery involved in the
accident – and manuals
⚪ Training records for the past 36 months
and refresher classes – to determine the
quantity and quality of the training received
by the victim and others
⚪ Safety committee minutes – to determine the
⚪ Employee handbook and standard operating
history of any discussion of related hazardous
procedures (SOP) – to determine the formally
conditions, unsafe behaviors, quarterly
established steps in the procedures
inspection reports, and follow-up status
⚪ Job hazard analysis (JHA) – to determine if
⚪ Copies of accident investigations
any hazards had been identified
⚪ Personnel records of victim(s) and others
⚪ Safety programs and safety policies, plans,
involved
rules – such as your emergency program –
⚪ Names of crew members and other witnesses
to determine their presence and adequacy,
along with the organizational chart, and
discipline procedures, and emergency
names of others who do similar work
medical plan
⚪ Safety inspection results along with PPE
⚪ Work schedules – to determine if the
victim might have been fatigued or requirements for the task
otherwise overworked

What type of helpful information might you find in safety committee

meeting minutes?

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Collecting facts
One of the biggest challenges facing an investigator is to determine what is relevant to what
happened, how it happened, and why it happened.

Identifying the facts that answer these questions is the purpose of an effective investigation.

Once the scene has been secured, it’s important to begin collecting the facts from as many
sources as possible.

Be careful with preconceived notions of what happened. If you think you know what happened,
you may subconsciously disregard important evidence.

List methods to document the accident scene and collect facts about
what happened:

What documents will you be interested in reviewing and why?

Once the emergency is being addressed, interviews should

occur as soon as possible.

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Initial statements
Get initial statements from the witnesses that include: an overview of what they saw, other people
they suggest who could give you more information about materials, equipment used at the time of
the accident, and anything that may have been moved or disturbed while tending to the accident
victim. If time does not allow for initial statements, conduct a full investigative interview.

Interviewing overview
When is it best to interview and why?

Who should be interviewed and why?

Where should we conduct the interview?

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Conducting interviews If you can, conduct your interviews in private,

in an office or meeting room where you can
The purpose of collecting facts is to gain an
talk comfortably and without interruptions.
accurate and comprehensive picture of what
Also, keep in mind that, for some traumatic
happened by capturing all pertinent facts,
events, the scene can provide a distraction or
interpretations, and opinions. Your job, as
emotional trigger. Because investigations can
the interviewer, is to construct a story using
lead to policy changes and/or administrative
the various accounts of the accident, and
action, don’t promise confidentiality.
other evidence.
Approach the investigation with an open mind.
Remember to keep the goal If you have preconceived ideas about the
of the interview in mind: to individuals or the facts, it will be obvious to the
determine the cause of the interviewees. It’s important to let the individual
accident so that similar events you’re interviewing talk. Ask background
will not occur. information first (name, job, etc.). Then ask the
witness to tell you what happened.
When conducting your interviews, try to make
your witnesses as comfortable as possible.

Do Don’t:

⚪ Be friendly ⚪ Ask leading questions

⚪ Be understanding ⚪ Interrupt
⚪ Ask one question at a time ⚪ Put witnesses on the defensive
⚪ Remain open-minded ⚪ Rush
⚪ Ask open-ended questions ⚪ Promise confidentiality
⚪ Schedule enough time ⚪ Make facial or verbal expressions of
approval or disapproval

Who to Interview? ⚪ Co-workers and others doing similar work,

Compiling an interview list is important and or those who work near the victim: establish
may include: if the safety procedures for the job were
being followed when the accident occurred,
⚪ Witnesses: gather all of the details of what and the normal practices for the task the
occurred from anyone present during any victim was completing
part of the accident ⚪ Direct supervisor: to understand the
⚪ The victim: determine which actions the background information on the victim and
victim took leading up to and including to get procedural information about the task
the accident that was being performed

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⚪ Management: discuss policies and Interviewing tips and points to

procedures specific to the victim’s job to remember
determine if all were followed ⚪ Prepare your questions ahead of time
⚪ Safety committee members: determine if ⚪ Arrange for a quiet room with a table and
there is a history of this safety issue chairs to foster a relaxed atmosphere
⚪ Training department: gather information ⚪ Introduce yourself and state the purpose of
on the quantity and quality of training the the interview
victim and others have received for the task ⚪ Ask clarifying questions
specific to the accident ⚪ No group interviews; only conduct one-on-one
⚪ Personnel department: collect information interviews
on the victim’s and others’ work history, ⚪ Let the witness speak freely
discipline, and appraisals
⚪ Do not argue; be considerate and calm
⚪ Maintenance personnel: understand the
⚪ Have witnesses verify the accuracy of your
background and maintenance on involved
sketch and note their location at the time of
equipment/machinery
the accident
⚪ Police: if they responded to the scene or
⚪ Accidents happen fast and witnesses may
filed a report
only recall a few key points
⚪ The victim’s spouse and family: they may
⚪ Avoid yes or no questions by asking: who,
have insight into the victim’s state of mind
what, where, when, why, and how questions
or any issues on the day of the accident
⚪ If not recording the interview, take notes as
⚪ Anyone else with information related
carefully and casually as possible
to the accident

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⚪ Get exact facts: time, sequence of events, Sample questions to consider:

and what was seen and heard ⚪ Who has provided you the training or
⚪ Write down impressions and judgments instruction on this process/procedure?
immediately after the interview ⚪ How was the job or process different on the
⚪ Recap and summarize main points of the day of the accident?
interview ⚪ How are workers held accountable for safety?
⚪ Allow yourself time to take and review notes ⚪ How is information about safety and health
at the end of each interview shared with you?
⚪ What effort does the company take to
Cooperation, not intimidation, is ensure employees are held accountable for
key to a successful interview. working safely?
⚪ Is there a history of prior accidents
or near misses?

