Title: Accident Investigation and Reporting
1Chapter 8
- Accident Investigation and Reporting
2Major 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
3Rationale 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.
4When 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.
5Accident 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.
6Most 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.
7Accident 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.
8Safety 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.
9Steps 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.
10Importance 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.
11Proper 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.
12Three 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.
13When 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.
14How 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.
15Purpose 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.
16Summary
- 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.
17Home 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.