Occupational Health and Safety Section
Department of Environmental Health
133 Environmental Health Building
Fort Collins, CO 80523
(970) 491-6151
Fax: (970) 491-7778
Guide to Accident/Incident Investigations
(Including a Sample Investigation Form)
(Text Adopte d f r o m
O R - O S H A
U p d a t e d 7/ 8 / 2 0 0 1
Course 102)
Introduction
Accidents occur when hazards escape detection during preventive measures, such as a job or process safety
analysis, when hazards are not obvious, or as the result of combinations of circumstances that were difficult to
foresee. A thorough accident investigation may identify previously overlooked physical, environmental, or process
hazards, the need for new or more extensive safety training, or unsafe work practices. The primary focus of any
accident investigation should be the determination of the facts surrounding the incident and the lessons that can be
learned to prevent future similar occurrences. The focus of the investigation should NEVER be to place blame. The
process should be positive and thought of as an opportunity for improvement.
Most accidents in the workplace result from unsafe work behaviors. According to the latest research, they represent
the direct cause for about 95% of all workplace accidents. Hazardous conditions represent the direct cause for only
about 3% of workplace accidents. "Acts of God" account for the remaining 2%. All these statistics imply that
management system weaknesses account for fully 98% of all workplace accidents. Effective accident investigation
identifies these root causes and recommends strategies to eliminate management system weaknesses.
When do you conduct an investigation?
As a general rule, investigations should be conducted for:
All injuries (even the very minor ones)
All accidents with potential for injury
Property and/or product damage situations
All Near Misses where there was potential for serious injury Near miss and incident reporting and
investigation allow you to identify and control hazards before they cause a more serious incident. Accident/incident
investigations are a tool for uncovering hazards that either were missed earlier or hazards where controls were
defeated. However, it is important to remember that the investigation is only useful when its objective is to identify
root causes. In other words, every contributing factor to the incident must be uncovered and recommendations
made to prevent recurrence.
Have a plan!
When a serious accident occurs in the workplace, everyone will be too busy dealing with the emergency at hand to
worry about putting together an investigation plan, so the best time to develop effective accident investigation
procedures is before the accident occurs. The plan should include procedures that determine:
Who should be notified of accident.
Who is authorized to notify outside agencies (fire, police, etc.)
Who is assigned to conduct investigations.
Training required for accident investigators:
Who receives and acts on investigation reports.
Timetables for conducting hazard correction.
Secure the accident scene
For a serious accident, the first action the accident team needs to take is to secure the accident scene so material
evidence is not moved or removed. Material evidence has a tendency to walk off after an accident. If the accident is
quite serious, OSHA may inspect and require that all material evidence be marked and remain at the scene of the
accident.
Gather information
The next step is to gather useful information about what directly and indirectly contributed to the accident. The
following tools should be used to gather as much information as possible:
Interview eye witnesses as soon as possible after the accident. Interview witnesses separately, never as a
group.
Interview other interested persons such as supervisors, co-workers, etc.
Review related records such as:
Training records
Disciplinary records
Medical records (as allowed)
Maintenance records
OSHA 200 Log (past similar injuries)
Safety Committee records
Document the scene with photographs, videotape, or sketches AND appropriate measurements.
Develop a sequence of events
Use the information gathered to develop a detailed step by step description of the accident. Make sure the
accident is documented in enough detail to enable an individual unfamiliar with the situation to envision the
sequence of events. Do not just describe the accident itself, include a description of events that led up to the
accident.
Analyze the accident
The next step is to determine the cause(s) of the accident. This is the most difficult step because first the events
must be analyzed to discover surface cause(s) for the accident, and then, by asking why a number of times, the
related root causes are uncovered. Remember, surface causes are usually pretty obvious and not too difficult to
determine. However, it may take a great deal more time to accurately determine the weaknesses in the
management system, or root causes, that contributed to the conditions and practices associated with the accident.
More on surface causes
The surface causes of accidents are those hazardous conditions and individual unsafe employee/manager
behaviors that have directly caused or contributed in some way to the accident.
Hazardous conditions may exist in any of the following categories:
Materials
Environment
Machinery
Workstations
Equipment
Facilities
Tools
People
Chemicals
Workload
It's important to know that most hazardous conditions in the workplace are the result of an unsafe behaviors that
produced them. Individual unsafe behaviors may occur at any level of the organization.