Exercise: Effective interviewing techniques

What should we say and why?

What should we not say and why?

What should we not do?

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Team exercise: Get the facts

Purpose: Gain as much information as possible about an accident.

Interviewing witnesses is both a science and an art, and can make the difference between a
failed or a successful accident investigation. This exercise will help you gain a greater awareness
of the interviewing techniques that will help ensure your success as an investigator. Remember,
you must communicate a message of cooperation, not intimidation.

Instructions: Your instructor will describe an accident. Your team and the instructor are located
at the scene of the accident and your job now is to ask follow-up questions to gather information
about the accident. Use the space below to list your questions or notes:

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Step 3 — Developing the be sure to identify the sequence of events,

Sequence of Events the causes that led up to the final accident,

The next two steps help you organize and and the root cause(s) that created the unsafe
analyze the information gathered so that you condition/action.
may accurately determine the surface and Each event in the unplanned accident
root cause(s). process identifies:

An accident is the final event in ⚪ Actor – an individual or object that directly

influenced the flow of the sequence of events:
an unplanned process.
– An actor initiates a change by performing
In this step, we take the information gathered or failing to perform an action.
in Step 2, “Collecting the Facts,” to determine – An actor may participate in the process
the events prior to, during, and after the or merely observe the process.
accident. You can then study each factor/
⚪ Action – something that is done by an
action to determine unsafe conditions (things actor. Failure to act should be thought of as
or circumstances that directly caused the an act in itself.
accident) and unsafe actions.
– Actions may or may not be observable.
These may include: – An action may describe something that
⚪ Actions taken or not taken that contributed is done or not done.
to the event When describing events, first indicate the
⚪ System weaknesses, such as underlying actor, then tell what the actor does. Remember,
inadequate or missing programs the actor is the doer, not the person or object
⚪ Plans, policies, processes, and procedures having something done to them. For instance,
that contributed to the accident
take a look at the statement below:
The key is to take the information gathered and
Stacy unhooked the harness from the anchor.
arrange it to accurately determine what initial
In this example, Stacy is the actor and
conditions and/or actions turned the planned
unhooking is the action. The harness and
work process into an unsafe environment.
There are many schools of thought about anchor, although objects, are not actors

how to do that. Some point to a single cause, because they are not performing an action.

whereas others root out multiple causes. Rather, something is being done to them.

Whichever method is used at your workplace,

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Exercise: Circle the actor and action in each of these below:

1. Beverly slipped on a banana peel.

2. As Beverly lay on the floor, a brick fell on her head.

3. Sam discovered Beverly unconscious on the floor and immediately began

initial first aid procedures.

Team exercise: What happened next?

Use the information gathered about the accident your instructor described in the interview exercise to
construct a sequence of events.
Identify the events leading up to and including the injury event. Be sure you include only one actor
and one action in each event. Decide where you want to start the sequence, then ask, “What
happened next?”

Event 1:

Event 2:

Event 3:

Event 4:

Event 5:

Event 6:

Event 7:

Event 8:

Event 9:

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Developing the Sequence of 11. Employee #2 ran to Employee #1.

Events (continued) 12. After assessing Employee #1’s wound,

Employee #2 yelled for the shop
Here’s an example of the sequence of events supervisor, who was a short distance away.
prepared for a serious injury investigation 13. The supervisor, after seeing the injury, called
conducted by Oregon OSHA: 911 and then attempted to make the victim
comfortable until the ambulance arrived.
1. At approximately 9 a.m. Employee #1 was
standing at the in-feed side of the table saw. 14. Paramedics stabilized the victim and
transported him to Providence Hospital,
2. Employee #1 was cutting a piece of maple,
measuring approximately 3/4” x 1/4” x 5’ where he underwent surgery for the injury.
long, into three lengths. This example is brief and there may be
3. Employee #1 had made two cuts and was other related factors/causes that indirectly
making the final cut. contributed to the accident. However, it does
4. Employee #1 placed the board on the table give you sufficient descriptive detail to paint a
saw and, with the 10-inch blade, ran the mental picture of what occurred immediately
board through its entire length. prior to and including the accident.
5. Employee #1 reached over to remove the
Note: Once the sequence of events are
off cut (waste).
developed, you can then study each factor/action
6. Employee #1 lightly touched the off cut
to determine:
with his hand when the piece, 3/4” x 1/4” x
approx. 5’ long, hit the spinning blade. ⚪ Unsafe conditions: things and situations
7. The blade was spinning at 3,500 rpm that directly caused the accident
and caused the piece to shoot toward ⚪ Unsafe actions: actions taken or not taken
employee #1. that contributed to the accident
8. The piece cut through Employee #1’s ⚪ System weaknesses: underlying
leather belt and waistband and went into inadequate or missing programs, plans,
his abdomen to a depth of approximately policies, processes, and procedures that
4 1/2 inches. contributed to the accident
9. Employee #1 fell backward and, as he was We’ll talk more about these in the next section,
falling to the floor, was able to pull the “Determining the Cause.”
piece from his abdomen.
10. Employee #2, a cabinet maker in the next
room, heard the saw and the cries of
the victim.

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Step 4 — Determining the Cause

Most accidents have more than one cause. If you address as many of the causes as possible,
you’re more likely to prevent future accidents.

