Accident and Incident

Investigation
 Objectives of this Section

●
To def ine the reasons for investigating
accident and incidents.
● To outline the process for effectively
investigating accidents and incidents.
● To facilitate an effective investigation.
What is an accident?
What is an incident?
What is a near miss?

A near miss is an unintentional

incident that could have caused
damage, injury or death but was
narrowly avoided
 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 f inancial 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 that there is
shown greater
consistently num a of less
accidents
ber than serious serious
accidents and
in the same way a greater number of
incidents than 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 def ining the principles of safety
management says that “an unsafe act, an unsafe
condition, an accident are symptoms of something
wrong within the management’s system.”
 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 the following diagram.

Deal with immediate

risks.

Select the level of

investigation.

Investigate the event.

Record and analyse the

results.

Review the process.

 Dealing with Immediate
Risks
Deal with immediate
risks. ●
When accidents and incident
occur immediate actio s may
Select the level of
necessary to: n be
investigation.
Make the situatio
prevent further
n injury. safe an
Investigate the event. Help, treat
and if rescue d necessa
injured persons.
Record and analyse the
results.
ry
●
An effective response c
Review the process.
an only be made if it
has been planned fo
r in
advance.
 Selecting the level of
investigation
The greatest effort should be put into:
Deal with immediate
risks. T h ose involving sev ill-
ere injuries, health or loss.
Those which could have
Select the level of
investigation. caused much greater harm or
damage.
These types of accidents and incidents
Investigate the event.
demand more careful investigation and
management time. This can usually be
achieved by:
Record and analyse the
results. Looking more closely at
underlying the causes of
Review the process. events. significant
Assigning the responsibility for
investigation of more signif
the
icant events to more senior
managers.
 Investigating the Event

Deal with immediate

risks.
The purpose of investigati
ons is to establish:
Select the level of ●
The way things were and how they came
investigation.
to be.
Investigate the event.
●
What happened – the sequence of events
that led to the outcome.
●
Why things happened as th
Record and analyse the
results.
analysing both the ey
im did
underlying
mediate causes. and
Review the process.
●
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.

Documents
Information from:
 Written instructions;
Procedures, risk
assessments, policies
 Reco rd s o f earlier
in sp ectio n s, tests,
Observation examinations and surveys.
Information from physical
sources including:
 Premises and place of work
 Access & egress  Checking reliability, accuracy
 Plant & substances in use Identifying conf licts and resolving differences

 Location & relationship of  Identifying gaps in evidence
physical particles
 Any post event checks,
sampling or reconstruction
Interviews
Information from:
 Those involved and their
line management;
 Witnesses;
 Those observed or
involved prior to the event
e.g. inspection &
maintenance staff.
 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.

T he
● i nte rv i e w styl e i s i m p o r tant wi th
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 inf luencing each other.
●
Que sti o ns whe n aske d sho ul d no t b e
intimidating as the investigator will be seen
as aggressive and ref lecting 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 f ind.
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 management’s 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.
 Recording & Analysing the
Results
●
Recorded in a similar an
d systematic manner.
Deal with immediate
risks.
●
Provides a historical record of the accident.
●
Analysis of the causes and recommended
Select the level of
preventative protective measures should
investigation. be listed.
●
Completed as soon after the accident as
Investigate the event. possible.
●
Information on the accident and remedial
actions should be passed to all
Record and analyse the
results.
supervisors.
●
Appropriate preventative measures may
Review the process.
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 events in isolation.
 Reviewing the Process
Reviewing the
Deal with immediate accident/incident investigation
risks.
process should consider:
Select the level of
– The results of investigations and analysis.
investigation. The operation of the investigation system
– (in terms of quality and effectiveness).
Investigate the event.
Line managers should follow
through and action the f indings of
Record and analyse the
results.
investigations and analysis. Follow
up systems should be established
Review the process. 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.
1.Based on your knowledge learnt in your course, Identify the stages in an
Accident/Incident Investigation related to your chosen case study.
•

Deal with immediate risks
•Select level of investigation
•Investigation of event
•Record and Analysis
•Review of process
2.




