Accident Investigation and Reporting

1
Chapter 8

• Accident Investigation and Reporting

2
Major Topics

• Types of accident investigations
• When to investigate
• What to investigate
• Who should investigate
• Conducting the investigation
• Interviewing the witness
• Reporting accidents
• Ten accident investigation mistakes to avoid

3
Rationale for investigating accidents

• The primary reason for investigating accidents is
  not to identify a scapegoat, but to determine the
  cause of the accident.
• This information benefits the ongoing effort of
  reducing the likelihood of accidents, and
  preventing similar accidents from happening in
  the future.

4
When should an investigation be reported? Why?

• According to OSHA document 2056 employers of 11
  or more employees must maintain records of
  occupational injuries and illnesses as they
  occur.
• If an accident results in the death of an
  employee or hospitalization of 5 or more
  employees, a report must be submitted to the
  nearest OSHA office within 48 hours. This rule
  applies regardless of the size of the company.
• The saddest part of non reporting of accidents is
  that they are not investigated to determine and
  eliminate the cause.

5
Accident report and accident analysis report

• An accident report is completed when the accident
  in question represents only a minor incident. It
  answers the following questions who, what,
  where, and when. However it does not answer the
  why question. Supervisors often complete accident
  reports. OSHA form 301 can be used for accident
  reports.
• An accident analysis report is completed when the
  accident in question is serious. It answers all
  the questions who, what, where, when, and why.
  Accident analysis must identify the actual root
  cause or the company will expend resources
  treating only the symptom or even worse solving
  the wrong problem. Serious accidents are always
  accompanied by the potential for litigation. If
  there might be legal action, it is important to
  have a professional conduct the investigation
  even if it means bringing in an outside
  consultant.

6
Most common causes of accidents

• Personal beliefs and feelings Individual did not
  believe the accident would happen to him or her
  individual had personal problems that clouded his
  or her judgment, etc.
• Decision to work unsafely Some people, for a
  variety of reasons, feel it is in their best
  interest or to their benefit to work unsafely.
• Mismatch or overload Individual is in poor
  physical condition individual is fatigued, etc.
• System failure Lack of rules, regulations,
  procedures failure to correct known hazards
  insufficient training for employees, etc.
• Traps Defective equipment failure to provide,
  maintain, replace proper personal protective
  equipment, etc.
• Unsafe conditions unsafe conditions created by
  the elements unsafe conditions created by a
  fellow employee, etc.
• Unsafe acts individual chooses to ignore the
  rules individual uses drugs or alcohol, etc.

7
Accident investigation guide

• The investigation should be guided by the
  following words who, what, when, where, why, and
  how. Causes of the accidents should be the
  primary focus.
• SME recommends the following questions
• What type of work was the injured person doing?
• Exactly what was the injured person doing or
  trying to do at the time of the accident?
• Was the injured person proficient in the task
  being performed at the time of the accident? Had
  the worker received proper training?
• Was the injured person authorized to use the
  equipment or perform the process involved in the
  accident?
• Were there other workers present at the time of
  the accident? If so, who are they, and what were
  they doing?
• Was the task in question being performed
  according to properly approved procedures?
• Was the proper equipment being used, including
  PPE?
• Was the injured employee new to the job?
• Was the process, equipment, or system involved
  new?
• Was the injured person being supervised at the
  time of the accident?
• Are there any established safety rules or
  procedures that were clearly not being followed?
• Where did the accident take place?
• What was the condition of the accident site at
  the time of the accident?
• Had a similar accident occurred before? If so,
  were corrective measures recommended? Were they
  implemented?
• Are there obvious solutions that would have
  prevented the accident?
• The answers to these questions should be
  recorded. You may find it helpful to dictate your
  findings into a micro-cassette recorder. This
  approach allows you to focus more time and energy
  on investigating and less time on taking notes.

8
Safety personnel role in accident investigation

• If the accident is very minor, the injured
  employees supervisor may conduct the
  investigation, but the safety and health
  professional should at least study the accident
  report and be consulted regarding recommendations
  for corrective action.
• If the accident is so serious that it has
  widespread negative implications in the community
  and beyond, responsibility for the investigation
  may be given to a high level manager or corporate
  executive. In such cases the safety and health
  professional should assist in conducting the
  investigation.
• If a company prefers the team approach, the
  safety and health professional should be a member
  of the team and in most cases should chair it.
• Regardless of the approach preferred by a given
  company, the safety and health professional
  should play a leadership role in collecting and
  analyzing the facts and developing
  recommendations.