Behind every accident there are many contributing factors, causes, and sub-causes. These factors
combine in a random fashion, causing accidents. We must find the fundamental root causes and
remove them to prevent a recurrence.

(Dan Petersen, “Safety Management: A Human Approach,” ASSE, Pages 10-11)

Exercise: Determining the cause

What may be the cause(s) of the accident, according to the multiple
causation theory?

What might be the solution to prevent the accident from recurring?

What are the strengths and weaknesses of this approach?

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The Four Steps of Cause Analysis

1. Analyze the injury event to identify and describe the direct cause of injury.
Examples:
Event 1: Laceration to right forearm resulting from contact with rotating saw blade.

Event 2: Contusion from head striking against/impacting concrete floor.

2. Analyze events occurring just before the injury event to identify those conditions
and behaviors that caused the injury (primary surface causes) for the accident.
Examples:
Event 1: An unguarded saw blade (condition or behavior?).

Event 2: Working at elevation without proper fall protection (condition or behavior?).

3. Analyze conditions and behaviors to determine other specific conditions

and behaviors (contributing surface causes) that contributed to the accident.
Examples:
Event 1: Supervisor not performing weekly area safety inspection (condition or behavior?).

Event 2: Fall protection equipment missing (condition or behavior?).

4. Analyze each contributing condition and behavior to determine if weaknesses

exist in carrying out safety policies, programs, plan, processes, procedures, and
practices (inadequate implementation).
Examples:
Event 1: Safety inspections are being conducted inconsistently.

Event 2: Safety is not being adequately addressed during new employee orientation.

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 STUDENT WORKBOOK

Exercise: Digging up the roots

1. Enter the direct cause of injury in the top field below from the previous exercise.
2. List one hazardous condition and one unsafe behavior from the sequence of events your
group developed.
3. Determine contributing surface causes for the hazardous condition and unsafe behavior.
4. Determine implementation and design root causes for contributing surface causes.

Direct cause of injury:

Hazardous condition: Unsafe behavior:

Contributing conditions: Contributing conditions:

Design root causes: Implementation root causes:

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ACCIDENT INVESTIGATION

Step 5 — Recommending Management/administrative controls

Improvements These can eliminate or reduce the frequency
Accident causes are addressed by and duration of exposure to unsafe conditions
recommending controls and safety system by addressing workers’ actions.
improvements. Controls eliminate or reduce Any procedure that significantly limits daily
the direct and surface cause(s) of an accident. exposure by control or manipulation of the
Safety system improvements address the work schedule or manner in which work
root cause, specifically, missing or inadequate is performed is considered a means of
safety system policies and procedures that management control.
contributed to the accident. Management controls may result in a
reduction of exposure through such methods
Types of controls: Engineering,
as changing work habits, improving sanitation
management/administrative, PPE and hygiene practices, and/or making other
Engineering controls changes in the way the employee performs the
These are physical fixes that eliminate job, such as:
the unsafe condition. If feasible, OSHA
1. Completing housekeeping activities:
recommends employers attempt to engineer
the unsafe condition out to remove the hazard. – Removal of tripping, blocking, and
The work environment and the job itself should slipping hazards
be designed to eliminate hazards or reduce – Removal of accumulated toxic dust on
exposure to hazards. surfaces
– Wetting down surfaces to keep toxic
Engineering controls are based on these
dust out of the air
broad principles:
1. If feasible, design/redesign the facility, 2. Changing work procedures and
equipment, or process to eliminate the practices. This is done by developing and
hazard or make it less hazardous. implementing a job hazard analysis (JHA).
2. If removal is not feasible, enclose the hazard 3. Changing work schedules to reduce
to prevent exposure in normal operations. employee exposure to a hazard. Methods
include:
This could be complete enclosure of moving
– Lengthened rest breaks
parts of machinery; containment of toxic
– Additional relief workers
liquids or gases; glove box operations to
enclose work with dangerous microorganisms – Exercise breaks to vary body motions
or radioisotopes; containment of noise, heat, – Rotation of workers through
or pressure-producing processes. different jobs
The use of PPE is not considered management control.
3. Where possible, substitute with a different
item.
4. If necessary, replace the item with a safer
version.

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 STUDENT WORKBOOK

Exercise: Types of controls

Why are engineering controls considered superior to management controls?

Personal protective equipment (PPE) controls

PPE should be used in conjunction with the other controls; not on its own. When exposure
to hazards cannot be engineered completely out of normal operations or maintenance work,
and when safe work practices and administrative controls cannot provide sufficient additional
protection from exposure, PPE is a control. Many tasks require the use of PPE in accordance with
Safety Data Sheets (SDS) and Oregon OSHA requirements.

PPE includes:
⚪ Face shields ⚪ Leather aprons ⚪ Gloves
⚪ Steel-toed shoes ⚪ Respirators ⚪ Welding Shields
⚪ Safety glasses ⚪ Hearing protection ⚪ Visibility vest
⚪ Hard hats ⚪ Safety goggles ⚪ Heat protection
⚪ Knee Guards ⚪ Harness

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ACCIDENT INVESTIGATION

Interim measures Surface causes are symptoms of a weak safety

When a hazard is recognized, the preferred system. Missing or inadequate safety system
correction or control cannot always be components are often the root causes for
accomplished immediately. However, in workplace accidents. Every effort should be
virtually all situations, interim measures made to improve your safety management
can be taken to eliminate or reduce system, which may include:
worker risk. These can range from taping down ⚪ Improving your safety policy to clearly
wires that pose a tripping hazard to temporarily establish safety responsibility and
shutting down an operation. accountability
There is no way to predict when a hazard will ⚪ Including safety checklists in your work
cause serious harm, and no justification to processes

continue exposing workers unnecessarily to risk. ⚪ Implementing a safety inspection process

that includes employees and management

Team exercise: Recommending corrective action

Use the hierarchy of control strategies as a guide to determine corrective actions that will
eliminate or reduce one of the hazardous conditions or unsafe behaviors identified on Page 27.