Some example of unsafe employee/manager behaviors include:
Failing to comply with rules
Allowing unsafe behaviors
Using unsafe methods
Failing to train
Taking shortcuts
Failing to supervise
Horseplay
Failing to correct
Failing to report injuries
Scheduling too much work
Failing to report hazards
Ignoring worker stress
More on root causes
The root causes for accidents are the underlying system weaknesses that have somehow contributed to the
existence of hazardous conditions and unsafe behaviors that represent surfaces causes of accidents. Root causes
2
always pre-exist surface causes. Inadequately designed system components have the potential to feed and nurture
hazardous conditions and unsafe behaviors. If root causes are left unchecked, surface causes will flourish!
Root causes may be separated into two categories:
System design weaknesses. Missing or inadequately designed policies, programs, plans, processes and
procedures will affect conditions and practices generally throughout the workplace. Defects in system
design represent hazardous system conditions.
System implementation weaknesses. Failure to initiate, carry out, or accomplish safety policies,
programs, plans, processes, and procedures. Defects in implementation represent ineffective management
behavior.
System Design Weaknesses
Missing or inadequate safety
policies/rules
Training program not in place
Poorly written plans
Inadequate process
No procedures in place
System Implementation Weaknesses
Safety policies/rules are not being
enforced.
Safety training is not being conducted
Adequate supervision is not
conducted
Incident/Accident analysis is
inconsistent Lockout/tagout
procedures are not reviewed annually
Develop preventive actions
This is the most important piece of any investigation. All of the work done to this point culminates with
recommendations to prevent similar accidents from happening in the future. Recommendations should relate
directly to the surface and root causes for the accident. These recommendations should include recommended
actions such as:
Engineering controls (for example, local exhaust ventilation or use of an lift assisting device)
Work practice controls (for example, pre-plan work or remove jewelry and loose fitting
clothing before operating machinery)
Administrative controls (for example, standard operating procedures or worker rotation)
Personal protective equipment (for example, safety glasses or respirators)
It is crucial that, after making recommendations to eliminate or reduce the surface causes, that the same procedure
is used to recommend actions to correct the root causes. If root causes are not corrected, it is only a matter of time
before a similar accident occurs.
Summary
A successful accident investigation determines not only what happened, but also finds how and why the accident
occurred. Investigations are crucial as an effort to prevent a similar or perhaps more disastrous sequence of
events. Research has shown that a typical accident is the result of many related and unrelated factors that
somehow all come together at the same time. It is estimated that there are usually more than ten factors that
contribute to a serious accident. Although, this combination of factors normally makes an investigation very time
consuming and resource intensive, the good news is that the accident can normally be prevented by removing only
a few of the contributing factors.
Attached is a typical accident/incident investigation form to assist you in determining surface and root causes as
well as track progress on preventative actions. Should you have additional questions on this subject, please feel
free to call us at (970) 491-6151.