In your case study, identify any related rules and regulation regarding to the
accident reporting
What is your def inition
of an “Accident”?
 What is an Accident
-anunplanned event
-an unplannedincidentinvolving injuryor
fatality
-a series of eventsculminatingin an
unplannedandunforeseen event
How do Accidents occur?
- Accidents (with or without injuries) occur when
a series of unrelated events coincide at a
certain time and space.

-This can be from a few events to a series of a

dozen or more
(Because the coincidence of the series of
events is a matter of luck, actual accidents only
happen infrequently)
 Unsafe Acts

-An unsafe act occurs in approx 85%- 95% of

all analyzed accidents with injuries
-An unsafe act is usually the last of a series of
events before the accident occurs (it could
occur at any step of the event)
-By stopping or eliminating the unsafe act, we
can stop the accident from occurring
 What is an Accident Investigation?

●
A systematic approach to the identification of
causal factors and implementation of
corrective actions without placing blame on
or f inding personal fault. The information
collected during an investigation is essential
to determine trends and taking appropriate
steps to prevent future accidents.
 Which Accidents should be
Recorded or Reported?

ALL accidents
(including illnesses) shall
be recorded and reported
through the established
procedures and guidance
as provided by
NOAA Safety Division
 Why Investigate Accidents?
●
Determine the cause
●
Develop and implement corrective
● actions Document the events
● Meet legal requirements

Primary Focus:
P R EV EN T R EO CCUR EN CE! ! !
P R EV EN T R EO CCUR EN CE! ! !
PREVENT REOCCURENCE!!!
 Accident vs. Near-Miss

Accident :
Any undesired, unplanned event arising out of a
given work-related task which results in
physical injury/ illness or damage to property.

Near-Miss :
Events which did not result in injury/illness or
damage but had the potential to do so.
 Accident Ratio Study

Serious or Disabling
1

10 Minor Injuries

30 Property Damage

600 Accidents with no visible injury or

damage

6000 Unsafe Acts or Conditions

 Accident Causes

●
Unsafe Act
-an act by the injured person or another
person (or both) which caused the accident,
and/or Unsafe Condition
● - s o m e e nv i ro nm e nt a l o r h a z a rd o u s

situation whic h c aused the ac c ident

independent of the employee
 Accident Causation Model

Results of the accident

-physical harm
-property damage
Incident Occurrence
-contact with
-type
Immediate causes
-practices
-conditions
Basic causes
-personal factors
-job factors
-supervisory performance
-management policy and
decisions
Results of the Accident

●
Physical Harm
- catastrophic (multiple deaths)
- single death
- disabling
- serious
- minor
●
Property Damage
- catastrophic
- major
- serious
- minor
 Incident Occurrence
● Type
- struck by - struck against
- slip, trip - fell from
- caught on - fell on same level
- caught in - overexertion

● Contact with
- electricity - equipment
- noise - vibration
- hazmat - heat/cold
- radiation - animals/insect
s
 Immediate Causes
●
Practices
-operating without
authority
-use equipment
improperly
-not using PPE when
required
-correct lifting
procedures not
established
- drinking or drug use
- horseplay
-equipment not
properly secured
 Immediate Causes (cont’d)

●
Conditions
-ineffective guards
-unserviceable tools and
equipment
-inadequate warning
systems
-bad housekeeping
practices
-poor work space
illumination
-unhealthy work
environment
 Basic Causes

●
Personal Factors
- lack of knowledge or skill
- improper motivation
- physical or mental
condition
- literacy or ability
●
Job Factors
- Physical environment
- sub-standard equipment
- abnormal usage
- wear and tear
- inadequate standards
- design and maintenance
 Basic Causes (cont’d)
●
Supervisory Performance
- inadequate instructions
- failure of SOPs
- rules not enforced
- hazards not corrected
- devices not provided

●
Management Policy and
Decisions
- set measurable standards
- measure work in progress
- evaluate work vs. standards
- correct performance