Recommendations for immediate actions to correct the surface causes:

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 STUDENT WORKBOOK

Improvement strategies Making system improvements might include

to fix the system: some of the following:
Make improvements to policies, programs,
⚪ Writing a comprehensive safety and health
plans, processes, and procedures in one or
plan including the above elements.
more of the following elements of the safety ⚪ Improving a safety policy to clearly
and health management system: establish responsibility and accountability.
1. Managementcommitment ⚪ Changing the training plan so that the use
2. Accountability of checklists are taught.

3. Employee involvement
⚪ Revising the purchasing policy to include
safety consideration as well as cost.
4. Hazard identification/control
⚪ Changing the safety inspection process to
5. Incident/accident analysis
include all supervisors and employees.
6. Training
7. Evaluation

Team exercise: Fix the system ... not the blame

Develop and write a recommendation to improve one or more policies, plans, programs,
processes, procedures, and practices identified as design weaknesses. This is to make sure the
case study accident doesn’t reoccur.

Recommendations:

Recommending corrective action and fixing the system will help you develop and propose solutions that
correct hazards, as well as design long-lasting system improvements.

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ACCIDENT INVESTIGATION

Step 6 — Writing the Report and/or conditions. The findings are proven
by evidence and documented in the report.
As you write your report, remember your
This can include a description of documents
primary objective as an investigator is to
(or the lack thereof), statements, interviews,
uncover the causes that contributed to the
photos, drawings, etc. The findings should
accident; the accident report isn’t about placing
also describe:
blame. Your challenge is to be as objective and
– direct cause(s) – Unsafe conditions
accurate as possible. Your findings and how
and/or actions that exist or occurred
you present them will shape perceptions and
immediately before the injury
the corrective actions taken by management.
We’ll now look further into what the report – surface cause(s) – Conditions and/or

includes and delve into each section. The actions that were in place before the

Report is a stand-alone document and should injury accident, such as work practices

address all points. – root cause(s) – System weaknesses

that produced the surface causes for
What’s in the report? Seven points: the accident
⚪ Background: The introduction of the ⚪ Recommendations: Describes corrective
report, it contains information about the actions and safety improvements and their
victim, the company, the accident time, costs, as well as ways to get rid of or reduce
date, location, and a description of the both surface and root causes. Consider
specific work performed at the scene. both short-term and long-term corrections.
⚪ Description of the accident: A narrative ⚪ Summary/Conclusion: This is a brief
that tells the events leading up to and during review of causes of the accident and
the accident, as well as the action taken recommendations, along with a cost and
afterward. It’s important for the narrative to benefits analysis of the corrective action(s).
paint a clear picture that answers the what, ⚪ Review and follow-up actions:
where, why, and how of the accident. This describes action taken and/or repairs,
⚪ Findings: These summarize what the and lists the people responsible for carrying
investigator found based on collected out each of the corrective actions and safety
evidence and describe the unsafe conditions, system improvements by name or job title.
unsafe actions, and system weaknesses. ⚪ Attachments: Contains photos taken
This also includes a list of violations or throughout the investigation, videos,
hazardous work practices sketches, notes, and relevant documents.

The primary reason accident investigations fail to help eliminate similar

accidents is that some report forms address only correcting surface
causes; root causes are ignored. Let’s look at one format for ensuring
an effective report.

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 STUDENT WORKBOOK

Sample Report
Accident investigation form (example 1)

Use this form to help you investigate workplace accidents or incidents. Note: this form is for use within your company. It is not
intended to replace DCBS Form 801: Worker’s and Employer’s Report of Occupational Injury or Disease.

Company: Report no.:

Operation: Investigator

Name of accident victim: Victim’s job title:

How long has accident victim been with this company? How long on this job?

(Attach this information for each additional person injured.)

Witnesses:

Name: Name:

Name: Name:

Name: Name:

When did the accident occur? Date: Time: Shift:

Where did the accident Department: Location:

occur?

What happened? (Describe sequence of events and extent of injury. Attach separate page if necessary.)

Has a similar accident ever occurred? Yes No If yes, when?

What caused the accident?

List all causes and contributing factors, which might include lack of supervision, inadequate training, poor equipment
maintenance, and inadequate policy.

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ACCIDENT INVESTIGATION

Accident investigation form (example 1)

List each corrective action to be taken. Who will do it and when will it be done?

1.

2.

3.

4.

5.

6.

7.

Attach photographs, sketches of the scene, or other relevant information.

Prepared by: Title: Date:

The report is an open document until2 all actions are complete.

For an accident investigation to be effective, management must consider the

findings and develop a plan for corrective action and system improvements.
Periodic evaluation of this plan is critical to maintaining an effective program.

