This document discusses accident reporting, investigation, and analysis. It defines different types of incidents from near misses to severe accidents and outlines appropriate response and investigation based on incident level. Level 1 incidents involve minor injuries or damage while level 3 are most severe, involving fatalities, serious injuries, major damage or production loss. The appropriate personnel to investigate and responsibilities for remedial actions increase according to incident level. The goal is to learn from incidents to prevent recurrences and improve safety.

1. ©Consultnet Ltd©Consultnet Ltd
Accident Reporting,Accident Reporting,
Investigation and AnalysisInvestigation and Analysis
‘‘ Those who cannot remember the past areThose who cannot remember the past are
condemned to repeat it’condemned to repeat it’

2. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
Presentation ContentsPresentation Contents
IntroductionIntroduction
 Incident ResponseIncident Response
 Incident InvestigationIncident Investigation
 Incident AnalysisIncident Analysis
 Remedial ActionsRemedial Actions
 Incident ReportIncident Report
 Near Miss ReportingNear Miss Reporting
 Cost of incidentsCost of incidents
 Incident StatisticsIncident Statistics
 Summary of ResponsibilitiesSummary of Responsibilities

3. Types of incident(as %) reported to HSA(>3days lost) 2002
32.2
19.46.3
5.3
5.3
4.6
3.9
3
2.4
2.1
2
1.5
0.4
0.4
0.3
0.1
10.9
Injured while handling, lifting or carrying
Slips, trips or falls on same level
Injured by hand tools
Injured by falling objects
Fall from height
Contact with moving machinery parts
Injured by a person – malicious
Transport (excluding road traffic accidents)
Exposure/contact with harmful substance
Road traffic accidents
Injured by a person – non-malicious
Struck by something collapsing/overturning
Contact with electricity
Injured by an animal
Fire or explosion
Drowning or asphyxiation
Miscellaneous or not otherwise classified

4. IntroductionIntroduction
Why report and investigateWhy report and investigate
accidents?accidents?
‘‘PREVENT A RECURRENCE OF THE SAME ACCIDENTPREVENT A RECURRENCE OF THE SAME ACCIDENT’’
It is worth doing it well!It is worth doing it well!
 Learn from what went wrongLearn from what went wrong
 Determine the causesDetermine the causes
 Prevent recurrencePrevent recurrence
 Improve the work environmentImprove the work environment
 Meet regulatory requirementsMeet regulatory requirements
 Cost of incidentsCost of incidents
 Moral ObligationMoral Obligation
 Define trendsDefine trends
 Provision of information in case of litigationProvision of information in case of litigation
 Reduction of operating costs by control ofReduction of operating costs by control of
accidental lossesaccidental losses
 Expression of concern by managementExpression of concern by management

5. IntroductionIntroduction
Incident DefinitionsIncident Definitions
 ACCIDENTACCIDENT - an undesired event that results in personal- an undesired event that results in personal
injury or property damage.injury or property damage.
 INCIDENTINCIDENT - an unplanned, undesired event that- an unplanned, undesired event that
adversely affects completion of a task.adversely affects completion of a task.
 NEAR MISSNEAR MISS - incidents where no property was damaged- incidents where no property was damaged
and no personal injury sustained, but where, given aand no personal injury sustained, but where, given a
slight shift in time or position, damage and/or injuryslight shift in time or position, damage and/or injury
easily could have occurred.easily could have occurred.
 Lost Time AccidentLost Time Accident – an accident resulting in time off– an accident resulting in time off
workwork
 Dangerous OccurrenceDangerous Occurrence - escape of flammable substance, explosion,- escape of flammable substance, explosion,
fire, collapse of load bearing apparatus, pipeline ruptures, pressure vesselfire, collapse of load bearing apparatus, pipeline ruptures, pressure vessel
ruptures, transport incidents, bursting of reveolving wheel, O/H electric lineruptures, transport incidents, bursting of reveolving wheel, O/H electric line
contact, building collapsecontact, building collapse((1993 Safety Health & Welfare at Work( General Application )1993 Safety Health & Welfare at Work( General Application )
RegulationsRegulations ))
 Reportable IncidentReportable Incident –– injured cannot return to work within 3 days ofinjured cannot return to work within 3 days of
incident(1993 Safety Health & Welfare at Work( General Application )incident(1993 Safety Health & Welfare at Work( General Application )
Regulations Form to be submitted to HSA( downloadable atRegulations Form to be submitted to HSA( downloadable at www.hsa.iewww.hsa.ie ))

