Causation, Reporting and Investigating of Accidents.

1. Accidents
Causation, Reporting &
Investigation

2. Causation Theories
Single Cause Domino Theory
Multiple Causation

3. Single Cause Domino Theory
Heinrich’s theory
Each factor is the fault of the factor that immediately
precedes it
A preventable injury is the natural culmination of a
series of events or circumstances, which occur in a
fixed logical order

4. Single Cause Domino Theory
Ancestry & Social
Environment
Fault of Person Unsafe Act or
Condition
Accident Injury

5. Single Cause Domino Theory
If one of the dominoes is removed then the chain
of events will be halted, and the accident will not
happen
Element 3 (unsafe act and/or mechanical or
physical hazard) is probably the easiest factor to
remove

6. Single Cause Domino Theory
 Bird & Loftus extended Heinrich’s theory to encompass the influence of
management in the cause & effect of accidents
 They suggested a modified sequence as follows:
 Lack of management control, permitting
 Basic causes (personal & job factors), leading to
 Immediate causes (substandard practices or conditions), which are the direct cause of
 The accident, which results in
 Loss (negligible, minor, serious or catastrophic
 This modified sequence can be applied to every accident and is of basic
importance to loss control management

7. Multiple Causation
May be more than one cause, not only in sequence, but
occurring at the same time
In accident investigation all causes must be identified
Usually simple accidents have a single cause
Major disasters normally have multiple causes

8. Multiple Causation
Cause a
Cause b Unsafe Act
Cause c
Accident
Injury or
Damage
Cause d
Cause e
Unsafe
Condition
Cause f

9. Unsafe Acts
 Categories:
 Operating without clearance
 Operating at unsafe speed
 Rendering safety devices inoperative
 Using unsafe equipment, or using it unsafely
 Unsafe methods e.g. loading, carrying, mixing
 Adopting unsafe position or posture
 Working on moving or dangerous equipment
 Horseplay e.g. distracting, teasing, startling
 Failure to wear PPE
 Lack of concentration; fatigue or ill health
 Human Factors

10. Unsafe Acts
Unsafe acts can be active or passive:
Active Unsafe Acts:
Worker deliberately removes machine guard
Passive Unsafe Acts:
More difficult to deal with
By pursuing an active safety policy, it is possible to achieve a
reduction in bad habit s and hence accidents

11. Unsafe Conditions
 Categories:
 Inadequate guarding
 Unguarded machinery
 Defective, rough, sharp, slippery, decayed, cracked surfaces
 Unsafely designed equipment
 Poor housekeeping, congestion
 Inadequate lighting, glare, reflections
 Inadequate ventilation, contaminated air
 Unsafe clothing or PPE
 Unsafe processes
 Hot, humid or noisy environment

12. Unsafe Acts/Conditions
 The picture shows how unsafe acts & conditions may interact to produce an accident. Accident
potential is increased when unsafe acts & conditions occur simultaneously. Of course, this is
not to say that an act or condition alone could not result in an accident.
Unsafe Acts Unsafe
Conditions
Accident
Potential

13. Accident Reporting
Information should be kept for all injuries, and
preferably for near misses
The safety practitioner needs to design a
suitable form to ensure that he gets the
information that he needs for investigations

14. Accident Investigation Records
 Format:
 Name & personal details of victim
 Date, day and time of accident
 Location of accident
 Occupation of victim
 Job being done at time
 Nature of injury or damage
 What inflicted the injury or damage
 Who had control of the cause of the injury or damage
 What actually happened
 Basic and immediate causes
 Immediate remedial action taken
 Recommendations to prevent recurrence

15. Use of Investigation Records
 Accident records are useless if they are used only to count accidents. Detailed and
thorough study of the records as part of the normal ongoing accident prevention
programme should yield the following useful information:
 Relative importance of the various injury & damage sources
 Conditions, processes, machines and activities which cause the injuries/damage
 The extent of repetition of each type of injury or accident in each operation
 Accident repeaters, I.e. those workers who tend to be repeatedly injured or are involved
in more accidents
 How to prevent similar accidents in future

16. Accident Investigation
 Could be carried out by:
 Safety Practitioner
 Management or Supervisor
 Safety Representative
 Inspector
 A joint investigation by company/safety rep is often a good idea
 An investigation which does not discover what went wrong, and produce
some useful information and recommendations for corrective action, is just a
waste of time

17. Accident Investigation
Initial Actions
Questioning the victim
Treatment of victim is first priority
Immediate questioning may not be possible - they should be allowed to collect their
thoughts and control their nerves
Witnesses & Conditions
Investigator can usually go to accident scene and get a fairly complete story from
on-site conditions and witnesses
In all serious accidents and in all other cases where practicable, conditions at
accident scene should remain undisturbed until investigation is complete

18. Investigators
Immediate supervisor:
Likely to know most about the situation
Knows his own people better than anyone
Has personal interest in determining causes, as accidents
affect the efficiency and morale of his department
Familiarity with staff could cause problems