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 STUDENT WORKBOOK

Appendix: Reference materials

Workers’ Compensation Claims in Oregon, 2021

Event or exposure Number of Average cost

leading to injury claims resolved of claim

1. Traumatic injuries, disorders 23,382 $19,670

2. Infectious, parasitic diseases 1,731 $6,780

3. Injury, illness combination 837 $82,200

4. Exposure to disease 655 $5,450

5. Systemic diseases 627 $23,720

These claims, provided by the Oregon Workers’ Summary of accident

Compensation Division, can help when you
investigation rules
present your recommendations to management
by showing the cost of the accident you are 437-001-0704(3) Reporting an
recommending eliminating or controlling. Occupational Fatality, Catastrophe,
or Accident.
For more Oregon claims details, go to:
3) You must report fatalities and
https://www.oregon.gov/dcbs/reports/
catastrophes to Oregon OSHA only in
protection/Pages/wc-benefits.aspx – click on
person or by telephone within eight hours
“Average claim costs tables (440-4863)” and
of occurrence or employer knowledge
select the year you would like to view. From
(reported to you or any of your agents) of
there, you can access:
a fatality or catastrophe:
Table 3: Average temporary disability days (a) Fatalities. You must report all work-
and claim costs paid for resolved accepted related fatalities. You must report all
disabling claims by accident event or exposure. fatalities caused by a heart attack at
Table 4: Average temporary disability days work. Report a fatality only if death occurs
and claim costs paid for resolved accepted within 30 days of the incident.
disabling claims by nature of injury or disease. Note: Work-related fatalities include those
caused by a motor vehicle accident that
happens during the employee’s work shift.

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ACCIDENT INVESTIGATION

(b) Catastrophe. A catastrophe is an incident 437-001-0170 Determination of Penalty –

in which two or more employees are Failure to Report an Occupational Fatality,
fatally injured, or three or more employees Catastrophe, or Accident.
are admitted to a hospital or an equivalent Failure to report an occupational fatality,
medical facility (for example, a clinic) as a catastrophe, or accident: a penalty shall
result of the same incident. be assessed.

437-001-0053 Preserving Physical OAR 437-001-0765 (8) Accident

Evidence at the Scene of an Accident. investigation.
(1) Employers, their representatives, or others The safety committee must evaluate all
shall not disturb the scene of a fatality or accident and incident investigations and make
catastrophe other than to conduct the recommendations for ways to prevent similar
rescue of injured persons or mitigate an events from occurring.
imminent danger until authorized by the
Administrator (or designee), or directed OAR 437-001-0760 (3)
by a recognized law enforcement agency. Investigations of Injuries.

(2) In order to preserve physical evidence at (3) Investigations of Injuries.

the scene of a fatality or catastrophe, the (a) Each employer must investigate or
Administrator is authorized to limit the cause to be investigated every lost time
number of employer representatives or injury that workers suffer in connection
employee representatives accompanying with their employment, to determine
the compliance officer during the the means that should be taken to
documentation of the scene. The employer prevent recurrence. The employer must
representative and employee representative promptly install any safeguard or take any
must be provided an opportunity to corrective measure indicated or found
document the scene prior to disturbance or advisable.
removal of physical evidence.
(b) At the request of authorized Department
(3) If an employer, their representative or representatives, it is the duty of
others disturb the scene of a fatality or employers, their superintendents,
catastrophe other than to conduct the supervisors, and employees to furnish all
rescue of injured person(s) or mitigate an pertinent evidence and names of known
imminent danger before authorized by the witnesses to an accident and to give
Administrator or directed by a recognized general assistance in producing complete
law enforcement agency, a minimum information which might be used in
penalty may be assessed. preventing a recurrence of such accident.

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 STUDENT WORKBOOK

At the request of the Department, persons c. There is reason to believe that the
having direct authority must preserve and employer was aware of the requirement of
mark for identification, materials, tools, the standard and knew it was in violation
or equipment necessary to the proper of the standard.
investigation of an accident.
Instances when Oregon OSHA
When to stop investigators found the employer
violated safety standards related to
analyzing the incident
employee training and emergency
Excerpt - CPL 2.113 - Fatality Inspection Procedures evacuation procedures:

H. FATALITY/CATASTROPHE Some maintenance electricians in the melting

INVESTIGATIONS plant were not adequately trained in the proper
safety adjustment procedures for the electronic
2. Fatalities and catastrophes shall be
flow sensors installed in the cooling water
thoroughly investigated to attempt to
system. The employer had installed electronic
determine the cause of the events, whether a
flow sensors approximately 18 months earlier
violation of OSHA safety or health standards
to replace mechanical switches with a history
related to the accident has occurred and any
of malfunctions. Ten of the plant’s 13 licensed
effect the standard violation has had on the
electricians had received training on the new
occurrence of the accident.
sensors, but the remaining three – including the
J. POTENTIAL CRIMINAL individual who happened to respond when the
INVESTIGATIONS furnace shut down the night of the explosion –

1. Section 17(e) of the Act provides criminal had not. Proposed penalty: $5,000.

penalties for an employer who is convicted Employees working in the melting department
of having willfully violated an OSHA who are responsible for setting up or operating
standard, rule or order when the violation the furnaces were not adequately trained
caused the death of an employee. for safe operation of the furnaces. While the

2. Early in investigations the Area Director employer’s own safety and health procedures

shall make an initial determination require that all employees newly assigned to a

whether there is potential for a criminal department receive very detailed safety training

violation, based on the following criteria. relating to the department and their specific
duties, none of the melting plant personnel at
a. A fatality has occurred.
the time of the explosion had ever received the
b. There is evidence that an OSHA standard training. Proposed penalty: $5,000.
has been violated and that the violation
contributed to the death.