6. IntroductionIntroduction
Incident Classification for ReportingIncident Classification for Reporting
 Near Miss Incident:Near Miss Incident: a near miss incident where there is no loss be it injurya near miss incident where there is no loss be it injury
or property damage however it could have resulted in personal harm/damageor property damage however it could have resulted in personal harm/damage
under slightly different circumstances, such incidents are reported to theunder slightly different circumstances, such incidents are reported to the
Supervisor and formally logged on a Near Miss Report.Supervisor and formally logged on a Near Miss Report.
 Level 1 - Minor Incident:Level 1 - Minor Incident: a level one incident can typically be dealt with bya level one incident can typically be dealt with by
the person identifying the problem. The supervisor should be informed andthe person identifying the problem. The supervisor should be informed and
the incident formally logged on an Incident Report; this will permitthe incident formally logged on an Incident Report; this will permit
assessment of the incident particularly with regard to the possibility of re-assessment of the incident particularly with regard to the possibility of re-
occurrence and the potential for a more serious event. Examples:occurrence and the potential for a more serious event. Examples: minorminor
localised fire, minor first aid injury(less than one day off work)localised fire, minor first aid injury(less than one day off work)
 Level 2 - Serious Incident:Level 2 - Serious Incident: immediate action should be taken whereimmediate action should be taken where
possible by the person identifying the incident. The supervisor should bepossible by the person identifying the incident. The supervisor should be
immediately informed and should assess the situation. Thereafter, theimmediately informed and should assess the situation. Thereafter, the
supervisor will contact the necessary emergency services and officials as persupervisor will contact the necessary emergency services and officials as per
the emergency plan. Examples: injury (person is likely to be out of work forthe emergency plan. Examples: injury (person is likely to be out of work for
more than one day but less than three days), containable fire, containablemore than one day but less than three days), containable fire, containable
environmental damageenvironmental damage..
 Level 3 - Severe Incident:Level 3 - Severe Incident: immediate action should be taken where possibleimmediate action should be taken where possible
by the person identifying the incident. The supervisor should be immediatelyby the person identifying the incident. The supervisor should be immediately
informed and should assess the situation. The supervisor will contact theinformed and should assess the situation. The supervisor will contact the
necessary emergency services and necessarynecessary emergency services and necessary personnelpersonnel as per the siteas per the site
emergency plan. Examples:persons trapped, serious fire, threat to the safetyemergency plan. Examples:persons trapped, serious fire, threat to the safety
of personnel, serious environmental damage, serious injury( person likely toof personnel, serious environmental damage, serious injury( person likely to
be out of work > 3days)be out of work > 3days), fatality, fatality..

7. Level of Incident and Investigation involvedLevel of Incident and Investigation involved
RISKRISK Level 1Level 1
LowLow
Level 2Level 2
ModerateModerate
Level 3Level 3
HighHigh
Injury SeverityInjury Severity First Aid
Medical Aid
(<1 day off work)
Medical Aid
(1<days off<3)
Fatality
Lost Time Accident
(>3 days)
Serious Incident
Reportable to HSA
Disabling injury
Damage SeverityDamage Severity Up to E30,000 Up to E100,000 Over E200,000
Production LossProduction Loss Less than 3 hoursLess than 3 hours 3 hours to one day3 hours to one day 1 day or more1 day or more
Customer ImpactCustomer Impact Product requires work to
meet customer standards
Product will not meet
customer standards
Loss of Customer
Major customer
dissatisfaction
PersonnelPersonnel
involved ininvolved in
investigationinvestigation
* Front line supervisor
* Worker(s) /Witnesses
involved
* Area Safety Representative
* Front line Supervisor
* Worker(s) /Witnesses
involved
* Area Safety Representative
* Safety Manager
* Front line supervisor
* Worker(s)/Witnesses
involved
* Area Safety Representative
* Head of Department
* Safety Manager
InvestigationInvestigation
ReportReport
ResponsibilityResponsibility
Supervisor - Within the
same shift
Supervisor - Immediately
after personnel and area
are safe
Supervisor -Immediately
after personnel and area
are safe
Responsibility forResponsibility for
Remedial ActionsRemedial Actions
Head of Department Head of Department Head of Department