Noanimalswerehurtasaresultofthisaccident
 Severity of Incident
(NOAA Safety Policy NAO-209-1)
● Major
- Employee fatality,
- Hospitalization of 3 or more employees,
- Permanent employee disability,
- Five or more lost workdays,
- Conditions that could pose an imminent and
threat of serious injury/illness to other
employees
- Property losses in excess of $1 Million
● Minor
- All other (less serious) incidents and unsafe
conditions reported by employees
 Who Investigates?
●
Major Accidents
- NOAA “GO TEAM” Investigation Team
- LO Representative
- Other agencies such as NTSB, USCG, OSHA

●
Minor Accidents
- First-Line Supervisor
- Site Director or Manager
- Site Safety Representative
- NOAA SECO (if needed)
 Investigator’s
Qualifications
● Technical knowledge Objectivity
●
Analytical approach
● Familiarity with the job, process or operation
● Tact in communicating
● Intellectual honesty Inquisitiveness and
● curiosity
●
 When to Investigate?

●
Immediately after incident
Witness memories fade
Equipment and clues are
moved

●
Finish investigation quickly
 What to Investigate?

●
All accidents and near-misses
- Conduct investigation upon
first notification
- Keeping the scene in-tact and
recording witnesses statements
early is key to a successful
investigation
 Accident Investigation
Kit
May Include:
●
Digital Camera
● Report forms, clipboard, pens Barricade tape
●
Flashlight Tape measure Tape recorder
● Personal Protective Equipment (as appropriate)
●

●
 The Accident Occurs
●
Employee or co-worker immediately reports
the accident to a supervisor
●
Supervisor secures/assesses the scene to
prevent additional injuries to other
employees, before assisting the injured
employee
●
Supervisor treats the injury or seeks
medical treatment for the injured
● The accident scene is left intact
● Site safety rep is contacted to assist the
supervisor in the investigation of the
accident.
 Beginning the Investigation

●
Gather investigation
members and kit
● Report to the scene
● Look at the big
picture
● Record initial
observations
● Take pictures
 What’s Involved?

●
Who was injured?
●
Medication, drugs, or
alcohol?
● Was employee ill or

fatigued?
● Environmental conditions?
 Witnesses
● Who witnessed the
accident?
●
Was a supervisor or
Team Lead nearby?
●
Where were other
employees?
●
Why didn’t anyone
witness the accident
(working alone, remote areas)?
 Interviewing Tips

●
Discuss what happened leading
up to and after the accident
● Encourage witnesses to describe
the accident in their own words
● Don’t be defensive or judgmental
● Use open-ended questions
● Do not interrupt the witness
 What was Involved?

●
Machine, tool, or
equipment
● Chemicals
● Environmental
conditions
● Field season prep
operations
 Time of
Accident
● Date and time?
● Normal shift or
working hours?
●
Employee coming
off a vacation?
 Accident
Location
●
Work area
●
On, under, in, near
● Off-site address
●
Doing normal job
duties
●
Performing non-
routine or routine
tasks (i.e., properly
trained)
 Accident Narrative

●
Describe the details so the reader
can clearly picture the accident
● Specif ic body parts affected
● Specif i c motions
of injured employee
just before,
during, and after
accident
 Employee’s Activity

●
Motion conducted
at time of accident
● Repetitive motion?
● Type of material
being handled
 Causal Factors
● Try not to accept single cause theory
● Identify underlying causes (root)
● Primary cause
● Secondary causes
Contributing causes
Effects
 Corrective Actions Taken
●
Include immediate interim controls
implemented at the time of accident
●
Recommended corrective actions
Employee training
Preventive maintenance activities
Better operating procedures
Hazard recognition (ORM)
Management awareness of risks involved
 Immediate
●
Notification
Supervisor shall complete the NOAA Web Based
Accident/ Illness Report Form and submit within
24 hours of incident occurrence (8 hours for major
incidents).
 Accident Analysis Summary

●
Investigate accident immediately
● Determine who was involved and
who witnessed it
● Ascertain what items or equipment
were involved
● Record detailed description
● Determine causal factors
● Implement corrective actions