2. Accident
Investigation

3. WHAT IS AN ACCIDENT?
• What is an accident?
o Any unexpected event
o Some may even be good
• Does an accident always involve an
injury?
• Does an injury always involve an
accident?

4. What Is An Accident?

5. Accidents
• Accident
o Any unplanned event that results in
 Personal injury
 Property damage

7. Accidents
• Usual causes
o Failure of people, equipment, supplies, or
surroundings to behave or react as
expected

9. WHY INVESTIGATE?
• Why investigate?
o To PREVENT injuries
• Investigations should not be witch
hunts
o If results show need for discipline, fine
But.....
o That is not the purpose

10. INVESTIGATIONS
• Include non injury accidents incidents
o Proactive
o Preventative
• Investigating only injuries
o Reactive

11. INJURY PYRAMID
Non-injury Accidents
1st Aid Cases
Recordable
Serious
Recordable
Fatality

12. Incident Investigation Plan
• Establish parameters
• Be aware of other requirements
o ADA, EEO, Union, etc.
• Establish procedures
• Develop forms
• Train employees

13. First Report
The “First Report of Injury”
sent to Workers’
Compensation Company is
NEITHER an accident report
NOR an investigation.

14. Incident Report
• Write an incident report
o As soon as possible
• Start with a supervisor’s report based
on information provided by employees
o “Employee said......”

15. Injury Potential
• Investigate based on POTENTIAL
FOR INJURY
• The greater the potential, the more
thorough the investigation

17. The Investigation
Avoid a “cold trail”

18. The Investigation
• Be methodical
• Gather as much information as
possible
o Throw out irrelevant information during the
analysis step

19. The Investigation
• Beware of preconceived conclusions
• Beware of “jumping the gun”
o Do not offer solutions before you find the
basic cause

20. The Investigation
• ASK QUESTIONS
• When you get an answer, ask “WHY”
• Then ask “WHY” again
• And AGAIN
• And “who?”, “what?”, and ...”why?”

21. Basic
Causes
Management Safety Policies & Decisions
Personal Factors Environmental Factors
Indirect
Causes Unsafe Act Unsafe Condition
Direct
Causes Unplanned Release of Energy
and/or Hazardous Material
Incident

22. The Investigation
• Investigate the scene
o Take measurements
o Take pictures
o Evaluate equipment
o Be imaginative

23. The Investigation
• Look for
o Guards off
o Lack of PPE
o Housekeeping issues
o Poor work practices
o Faulty equipment
o Inadequate training
o Poorly written procedures
o Etc.

26. The 4 “Ps”
• People
• Position
• Parts
• Paper

27. Interviews
• Interview employee involved
• Interview witnesses
• Interview other employees in area
• Look for similar incidents

28. Interviews
• Explain the purpose of the investigation
o Accident prevention
• Put at ease
• Let speak freely
• Take notes without distracting
• Only use a tape recorder with the
person’s knowledge and consent.
• Interview as soon as possible

29. Analysis Techniques
• Change analysis
• Job Safety Analysis (JSA)
• Event and Causal Factors Analysis
• Multi linear Events Sequencing (MES)
• Project Evaluation Tree (PET)
• Combination

30. Report of Investigation
• 1. Background
information
• 2. Detailed account
of the incident
• 3. Resolution
• 4. Corrective actions

31. RESOLUTION
• Discuss ways of preventing future
incidents
• Solicit ideas from employees & others
• Be creative
• Make recommendations

32. Corrective Actions
• Corrective actions
o Recommendations that are adopted
• Inform and train employees and
supervisors

33. Follow-Up
• Involve supervisors & employees
• Are solutions:
o Used?
o Effective?
• Solicit feedback

34. Trend Analysis
• Evaluate for incident, accident and
injury trends in order to focus efforts
• Use 300 forms, incident & accident
reports, first aid logs, inspection
reports, etc.
• Analyze by entity, facility, time, job,
etc.
• Do at least a 3 year comparison

35. Resource
• Ask for help from your workers’
compensation carrier

37. Sandra A. Mihalik, WSO-CST
Safety & Health Specialist
Montana Safety & Health Bureau
Phone: 406.444.6418
E-mail: smihalik@mt.gov