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ACCIDENT INVESTIGATION

Exits were not maintained free of obstructions for improving these system weaknesses.
or impediments to full instant use in the When we handle incident/accident
event of an emergency. When the explosion analysis as a search for facts, employees
occurred, employees used designated are more likely to work together to report
evacuation routes to leave the facility. A gate incidents/accidents and to correct
in a cyclone fence that blocked one of those deficiencies, be they procedural, training,
routes was locked, so that two employees had human error, managerial, or other.
to climb the fence. Proposed penalty: $1,500. Consequently, our policy is to analyze
accidents to primarily determine how we
Example accident analysis plan can fix the system. We will not investigate
1.0 General Policy accidents to determine liability. A “no-
_______________________________________ fault” incident/accident analysis policy
Business/Company Name
will help ensure we improve all aspects of
considers employees to be our most valued
our manufacturing process.
asset and as such we will ensure that all
incident and accidents are analyzed to correct 2.2 Policy. All employees will immediately
the hazardous conditions, unsafe practices, report any unusual or out of the ordinary
and improve related system weaknesses that condition or behavior at any level of the
produced them. This incident/accident analysis organization that has or could cause an
plan has been developed to ensure our policy is injury or illness of any kind.
effectively implemented. Supervisors will recognize employees
immediately when an employee reports
______________________________________ an injury or a hazard that could cause
Business/Company Name
serious physical harm or fatality, or could
will ensure this plan is communicated,
result in production downtime. (See
maintained, and updated as appropriate.
recognition program procedures).
2.0 Incident/Accident Reporting
2.3 Statement. Our business will ensure
2.1 Background. We can’t analyze incidents
effective reporting procedures are
and accidents if they are not reported.
developed so we can quickly eliminate
A common reason they go unreported
or reduce hazardous conditions, unsafe
is that the incident/accident analysis
practices, and system weaknesses.
process is perceived to be a search for
the “guilty party” rather than a search 3.0 Preplanning
for the facts. We agree with current Effective incident/accident analysis starts
research that indicates most accidents before the event occurs by establishing a
are ultimately caused by missing well thought-out incident/accident analysis
or inadequate system weaknesses. process. Preplanning is crucial to ensure
Management will assume responsibility accurate information is obtained before it

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 STUDENT WORKBOOK

is lost over the time following the incident/ 2. Immediately collect transient
accident as a result of cleanup efforts or information;
possible blurring of people’s recollections. 3. Interview personnel.

4.0 Incident/Accident Analysis 6.0 Incident/Accident Analysis Team

4.1 All supervisors are assigned the 6.1 Background: It is important to establish
responsibility for analyzing incidents in incident/accident analysis teams before
their departments. All supervisors will be an event occurs so the team can quickly
familiar with this plan and properly trained move into action if needed.
in analysis procedures. The makeup of the team is another
4.2 Each department supervisor will important factor affecting the quality of
immediately analyze all incidents that the analysis. We will appoint competent
might have resulted in serious injury or employees who are trained, and have the
fatality. Supervisors will analyze incidents knowledge and skills necessary to conduct
that might have resulted in minor injury or an effective analysis. Doing so will show
property damage within four hours management’s commitment to the process.
from notification. 6.2 Incident/Accident Analysis Team Makeup
4.3 The supervisor will complete and submit Although team membership may vary
a written incident/minor injury report according to the type of incident, a typical
through management levels. If within the team analyzing an incident/accident
capability/authority of the supervisor, may include:
corrective actions will begin immediately
1. A third-line or higher supervisor from
to eliminate or reduce the hazardous
the section where the event occurred;
condition or unsafe work practice the
2. Personnel from an area not involved in
might result in injury or illness.
the incident;
5.0 Management Responsibilities 3. An engineering and/or maintenance
5.1 When our company has an incident/ supervisor;
accident such as a fire, release, or 4. The safety supervisor;
explosion emergency, management will: 5. A first-line supervisor from the
affected area;
1. Provide medical and other safety/
health help to personnel; 6. Occupational health/environmental
personnel;
2. Bring the incident under control, and
7. Appropriate wage personnel (i.e.,
3. Investigate the incident effectively to
operators, mechanics, technicians);
preserve information and evidence.
and,
5.2 To preserve relevant information the 8. Research and/or technical personnel.
analyst will:
1. Secure or barricade the scene;

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ACCIDENT INVESTIGATION

Team Member Department Shift Phone

6.3 The incident/accident analysis team 4. Obtain on-the-spot information from

leader eyewitnesses, if possible. Soon after,
interview those directly involved, and any
The incident/accident analysis team leader will:
others whose input might be useful. The
1. Control the scope of team activities by interviews should be conducted privately
identifying which lines of analysis should and individually.
be pursued, referred to another group for 5. Observe key mechanical equipment as it is
study, or deferred; disassembled. Include: as-built drawings,
2. Call and preside over meetings; operating logs, recorder charts, previous
3. Assign tasks and establish timetables; reports, procedures, equipment manuals,
4. Ensure that no potentially useful data oral instruction, change of design records,
source is overlooked; and, design data, records indicating the
5. Keep site management advised of the previous training and performance of the
progress of the analysis process. employees involved, computer simulations,
laboratory tests, etc.
7.0 Determining the facts
6. Determine which incident-related items
A thorough search for the facts is an important
should be preserved. When a preliminary
step in incident/accident analysis. During analysis reveals that an item may have failed
the fact-finding phase of the process, team to operate correctly, was damaged, etc.,
members will: arrangements should be made to either
preserve the item or carefully document any
1. Visit the scene before the physical
subsequent repairs or modifications.
evidence is disturbed
7. Document the sources of information
2. Sample unknown spills, vapors, residues, etc.,
contained in the incident report. This will
noting conditions that may have affected
be valuable should it subsequently be
the sample
determined that further study of the incident
3. Prepare visual aids, such as photographs, or potential incident is necessary.
field sketches, missile maps, and other
graphical representations to provide data
for the analysis