8. Accident
or
Incident
Occurs
Initial response Supervisor
actions as per emergency plan
Medical Aid
Prevent secondary accidents
Notify emergency services
Safety Manager
Contact insurance
Contact hsa if required
Is the Incident Level 1?
•First Aid
•Medical Aid (<1 day off work)
•Damage < E30,000
•Production Loss < 3 hours
•Product requires work to meet
customer standards
Is the Incident Level 2?
•Medical Aid(1<days off<3)
•E30,000<Damage<E200,000
•1 day >Production Loss > 3 hours
•Product will not meet customer
standards
Is the Incident Level 3?
•Fatality
•Serious Injury - Lost Time(>3 days)
•Serious Incident Reportable to HSA
•Damage>E200,000
•Production Loss < 1 day
•Loss of Customer or major customer dissatisfaction
Accident Team
Investigates
•Front line supervisor
•Worker(s)/Witnesses
involved
•Area Safety
Representative
Accident Team
Investigates
•Front line supervisor
•Worker(s) /Witnesses involved
•Area Safety Representative
•Safety Manager
Accident Team
Investigates
•Front line supervisor
•Worker(s) /Witnesses involved
•Area Safety Representative
•Safety Manager
•Head of Department
Incident Report
Supervisor
Responsible for
completion and
forward to Safety
Manager within 24
Hours
Management
Actions
•Head of
Department
track remedial actions
•Safety Manager
add to incident
database
Include in incident
analysis
Collect more
evidence and
re-analyse
Does analyses show what happened,
what should have happened and why?
Collect Evidence
•Interview witnesses
•Photographs
•Sketches, survey, site maps
•Relative positions
•Examine equipment & machinery
•Failed parts
•Examine Materials
•Examine records
Analyse
•Response and loss limiting actions
•Immediate causes (Substandard
acts and conditions)
•Basic causes (personal & job
factors)
•Program management (standards
and compliance)
Analyse causes
Develop Remedial Actions
inc. timescales and
responsibilities
Management
Actions
•Managing Director
review at next management
meeting
•Head of Department
track remedial actions
•Safety Manager
Issue incident information
add to incident database
Review at next safety
committee meeting
Include in incident analysis
Report findings
and actions
No
Yes
Yes Yes
Yes
No
No
Incident Investigation FlowchartIncident Investigation Flowchart

9. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
 IntroductionIntroduction
Incident ResponseIncident Response
 Incident InvestigationIncident Investigation
 Incident AnalysisIncident Analysis
 Remedial ActionsRemedial Actions
 Incident ReportIncident Report
 Near Miss ReportingNear Miss Reporting
 Cost of incidentsCost of incidents
 Incident StatisticsIncident Statistics
 Summary of ResponsibilitiesSummary of Responsibilities

10. IntroductionIntroduction
Reporting IncidentsReporting Incidents
 Employee must report to SupervisorEmployee must report to Supervisor
 Supervisor responsible for initiating reporting procedureSupervisor responsible for initiating reporting procedure
 Supervisor responsible for complete of incident report forSupervisor responsible for complete of incident report for
near-miss, Level 1 and Level 2 incidents involves Safetynear-miss, Level 1 and Level 2 incidents involves Safety
Manager and Area Safety RepresentativeManager and Area Safety Representative
 Supervisor in conjunction with relevant Head ofSupervisor in conjunction with relevant Head of
Department responsible for completion of Level 3 incidentDepartment responsible for completion of Level 3 incident
reports and also involves Safety Manager and Area Safetyreports and also involves Safety Manager and Area Safety
RepresentativeRepresentative
 Head of Department responsible for completion ofHead of Department responsible for completion of
corrective actionscorrective actions
 Reports to Senior Manager and Safety ManagerReports to Senior Manager and Safety Manager

11. Initial ResponseInitial Response
Typical ProcedureTypical Procedure
All incidents must be reported immediately by the employeeAll incidents must be reported immediately by the employee
concerned to their Supervisor:concerned to their Supervisor:
 If aIf a Near MissNear Miss incident the Supervisor shall ensure a Near Miss Report isincident the Supervisor shall ensure a Near Miss Report is
completed immediatelycompleted immediately..
 If aIf a Level 1Level 1 incident the Supervisor in conjunction with the area Safetyincident the Supervisor in conjunction with the area Safety
Representative completes the Incident Report Form and forwards to SafetyRepresentative completes the Incident Report Form and forwards to Safety
Manager within 24 hours.Manager within 24 hours.
 If aIf a Level 2Level 2 incident immediately after attending to any victim andincident immediately after attending to any victim and
minimisation of property damage the Supervisor ensures the accidentminimisation of property damage the Supervisor ensures the accident
scene is secured, prevents access by unauthorised persons and calls thescene is secured, prevents access by unauthorised persons and calls the
SafetySafety ManagerManager and the area Safety Representative who will assist theand the area Safety Representative who will assist the
Supervisor in completing the Incident Report FormSupervisor in completing the Incident Report Form, taking witness, taking witness
statementsstatements andand completion of thecompletion of the investigationinvestigation..
 If aIf a Level 3Level 3 incident the Supervisor immediately after attending to anyincident the Supervisor immediately after attending to any
victim and minimisation of property damage ensures the accident scene isvictim and minimisation of property damage ensures the accident scene is
secured, prevents access by unauthorised persons and calls the Safetysecured, prevents access by unauthorised persons and calls the Safety
ManagerManager, the area Safety Representative and the relevant Head of, the area Safety Representative and the relevant Head of
DepartmentDepartment,, who will assist the Supervisor in completing the Incidentwho will assist the Supervisor in completing the Incident
Report FormReport Form, taking witness statements, taking witness statements andand completion of thecompletion of the
investigationinvestigation..