Incident Investigation Form
INCIDENT INFORMATION
Time
Date of Accident
Shift
321
Department
Day of Week
SMTWTFS
INJURED PERSON
Name: Mr. X
Address: CEPU
Age: 35
Phone:
Job Title: Pekerja Galian Konstruksi Pipa
Supervisor Name: Andi Taufik
Length of Employment at Company:
Length of Employment at Job: 2 years
Employee Classification: Full Time Part Time Contract Temporary
Nature of Injury
Bruising
Dislocation
Other (specify)
Injured Part of Body:
Strain/Sprain
Scratch/Abrasion
Internal
Died
Died
Fracture
Amputation
Foreign Body
Remarks:
Laceration/Cut
Burn/Scald
Chemical Reaction
Treatment
Name and Address of Treating Physician or Facility
First Aid
Emergency Room
Dr.s Office
L Hospitalization
DAMAGED PROPERTY
Property, Equipment, or Material Damaged
Describe Damage
Object or Substance Inflicting Damage:
Perlengkapan pekerja pada saat pekerjaan penggalian dan
alat berat yang dipakai dlm mengoperasikan
Pekerja terlindas alat berat disamping tidak diikuti perintah
sesuai SOP
INCIDENT DESCRIPTION
Describe what happened (attach photographs or diagrams if necessary)
1. Banyak lubang
2. Tanah becek
3. Material berceceran
4. Tanah yang dilewati excavator tidak rata dan tdlk stabil
5. Pekerja tidak menghiraukan tanda
6. Sopir excavator tidk memperhatikan keadaan jalan (Photo at power point)
ROOT CAUSE ANALYSIS (Check All that Apply)
Unsafe Acts
Improper work technique
Safety rule violation
Improper PPE or PPE not used
Operating without authority
Failure to warn or secure
Operating at improper speeds
By-passing safety devices
V
V
V
V
V
V
Unsafe Conditions
Poor workstation design or layout
Congested work area
Hazardous substances
Fire or explosion hazard
Inadequate ventilation
Improper material storage
Improper tool or equipment
V
V
V
V
Management Deficiencies
Lack of written procedures or policies
Safety rules not enforced
Hazards not identified
PPE unavailable
Insufficient worker training
Insufficient supervisor training
Improper maintenance
V
V
V
V
V
V
Guards not used
Improper loading or placement
Improper lifting
Servicing machinery in motion
Horseplay
Drug or alcohol use
Unnecessary haste
Unsafe act of others
Other:
V
V
V
V
V
-
Insufficient knowledge of job
Slippery conditions
Poor housekeeping
Excessive noise
Inadequate guarding of hazards
Defective tools/equipment
Insufficient lighting
Inadequate fall protection
Other:
V
V
V
V
V
Inadequate supervision
Inadequate job planning
Inadequate hiring practices
Inadequate workplace inspection
Inadequate equipment
Unsafe design or construction
Unrealistic scheduling
Poor process design
Other:
V
V
V
V
V
V
-
INCIDENT ANALYSIS
Using the root cause analysis list on the previous page, explain the cause(s) of the incident in as much detail as possible.
1. Tidak stabilnya material lumpur pada puncak dari lapisan tanah keras hal ini menyebabkan licin akibat air yang
mengalir dari bukit.
2. Tidak mencukupinya kemampuan dari operator .
3. Kurangnya instruksi dan informasi kepada operator
4. Lingkungan Material Manusia Ruang/area kerja kurang memberi keluwesan bergerak.
5. Tumpukan galian diletakkan terlalu di bibir lubang galian, sehingga tekanan terhadap tanah di bawahnya meningkat,
mendorong untuk terjadinya ambruk.
6. Material yang digunakan dan berada di sekitar tempat kerja tidak tertata dengan aman dan baik. (tanah galian, besi
beton, dsb)
What is the chance of the accident happening again?
Frequent Occasional Rare
How bad could the accident have been?
Very Serious Serious
Minor
PREVENTIVE ACTIONS
Describe actions that will be taken to prevent recurrence.
Membuat daftar resiko kecelakaan yang mungkin terjadi disetiap item pekerjaan
misalnya pada pekerjaan galian tanah akan memungkinkan terjadi kelongsoran
tanah, pekerja terkena cangkul, sehingga diketahui upaya pencegahanya seperti
pembuatan tembok sementara dari bambu untuk menahan tanah serta memasang
rambu-rambu hat-hati pada lokasi galian tanah
Deadline By Whom
Kepala
Proyek/Man
dor
Membuat rambu-rambu kecelakaan kerja, memasang pagar pengaman pada void
yang memungkinkan adanya resiko jatuh, memasang tabung pemadam kebakaran
pada area rawan kebakaran.
Kepala
Proyek/Man
dor
Penyediaan perangkat pengaman kecelakaan kerja dari mulai personil sampai
peralatan mungkin terlihat mahal namun biaya tersebut akan lebih murah jika tidak
mengadakanya sehingga terjadi kecelakaan sehingga dapat menghentikan jalanya
pekerjaan atau pengalihan aktifitas pekerjaan pada upaya menyelamatkan korban
kecelakaan
Kepala
Proyek/Man
dor
INVESTIGATION TEAM
Signature
1.
2.
3.
4.
Name
Andi Taupeik
Arief Danang N
Aris Nur Zain
Deby Awalia Putri
Position
Migas Inspector
Complete