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 STUDENT WORKBOOK

8.0 Determining the Cause 9.0 Making Recommendations —

It is critical to establish the root cause(s) Corrective Actions and System
of an incident/accident so that effective Improvements
recommendations are made to correct the Usually, making recommendations for
hazardous conditions and unsafe work corrective actions and system improvements
practices, and make system improvements to follow in a rather straightforward manner
prevent the incident from recurring. from the cause(s) that were determined. A
recommendation for corrective action and
The incident/accident analysis team will use
system improvement will contain three parts:
appropriate methods to sort out the facts,
inferences, and judgments they assemble. 1. The recommendation itself, which describes
Even when the cause of an incident appears the actions and improvements to be taken
obvious, the investigation team will still conduct to prevent a recurrence of the incident.
a formal analysis to make sure any oversight or 2. The name of the person(s) or position(s)
a premature/erroneous judgment is not made. responsible for accomplishing actions
and improvements.
Below is one method to develop cause and
3. The correction date(s).
effect relationships.
10.0 _ Follow-up System: Assignment
1. Develop the chronology (sequence) of Print full name
events occurring before, during, and after
the incident. The focus of the chronology ______________________________________
should be solely on what happened and will develop and implement a system to track
what actions were taken. List alternatives open recommendations and document actions
when the status cannot be definitely taken to close out those recommendations.
established because of missing or Such a system will include a periodic status
contradictory information. report to site management.
2. List conditions or circumstances that
deviated from normal, no matter how
insignificant they may seem.
3. List all hypotheses of the causes of the
incident based on these deviations.

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ACCIDENT INVESTIGATION

11.0 _Incident After Action — Review and Approval

Appropriate operating, maintenance, and other personnel will review all incident/accident
analysis reports. Personnel at other facilities will also review the report to preclude a similar
occurrence of the incident.

Plan reviewed by:

_______________________________________________ Date:___________________________

_______________________________________________ Date:___________________________

_______________________________________________ Date:___________________________

_______________________________________________ Date:___________________________

Plan approved by:

_______________________________________________ Date:___________________________

Sample incident/accident
Essential items: Additional helpful items:
1. Camera 1. Accident investigator’s checklist
2. Tape measure—preferably 100 feet 2. Sturdy gloves
3. Clipboard and blank paper 3. High-visibility plastic tape to mark off area
4. Graph paper 4. First aid kit
5. Straight-edge ruler. Can be used as 5. Audio or video recorder
a scale reference in photos. 6. ID tags
6. Pens and pencils 7. Tape, bags, specimen containers to
7. Accident investigation forms secure items
8. Flashlight 8. Compass
9. Pain stick or chalk to mark the scene
10. Protractor to sketch the scene
11. Tarp
12. Investigator’s template
13. PPE appropriate to your business

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 STUDENT WORKBOOK

Sketching techniques
1. Make sketches large, on 8”x10” paper
2. Make sketches clear and use labels
3. Include measurements
4. Print legibly; all print should be
on the same plane
5. Indicate direction (e.g., north, south,
east, or west)
6. Measure from a permanent point (e.g., a
telephone pole)
7. Make copies of the sketch to use when
interviewing people; they can indicate
where they were and what they were
doing when the accident happened.

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ACCIDENT INVESTIGATION

Forms of energy that describe the 6. Thermal – Extreme or excessive heat,

direct cause of injury extreme cold, sources of flame ignition, flame
1. Mechanical – Components that cut, crush, propagation, and heat-related explosions.
bend, shear, pinch, wrap, pull, and puncture as Example: An oil fryer spits hot oil on an
a result of rotating, transverse, or reciprocating employee’s bare skin, causing burns.
motion.
7. Acoustic – Excessive noise and vibration.
Example: A box crusher causing injury.
Example: Loud machinery causing hearing
2. Electrical – damage over time.
Low-voltage hazards = below 40 volts 8. Radiant – Relatively short wavelength
High-voltage hazards = above 440 volts energy forms within the electromagnetic
Example: Being electrocuted by an spectrum, including radar, infrared, ultraviolet,
ungrounded circuit. X-ray, and ionizing radiation.
3. Chemical – Corrosive, toxic, flammable, or Example: An X-ray technician doesn’t wear
reactive/involving a release of energy ranging PPE and is overexposed to radiant energy.
from “not violent” to “capable of detonation.” 9. Atmospheric/geological/oceanographic
Toxics include poisonous plants, dangerous – Atmospheric weather circumstances such as
animals, biting insects, and disease-carrying wind and storm conditions; geologic structure
bacteria. characteristics such as underground pressure;
Example: Ingesting a poisonous pesticide due and oceanographic currents, wave action, etc.
to residue from spaying. Example: A large wave catches a boat worker
4. Kinetic (impact) – Collision of objects; unaware and flings the person across the boat.
including impact of a moving object against a
Adapted from Nelson and Associates,
stationary object, falling objects, flying objects,
hazardcontrol.com
and flying particles.

Example: A pallet falling and striking an

employee as it hits the ground.

5. Potential (stored) – Sudden unexpected

movement due to gravity, pressure, tension, or
compression.

Example: A pressurized tank valve exploding

and hitting someone.