12. Initial ResponseInitial Response
The SupervisorThe Supervisor
 Takes control of the sceneTakes control of the scene
 Calls first aid and emergencyCalls first aid and emergency
servicesservices
 Controls secondary incidentsControls secondary incidents
 Identifies sources of evidenceIdentifies sources of evidence
 Preserves evidence from alteration orPreserves evidence from alteration or
removalremoval
 Determines the loss potentialDetermines the loss potential
 Notifies appropriate managementNotifies appropriate management
Discuss you company’s emergency responseDiscuss you company’s emergency response
procedures in the event of fire, injury,procedures in the event of fire, injury,
chemical spillchemical spill

13. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
 IntroductionIntroduction
 Incident ResponseIncident Response
Incident InvestigationIncident Investigation
 Incident AnalysisIncident Analysis
 Remedial ActionsRemedial Actions
 Incident ReportIncident Report
 Near Miss ReportingNear Miss Reporting
 Cost of incidentsCost of incidents
 Incident StatisticsIncident Statistics
 Summary of ResponsibilitiesSummary of Responsibilities

14. Incident Investigation and AnalysisIncident Investigation and Analysis
Tips for investigation and analysisTips for investigation and analysis
 Encourage a no-blame reporting cultureEncourage a no-blame reporting culture
 Focus must be to improve working conditions and methodsFocus must be to improve working conditions and methods
 Approach with an open and objective mindApproach with an open and objective mind
 All facts learnt corrective action takenAll facts learnt corrective action taken
 Fact finding not fault findingFact finding not fault finding
 An opportunity for employees and management to work togetherAn opportunity for employees and management to work together
to correct an unacceptable situationto correct an unacceptable situation
 An incident will happen again if underlying causes are notAn incident will happen again if underlying causes are not
correctedcorrected
 Delve deep to establish underlying causes do not accept allDelve deep to establish underlying causes do not accept all
answers given at face valueanswers given at face value
 Be prepared to look beyong the injured person, his co-workers,Be prepared to look beyong the injured person, his co-workers,
supervisor, managersupervisor, manager
 Consider communication skills and language barriersConsider communication skills and language barriers
 Get as much factual information as possible to get the completeGet as much factual information as possible to get the complete
picturepicture

15. Incident InvestigationIncident Investigation
Effective Incident InvestigationEffective Incident Investigation
 Establish the facts:Establish the facts:
Who? What? When? Where? The size?Who? What? When? Where? The size?
 Analyse the facts isolating contributary factors:Analyse the facts isolating contributary factors:
 Who or what was involvedWho or what was involved
 What hazards were present?What hazards were present?
 What controls failed?What controls failed?
 Identify actions to prevent a recurrenceIdentify actions to prevent a recurrence
 Implement the corrective actionsImplement the corrective actions

16. Incident InvestigationIncident Investigation
Who should lead investigation?Who should lead investigation?
The Supervisor(The Supervisor(of those involvedof those involved), why?), why?
 They have a personal interestThey have a personal interest
 They know the people and conditionsThey know the people and conditions
 They know how best and where to get theThey know how best and where to get the
information neededinformation needed
 They will initiate or take any remedial actionThey will initiate or take any remedial action
 They benefit from investigatingThey benefit from investigating
Where there is major loss or loss potential orWhere there is major loss or loss potential or
where multiple supervisors are involved it iswhere multiple supervisors are involved it is
beneficial that the investigation also involvesbeneficial that the investigation also involves
the Head of Department for the area. In allthe Head of Department for the area. In all
cases it is recommended that the Supervisorcases it is recommended that the Supervisor
involves the safety professional on his/her siteinvolves the safety professional on his/her site
to assist in the investigationto assist in the investigation

17. Incident InvestigationIncident Investigation
Collecting evidence and informationCollecting evidence and information
Record:Record:
Pre-accident conditions, Accident sequence,Pre-accident conditions, Accident sequence,
Post-accident conditionsPost-accident conditions
 Position evidencePosition evidence – people(witnesses), equipment, materials &– people(witnesses), equipment, materials &
environment, use sketches maps, photos, videoenvironment, use sketches maps, photos, video
(Consider plant line up, valve alignment, tools labels, signs)(Consider plant line up, valve alignment, tools labels, signs)
 People evidencePeople evidence – statements from all involved and witnesses,– statements from all involved and witnesses,
interview separatelyinterview separately
 Parts evidenceParts evidence – machinery, tools and other equipment that– machinery, tools and other equipment that
could have contributed to the incidentcould have contributed to the incident
 Paper evidencePaper evidence – all relevant records such as training records,– all relevant records such as training records,
equipment records( maintenance, servicing), MSDS,equipment records( maintenance, servicing), MSDS,
procedures, codes of practice, pre-start checklists, permits,procedures, codes of practice, pre-start checklists, permits,
area rules, standardsarea rules, standards
Consider reconstructing incident from above informationConsider reconstructing incident from above information

