An accident investigation aims to prevent future injuries by determining the root causes of incidents. It should be conducted promptly by gathering information from employees, witnesses, and examining the site. The investigation identifies direct causes such as unsafe acts and conditions as well as indirect causes involving management policies and personal or environmental factors. A report is produced with corrective actions to address the causes and prevent recurrences. Regular trend analysis of incidents can help focus accident prevention efforts.

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