19. Investigators
 Recognising Hazards
 Familiarity with plant, equipment and layout of operations will assist in
recognising hazards that have been overlooked for some time
 Unsafe acts, as well as conditions, contribute towards most accidents
 It is not sufficient merely to recommend fitting a guard while overlooking the
unsafe act, such as rendering the guard ineffective or placing hands in the
danger zone
 It is also insufficient to limit attention to an unsafe act if fitting a better guard
would reduce the likelihood of injury

20. Investigators
Safety Practitioner
Necessary in more serious cases
Supervisor may not have necessary authority
Should seek assistance from local supervisor
Investigator must have authority to go as far as is
necessary to get to the cause of the problem

21. The Investigation
Promptness
As soon as possible after the event
Facts will be easier to determine and more details will be
remembered by those involved
Fire
Helpful if investigator is present during the fire
Investigator may gain useful information by watching the
activities of firemen

22. The Investigation
Evidence
Depending on severity of any injuries or damage, investigator
should be present during clear-up and reinstatement as
valuable clues may otherwise be missed
Failing which, supervisor should take it upon himself to collect
the necessary evidence

23. The Investigation
 Equipment
 Photographic equipment
 Portable lights (electricity may be switched off or accident scene may be poorly lit)
 Sketchpad, pencils and measuring equipment
 Record-keeping equipment e.g. notebook and cassette recorder
 Sample collection equipment e.g. jars, paper bags, cartons etc.
 Tools for cleaning debris or spillages should also be available
 Portable gas/vapour detecting equipment

24. Accident Investigation Procedure
1. Inspection of the accident scene to collect any information relating to
physical conditions of the plant, equipment and building
2. Interview witnesses and others likely to give information concerning any
unsafe acts or conditions which may have contributed to the accident
3. Summarise all available evidence accurately in a written report to
management, recommending future actions to prevent a recurrence

25. Inspection of the Scene
 Careful, detailed look at accident scene, evaluating and noting the following:
Extent & severity of damage
Damage to surrounding property
Environmental conditions which may have had some bearing
on the accident, such as temperature, ventilation, humidity and
illumination
 Survey the accident scene to see if there are any obvious dangerous physical
conditions which may have been responsible for the accident

26. Inspection of the Scene
 In the case of spillages, splashes or other escapes of poisonous, explosive,
flammable or other dangerous material, it may be necessary to take samples
for subsequent investigation
 Where machinery or other equipment has been involved, it may be necessary
to issue instructions prohibiting the use or repair of it until the investigation
has been completed

27. Talking with On-Site Personnel
 Easy to upset people when asking questions about what has been done, or
what has not been done
 Casual remarks made during the site inspection may be quite revealing and
the investigator should continue to talk to any personnel involved near the
scene of the accident
 This would also serve as an ideal opportunity to explain the object of the
exercise is to discover and root out the causes so as to prevent a repetition. It
is not to apportion blame or to criticise any individual

28. Interviewing Witnesses
Types of Witness
Primary witness
The victim
Secondary witness
Extremely rare, the eyewitness
How many people really see the instant of an accident?
Tertiary witness
Can offer variety of corroborative statements regarding the acts of people or
environmental

29. Interviewing Witnesses
Putting witnesses at ease
Explain fully purpose of investigation
Encourage participation and involvement
Show interest in any ideas they might have about possible
preventive measures
Witness must be assured that the purpose of the investigation
is not to blame anyone, but to attempt to find out the cause and
thereby reduce possibility of a recurrence

30. Interviewing Witnesses
Interview Location
Best to carry out interviews at scene of accident, as it is
easier for those involved to communicate effectively with
“props” close to hand
Easier to explain what happened if witnesses are able to
point out specific things and recall their actions related to
specific locations

31. Interviewing Witnesses
Question Phrasing
Open ended question - what, where, when, how or who
Questions starting with why may put witness on the defensive
Typical questions:
 What happened? What did you see?What time was it?
 Where were you at the time? Where was the victim?
 When did you realise something was wrong?
 How did it happen? How were you involved?
 How could it have been prevented?
 Who else was involved? Who else saw it? Who reported it?

32. Interviewing Witnesses
Attitude
 “What happened” will often promote the fullest response and it is vital the investigator
listens, without interruption, to the witness’s account of the accident
 If something is not understood, investigator should wait until witness has completed his
account before asking for clarification
 Do not disagree with any of witness’s statement or make any judgements on his
evidence alone
 What a witness believes to have happened will depend to some extent on just how he
perceived the situation, even though this might conflict with the actual facts

33. Interviewing Witnesses
Conclusion
When witness’s account of accident has been heard,
investigator should repeat it to witness to ensure account is fully
understood
Interview should be concluded on a positive note, which is best
achieved by discussing any ideas he may have regarding
prevention of a similar occurrence - this will serve to reaffirm
the purpose of the interview and ensure the witness’s further
co-operation, should it be needed

34. Interviewing the Victim
Ideally first to be interviewed
Injuries may be serious, or may be suffering
from shock
Should be interviewed at the earliest opportunity
General principles for interviewing witnesses
apply

35. What Should be Investigated
ALL incidents/accidents should be investigated
Purpose is to find the cause, with the intention of
preventing a recurrence, rather than
apportioning blame
An injury usually involves some degree of blame
falling on management, supervision, victim or
workers