18. Initial ResponseInitial Response
Typical ProcedureTypical Procedure
 Photographs of the scene are taken
 If there is a possibility that the accident could become a fatality theIf there is a possibility that the accident could become a fatality the
scene must remain undisturbed until viewed by HSA Inspector andscene must remain undisturbed until viewed by HSA Inspector and
Gardai where required.Gardai where required.
 Arrange for survey plans of the site to be prepared. These are toArrange for survey plans of the site to be prepared. These are to
include the following :include the following :
 Locality Plan & details of accident site;Locality Plan & details of accident site;
 Detailed plan of view showing details after the accident and include such things as:Detailed plan of view showing details after the accident and include such things as:
Equipment used in rescue operations; Position of materials, ladders, equipment,Equipment used in rescue operations; Position of materials, ladders, equipment,
etc. involved in the accident; Position from where photographs were taken; Positionetc. involved in the accident; Position from where photographs were taken; Position
of persons involved in the accident; and other relevant information.of persons involved in the accident; and other relevant information.
 A sectional view (if necessary). Any sections made are to be marked on the detailedA sectional view (if necessary). Any sections made are to be marked on the detailed
plan.plan.
 Take evidence from witnesses at the scene and make note of anyTake evidence from witnesses at the scene and make note of any
piece of evidence.piece of evidence.
 Check relevant equipment, maintenance and training recordsCheck relevant equipment, maintenance and training records
 Analyse condition of equipment materials with specalist input whereAnalyse condition of equipment materials with specalist input where
necessarynecessary
 Prepare a report detailing the circumstances of the accident withinPrepare a report detailing the circumstances of the accident within
24 hours and submit to the Safety Manager24 hours and submit to the Safety Manager.. The report will includeThe report will include
the Incident Report Formthe Incident Report Form and witness incident analysis formsand witness incident analysis forms whichwhich
provides for systematically identifying immediate causes, basicprovides for systematically identifying immediate causes, basic
causes and lack of control.causes and lack of control.
In the event of a LevelIn the event of a Level 2 or Level2 or Level 3 incident, immediately following the incident the3 incident, immediately following the incident the
SupervisorSupervisor shall ensure the following:shall ensure the following:

19. Incident InvestigationIncident Investigation
Accident PhotographyAccident Photography
 Photograph the scene from all sidesPhotograph the scene from all sides
 Use long, medium, close-up sequenceUse long, medium, close-up sequence
 Accompany with good notes and sketchesAccompany with good notes and sketches
 Identify by number, time, date & name ofIdentify by number, time, date & name of
photographerphotographer

20. Incident InvestigationIncident Investigation
Interviewing WitnessesInterviewing Witnesses
 Calm, objective, impartial, open mind, search for facts not opinionsCalm, objective, impartial, open mind, search for facts not opinions
 Do not interrogate/cross examineDo not interrogate/cross examine
 As soon asAs soon as possible( theorising increases as memory decreases)possible( theorising increases as memory decreases)
 Interview separately and privately, use a tape recorder only withInterview separately and privately, use a tape recorder only with
witness permissionwitness permission
 If significant conflict follow up interviews may be necessaryIf significant conflict follow up interviews may be necessary
 Assure them the information is being used for accident prevention notAssure them the information is being used for accident prevention not
to apportion blameto apportion blame
 Get the individuals versionGet the individuals version
 Use open questions (cannot be answered with a simple yes or no)Use open questions (cannot be answered with a simple yes or no)
 Do not express an opinion or argueDo not express an opinion or argue
 Record critical information quicklyRecord critical information quickly
 If not at the site of the accident use visual aids, sketches etc.If not at the site of the accident use visual aids, sketches etc.
 End on a positive note and keep the line openEnd on a positive note and keep the line open
 Review completed statement with witness and have it signedReview completed statement with witness and have it signed
Helpful Interview QuestionsHelpful Interview Questions
What were you doing? Where were you working? How were you injured? How
do you think the accident occurred? What is the safety procedure for the job? How
were you trained for the job? Have you fully described the circumstances of the
accident as you know them?
Take a look at the Witness Incident Analysis form recommended for Level 2/3 incidents

21. Incident InvestigationIncident Investigation
Parts ExaminationParts Examination
Parts – machinery, tools and other equipment that could have contributed
to the incident
 Proper item for taskProper item for task
 Damage - type, extent, patternDamage - type, extent, pattern
 Previous damage – defects, misusePrevious damage – defects, misuse
 WearWear
 Safeguards – machine guards, emergency cut-offsSafeguards – machine guards, emergency cut-offs
 Labels, signs, markingsLabels, signs, markings

22. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
 IntroductionIntroduction
 Incident ResponseIncident Response
 Incident InvestigationIncident Investigation
Incident AnalysisIncident Analysis
 Remedial ActionsRemedial Actions
 Incident ReportIncident Report
 Near Miss ReportingNear Miss Reporting
 Cost of incidentsCost of incidents
 Incident StatisticsIncident Statistics
 Summary of ResponsibilitiesSummary of Responsibilities