9
Steps for conducting an accident investigation

• Five steps
• Isolate the accident scene This is done to keep
  curious onlookers from removing, disturbing, or
  unknowingly destroying vital evidence. Nothing
  but the injured worker should be removed from the
  scene.
• Record all the evidence As quickly as possible
  because certain types of evidence may be
  perishable accident scene may be disturbed
  knowingly or unknowingly, pressure may mount to
  get a critical piece of machinery back into
  operation. If in doubt, record it.
• Photograph or videotape the scene Both still and
  video cameras must be on hand, loaded, and ready
  to use should an accident occur. Place a ruler or
  coin next to the object when making a close-up
  photograph to get the objects size or proper
  perspective.
• Identify witnesses Primary witness, secondary
  witness and tertiary witness list.
• Interview witnesses Primary witness first. May
  be necessary to re-interview witness.

10
Importance of recording all evidence immediately

• It is important to make a record of all pertinent
  evidence as quickly as possible. There are 3
  reasons for this
• 1. Certain types of evidence may be perishable.
• 2. The longer an accident scene must be isolated,
  the more likely it is that evidence will be
  disturbed, knowingly or unknowingly.
• 3. If the isolated scene contains a critical
  piece of equipment, pressure will quickly mount
  to get it back in operation.
• Evidence can be recorded in a variety of ways
  including written notes, sketches, photography,
  videotape, dictated observations, and diagrams.
  In deciding what to record, a good rule of thumb
  is, if in doubt record it.

11
Proper perspective of close-up photographs

• A problem with photographs is that, by
  themselves, they do not always reveal objects in
  their proper perspective.
• The National Safety Council recommends that when
  photographing objects involved in an accident be
  sure to identify and measure them to show the
  proper perspective. Place a ruler or coin next to
  the object when making a close-up photograph.
  This technique will help to demonstrate the
  objects size or perspective.

12
Three categories of witnesses to an accident

• In identifying witnesses, it is important to
  compile a witness list.
• Names on the list should be recorded in three
  categories
• 1. Primary witness.
• 2. Secondary witness.
• 3. Tertiary witness.
• When compiling the witness list, ask employees to
  provide names of all three types of witnesses.

13
When and where of interviewing witnesses

• To ensure that the information is objective,
  accurate, and untainted by the personal opinion
  and feelings of the witness, and able to be
  corroborated.
• When to interview Immediately after the list has
  been compiled. The witnesses recollection will be
  best right after the accident. Immediacy also
  avoids the possibility of comparing notes and as
  a result changing their story. Individuals should
  be interviewed individually and separately,
  preferably before they have talked to each other.
• Where to interview The best place to interview
  is at the accident scene. Ensure that
  distractions are removed, interruptions are
  guarded against, and witness is not accompanied
  by other witnesses. If it is not possible to
  interview at the accident scene, select a
  location that is not intimidating to the witness.

14
How to interview

• The information being sought is who, when, where,
  why, and how.
• The key to getting at the facts is to put the
  witness at ease and listen.
• Listen to what is said, how it is said, and what
  is not said.
• Ask questions, but phrase them in an open ended
  format What did you see?
• Do not lead the witness with your questions, and
  interrupt only if absolutely necessary.
• Remain non judgmental and objective.
• Ask witness to simulate rather than actually
  perform the steps that led to the accident if
  possible. Record if possible and it is not
  intrusive.
• At the end of the interview summarize what you
  have heard and ask have the witness verify your
  summary.

15
Purpose of an accident report

• An accident investigation should culminate in a
  comprehensive accident report.
• The purpose of the report is to record the
  findings of the accident investigation, the cause
  of the accident, and recommendation for
  corrective actions.
• According to OSHA document 2056 employers of 11
  or more employees must maintain records of
  occupational injuries and illnesses as they
  occur.
• If an accident results in the death of an
  employee or hospitalization of 5 or more
  employees, a report must be submitted to the
  nearest OSHA office within 48 hours. This rule
  applies regardless of the size of the company.
• The saddest part of non reporting of accidents is
  that they are not investigated to determine and
  eliminate the cause.
• More in the text book.

16
Summary

• Accidents are investigated to identify causes, so
  that they can be corrected, not to assign blame.
• Accidents should be investigated as soon as
  possible so that evidence and memories of
  witnesses are still fresh.
• An accident investigation should ask the
  questions who, what, when, where, and how.
• A safety and health professional should play an
  active role in the accident investigation.
• Steps in an accident investigation isolate the
  accident scene, record all evidence, photograph
  or video tape the accident scene, identify
  witnesses, and interview witnesses.
• Interviews should take place at the accident site
  whenever possible.
• Ask open ended questions.
• Accident report forms must meet the
  specifications of OSHA.

17
Home work

• Answer questions 2, 6, 7, 8, 11, and 12 on page
  179-180.
• 2. When should an investigation be reported? Why?
• 6. What role should the safety and health
  professional play in the conduct of an accident
  investigation?
• 7. List and explain the steps for conducting an
  accident investigation.
• 8. Why is it important to record all pertinent
  evidence relating to an accident immediately
  after an accident has occurred?
• 11. Briefly explain the when and where of
  interviewing witnesses.
• 12. Briefly explain the how of interviewing
  witnesses.