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 STUDENT WORKBOOK

Accident types and examples Caught between: A person is crushed,

pinched or otherwise caught between either
Struck by: A person is forcefully struck by an
a moving object and stationary object, or
object. The force of contact is provided by the
between two moving objects.
object. Example: A pedestrian is struck by a
moving vehicle. Example: A person’s finger is caught between
a door and its casing.
Struck against: A person forcefully strikes an
object. The person provides the force. Fall to surface: A person slips or trips and
falls to the surface on which they are standing
Example: A person strikes a leg on a
or walking on.
protruding beam.
Example: A person trips on debris in the
Contact by: Contact by a substance or
walkway and falls.
material that by its very nature is harmful and
causes injury. Example: A person is contacted Fall to below: A person slips or trips and falls
by steam escaping from a pipe. to a surface level below the one they were
walking or standing on.
Contact with: A person comes in contact with
a harmful material. The person initiates the Example: a person trips on a stairway and falls
contact. Example: A person touches the hot to the floor below.
surface of a boiler. Exertion: Someone overexerts or strains
Caught on: A person or part of their clothing oneself while doing a job.
or equipment is caught on an object that is Examples: A person is lifting heavy objects
either moving or stationary. This may cause and repeatedly flexes the wrist and twists the
the person to lose their balance and fall, be torso to place materials on a table. Interaction
pulled into a machine, or suffer some other with objects, materials, etc., is involved.
harm. Bodily reaction: Caused solely from stress
Example: A person snags a sleeve on the end imposed by free movement of the body or
of a handrail. assumption of a strained or unnatural body
Caught in: A person is trapped, stuck, or position. A leading source of injury.
otherwise caught in an opening or enclosure. Example: A person bends or twists to reach a
Example: A person’s foot is caught in a hole in valve and strains their back.
the floor. Exposure: Over time, someone is exposed to
harmful conditions.

Example: A person is exposed to levels of

noise in excess of 90 decibels for eight hours.

45
ACCIDENT INVESTIGATION

Oregon OSHA Services Enforcement

Oregon OSHA offers a wide variety of safety and ¨ 503-378-3272; 800-922-2689;
health services to employers and employees: enforce.web@dcbs.oregon.gov
Appeals ⚪ Offers pre-job conferences for mobile employers in

industries such as logging and construction.

¨ 503-947-7426; 800-922-2689;
admin.web@dcbs.oregon.gov ⚪ Inspects places of employment for occupational
⚪ Provides the opportunity for employers to hold safety and health hazards
informal meetings with Oregon OSHA on concerns and investigates workplace complaints and
about workplace safety and health. accidents.
⚪ Discusses Oregon OSHA’s requirements and ⚪ Provides abatement assistance to employers who
clarifies workplace safety or health violations. have received citations and provides compliance
⚪ Discusses abatement dates and negotiates and technical assistance by phone.
settlement agreements to resolve disputed citations.
Public education
Conferences ¨ 503-947-7443; 888-292-5247, Option 2;
ed.web@dcbs.oregon.gov
¨ 503-378-3272; 888-292-5247, Option 1;
⚪ Provides workshops and materials covering
oregon.conferences@dcbs.oregon.gov
⚪ Co-hosts conferences throughout Oregon that enable
management of basic safety and health programs,
employees and employers to learn and share ideas safety committees, accident investigation, technical
with local and nationally recognized safety and health topics, and job safety analysis.
professionals.
Standards and technical resources
Consultative services ¨ 503-378-3272; 800-922-2689;
tech.web@dcbs.oregon.gov
¨ 503-378-3272; 800-922-2689;
⚪ Develops, interprets, and gives technical advice on
consult.web@dcbs.oregon.gov
⚪ Offers no-cost, on-site safety and health assistance
Oregon OSHA’s safety and health rules.
to help Oregon employers recognize and correct ⚪ Publishes safe-practices guides, pamphlets, and
workplace safety and health problems. other materials for employers and employees.
⚪ Provides consultations in the areas of safety, ⚪ Manages the Oregon OSHA Resource Center,
industrial hygiene, ergonomics, occupational which offers safety videos, books, periodicals, and
safety and health programs, assistance to new research assistance for employers and employees.
businesses, the Safety and Health Achievement
Recognition Program (SHARP), and the Voluntary
Protection Program (VPP).

46
 STUDENT WORKBOOK

Need more information?

Call your nearest Oregon OSHA office.
Eugene Portland
Salem Central Office 1500 Valley River Drive, Suite 150 Durham Plaza
350 Winter St. NE Eugene, OR 97401-4643 16760 SW Upper Boones
Salem, OR 97301-3882 541-686-7562 Ferry Road, Suite 200
Phone: 503-378-3272 Consultation: 541-686-7913 Tigard, OR 97224-7696
Toll-free: 800-922-2689 503-229-5910
Medford
Fax: 503-947-7461 Consultation: 503-229-6193
1840 Barnett Road, Suite D
en Español: 800-843-8086
Medford, OR 97504-8293 Salem
Website: osha.oregon.gov
541-776-6030 1340 Tandem Ave. NE, Suite 160
Consultation: 541-776-6016 Salem, OR 97301-8080
Bend 503-378-3274
Pendleton
Consultation: 503-373-7819
Red Oaks Square 200 SE Hailey Ave.
1230 NE Third St., Suite A-115 Pendleton, OR 97801-3072
Bend, OR 97701-4374 541-276-9175
541-388-6066 Consultation: 541-276-2353
Consultation: 541-388-6068

47
 WORKER HEALTH AND SAFETY

Salem Central Office

350 Winter St. NE
Salem, OR 97301-3882
Phone: 503-378-3272
Toll-free: 800-922-2689
Fax: 503-947-7461
en Español: 800-843-8086

osha.oregon.gov
440-5876 (11/23/COM)