23. Incident analysisIncident analysis
What’s involved?What’s involved?
 Determine what happened –immediate cause –Determine what happened –immediate cause –
unsafe practices/conditionsunsafe practices/conditions ( ask the question would the( ask the question would the
accidnet have happened if this particular factor was not present?)accidnet have happened if this particular factor was not present?)
 Determine why it happened basic causes –Determine why it happened basic causes –
personal/job factorspersonal/job factors
 Cover deficiencies in the management systemCover deficiencies in the management system
WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT?WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT?
 Determine appropriate remedial action based onDetermine appropriate remedial action based on
the immediate and basic causesthe immediate and basic causes
 Apportion responsibility to implement correctiveApportion responsibility to implement corrective
actionsactions
 Report findings to senior managementReport findings to senior management
 Follow-up and monitor corrective actionsFollow-up and monitor corrective actions

24. Incident AnalysisIncident Analysis
THE DOMINO SEQUENCE
How Accidents Happen
The domino described below is a model that will help you see
how accidents happen.
Lack of Control Basic
Cause
Immediate
Cause Accident Loss
Organizational
Failure to:
- Plan
 Direct
 Organize
 Control
Lack Of:
Training
Resources
Belief
 Unsafe Act
 Unsafe Condition
Undesired,
Unplanned
Event Which
Disrupts Work
Activity
Death
 Injury
 Property damage
 Lost Time
 Lost Productivity

25. Incident AnalysisIncident Analysis
Lack of Control
Organisational failure means that the organisation, at one or more
levels, did not effectively/properly plan, direct, organize, control or
combination thereof, its resources
Resources are: Time, Tools, Equipment, Materials, Manpower
 Failure to PLAN means: All aspects of the job, task or operation
were not planned effectively so that an unexpected accident was
not eliminated.
 Failure to DIRECT means: Personnel involved in the job, task or
operation were not instructed and trained as to the potential
hazards involved and means to eliminate or control those hazards.
 Failure to ORGANIZE means: All resources that were needed to
do the job safely were not present, proper, and/or in safe
operating condition.
 Failure to CONTROL means: Failure to ensure that the job or task
was actually conducted as planned, organized and directed.

26. Incident AnalysisIncident Analysis
Basic Cause
Personal and job factors - lead a person to commit an unsafe condition or act
 Job factor - Lack of Training/ Lack of Resources
 No training at all
Training that was incomplete or inadequate or not understood
Training that was not repeated frequently enough
Resources (time, tools, equipment, materials, manpower) necessary
to do the job safely are not provided
Resources not proper (skills, size, abilities, type)
Resources not in safe operating condition
Inadequate supervision
Inadequate work standards, procedures, work practices, maintenance
 Personal factor - Lack of Belief
There is a belief that a negative consequence will not result because of their
action. Lack of belief is almost always caused by past experience. Factors that
can contribute to it are:
 Poor morale/low motivation/stress
 Peer pressure
 Productivity pressures
 Inadequate resources
Inadequate capability

27. Incident Analysis
Immediate Cause
Immediate causes are the unsafe acts and/or conditions
that lead directly to the accident.
 Unsafe acts account for 85% of accidents; unsafe
conditions account for 14% of accidents.
 However, 85% of the unsafe conditions were caused
by an unsafe act.
 Therefore, we can say that 97% of all accidents are
caused directly or indirectly by an unsafe act.

28. Incident Analysis
Accident
 An accident is:
“An unplanned, undesirable event which
disrupts work activity”
 An accident always results in a loss.

29. Incident Analysis
Loss
 The loss is the result of an accident. (Disruption of
work activity).
 Approximately 30 different losses have been identified
as potential results of accidents, for example:
Death Lost Productivity
Injury Civil Penalties
Lost Time Replacement Costs
Damaged Morale Economic Loss
Damaged Tools Loss of Client Goodwill
Damaged Equipment Lost Competitiveness
Lost Materials

30. Human Element of Accident CausationHuman Element of Accident Causation
Latent Failures Active & LatentActive FailuresLatent FailuresLatent Failures
Fallible
Decisions
Training & Skills
Work Atmosphere
Line
Management
Deficiencies
Planning
Supervision
Psychological
Precursors
of
Unsafe Acts
Communication
Job Factor
Team Work
Unsafe Acts
Communication
Person Factor
Inadequate
Defences
Tools &
Equipment
Organisational
Process
Local Working Conditions Active Failures Defences
Senior
Management
Line
Management
Frontline
Supervisor
Operators
Maintenance
Crews
Safety
Equipment
Casual SequenceCasual Sequence
Human Elements of Accident Causation (Reason 1990)

31. Incident analysisIncident analysis
Loss Causation ModelLoss Causation Model
Lack of
Control
Inadequate
•Systems
•Standards
•Compliance
Basic
Causes
Personal
Factors
Job/system
factors
Immediate
Causes
Substandard
Acts/practices
Substandard
Conditions
Incident
Event
Contact
with
energy or
surface
Loss
Unintended
harm or
damage
•People
•Property
•Processes
In an incident analysis situation use this model and write down
the loss, incident event, immediate, basic causes and relevant lack
of controls under each heading in list form as per the Incident
Report Form
This makes it possible to identify the causes and relevant
corrective actions to prevent a reoccurrence.
Problem Solving ModelProblem Solving Model

32. Incident Form: Immediate CausesIncident Form: Immediate Causes
Immediate CausesImmediate Causes (What sub standard actions &
Conditions caused the event)::
Tick all applicable below and explain here:
SUBSTANDARD ACTIONS
Operating equipment withoutOperating equipment without
authorityauthority
Failure to warnFailure to warn
Failure to secureFailure to secure
Operating at improper speedOperating at improper speed
Making safety devices inoperableMaking safety devices inoperable
Removing safety devicesRemoving safety devices
Using defective equipmentUsing defective equipment
Using equipment improperlyUsing equipment improperly
Failure to use PPE properlyFailure to use PPE properly
Improper loadingImproper loading
Improper placementImproper placement
Improper liftingImproper lifting
Improper position for taskImproper position for task
Servicing equipment in operationServicing equipment in operation
HorseplayHorseplay
Under influence of alcohol or drugsUnder influence of alcohol or drugs
Working in dangerous situationWorking in dangerous situation
Non-adherence to rules/standardsNon-adherence to rules/standards
SUBSTANDARD CONDITIONSSUBSTANDARD CONDITIONS
Inadequate guards or barriersInadequate guards or barriers
Inadequate or improper protectiveInadequate or improper protective
equipmentequipment
Defective tools equipment orDefective tools equipment or
materialsmaterials
Congested or restricted actionCongested or restricted action
Inadequate warning systemInadequate warning system
Fire and explosion hazardFire and explosion hazard
Poor housekeeping disorderPoor housekeeping disorder
Hazardous environmentalHazardous environmental
conditions(gas, dust etc.)conditions(gas, dust etc.)
Noise exposuresNoise exposures
Radiation exposureRadiation exposure
High or low temperature exposuresHigh or low temperature exposures
Inadequate or excess illuminationInadequate or excess illumination
Inadequate ventilationInadequate ventilation
Defective PPE

33. Incident Form: Basic CausesIncident Form: Basic Causes
Basic CausesBasic Causes (What personal factors & job factors
caused the event)::
Tick all applicable below and explain here:
Personal factorsPersonal factors
Inadequate capabilityInadequate capability
Lack of knowledge
Lack of skillLack of skill
StressStress
Improper motivationImproper motivation
Job FactorsJob Factors
Inadequate LeadershipInadequate Leadership
Inadequate engineeringInadequate engineering
Inadequate purchasingInadequate purchasing
Inadequate maintenanceInadequate maintenance
Inadequate tools &Inadequate tools &
equipmentequipment
Inadequate work standardsInadequate work standards
Wear & TearWear & Tear
Abuse or misuseAbuse or misuse

34. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
 IntroductionIntroduction
 Incident ResponseIncident Response
 Incident InvestigationIncident Investigation
 Incident AnalysisIncident Analysis
Remedial ActionsRemedial Actions
 Incident ReportIncident Report
 Near Miss ReportingNear Miss Reporting
 Cost of incidentsCost of incidents
 Incident StatisticsIncident Statistics
 Summary of ResponsibilitiesSummary of Responsibilities

35. Incident analysisIncident analysis
Remedial ActionsRemedial Actions
 Temporary ActionsTemporary Actions – correct– correct
substandard actions and conditionssubstandard actions and conditions
 Permanent ActionsPermanent Actions – remedy personal– remedy personal
factors and job factorsfactors and job factors
Remedial ActionsRemedial Actions must bemust be::
 Communicated clearlyCommunicated clearly
 Responsible person identified and timescaleResponsible person identified and timescale
established for their completionestablished for their completion
 Follow-up conducted by Investigation TeamFollow-up conducted by Investigation Team
 Department Manager responsible to ensureDepartment Manager responsible to ensure
completioncompletion

36. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
 IntroductionIntroduction
 Incident ResponseIncident Response
 Incident InvestigationIncident Investigation
 Incident AnalysisIncident Analysis
 Remedial ActionsRemedial Actions
Incident ReportIncident Report
 Near Miss ReportingNear Miss Reporting
 Cost of incidentsCost of incidents
 Incident StatisticsIncident Statistics
 Summary of ResponsibilitiesSummary of Responsibilities

37. Incident ReportIncident Report
Typical ContentsTypical Contents
 Title, date and timeTitle, date and time
 Location of the accidentLocation of the accident
 Type of injury or damage/who and what was involvedType of injury or damage/who and what was involved
 Cost of lossesCost of losses
 Description of what happened including emergencyDescription of what happened including emergency
response sequenceresponse sequence
 How the accident occurred/extent of damageHow the accident occurred/extent of damage
 Immediate(direct(energy sources, haz. materials etc.) &Immediate(direct(energy sources, haz. materials etc.) &
indirect causes(unsafe acts and conditions) & basicindirect causes(unsafe acts and conditions) & basic
causes (personal/environmental factors)causes (personal/environmental factors)
 Lack of control(management policies)Lack of control(management policies)
 Remedial actions temporary & permanentRemedial actions temporary & permanent
 Management reviewManagement review
 OtherOther
Note:Note:
 Timeliness of report is critical, best reports are writtenTimeliness of report is critical, best reports are written
promptlypromptly
 Accident reports are usually ‘discoverable’ this means theyAccident reports are usually ‘discoverable’ this means they
can be used by parties to an action for damages or criminalcan be used by parties to an action for damages or criminal
chargescharges

38. Incident ReportIncident Report
Where to?Where to?
Incident reports forwarded to the Safety Manager areIncident reports forwarded to the Safety Manager are
processed as follows :processed as follows :
 All incident reports are analysed and the summaryAll incident reports are analysed and the summary
information is presented at the next monthlyinformation is presented at the next monthly
management meetingmanagement meeting and safety committee meetingand safety committee meeting
 All Level 2 and Level 3 incidents are reviewed at theAll Level 2 and Level 3 incidents are reviewed at the
next weekly management meetingnext weekly management meeting.. Any lessonsAny lessons
learned are communicated to management andlearned are communicated to management and
employeesemployees from ifrom information distributed to allnformation distributed to all
Supervisors(for inclusion in tool box talk ) andSupervisors(for inclusion in tool box talk ) and onon
Company Notice BoardCompany Notice Boardss
 Incident reports are copied to the relevant Head ofIncident reports are copied to the relevant Head of
Department and General Manager in the case of LevelDepartment and General Manager in the case of Level
2 and Level 3 incidents2 and Level 3 incidents

39. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
 IntroductionIntroduction
 Incident ResponseIncident Response
 Incident InvestigationIncident Investigation
 Incident AnalysisIncident Analysis
 Remedial ActionsRemedial Actions
 Incident ReportIncident Report
Near Miss ReportingNear Miss Reporting
 Cost of incidentsCost of incidents
 Incident StatisticsIncident Statistics
 Summary of ResponsibilitiesSummary of Responsibilities

40. Near Miss ReportingNear Miss Reporting
Reporting of Near Miss Incidents is criticalReporting of Near Miss Incidents is critical
 Near misses provide a much larger base for more effective control of accidental lossNear misses provide a much larger base for more effective control of accidental loss
 Eliminate the causes of near misses, reduce the potential for more serious accidents,Eliminate the causes of near misses, reduce the potential for more serious accidents,
this is the basis of any proactive safety management systemthis is the basis of any proactive safety management system
 High potential incidents should be analysed thoroughlyHigh potential incidents should be analysed thoroughly
1
Serious or Major Injury
10
Minor Injuries
30
Property Damage
600
Incidents with no visible
injury or damage
Near miss
Accident
Ratio
Study

41. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
 IntroductionIntroduction
 Incident ResponseIncident Response
 Incident InvestigationIncident Investigation
 Incident AnalysisIncident Analysis
 Remedial ActionsRemedial Actions
 Incident ReportIncident Report
 Near Miss ReportingNear Miss Reporting
Cost of incidentsCost of incidents
 Incident StatisticsIncident Statistics
 Summary of ResponsibilitiesSummary of Responsibilities

42. Analysis of costsAnalysis of costs
Consider the following:Consider the following:
 Cost of dealing with incident( such as first aid,Cost of dealing with incident( such as first aid,
emergency supplies, staff downtime)emergency supplies, staff downtime)
 Costs of incident investigation( such as staff time,Costs of incident investigation( such as staff time,
consultants time)consultants time)
 Cost of getting back to business( such as re-Cost of getting back to business( such as re-
scheduling, clean-up, hire of equipment)scheduling, clean-up, hire of equipment)
 Business Costs( such as cost of injured personsBusiness Costs( such as cost of injured persons
salary, replacement salary, lost orders)salary, replacement salary, lost orders)
 UK HSE useful incident cost calculator template –UK HSE useful incident cost calculator template –
next slidenext slide

43. ©Consultnet Ltd©Consultnet Ltd

44. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
 IntroductionIntroduction
 Incident ResponseIncident Response
 Incident InvestigationIncident Investigation
 Incident AnalysisIncident Analysis
 Remedial ActionsRemedial Actions
 Incident ReportIncident Report
 Near Miss ReportingNear Miss Reporting
 Cost of incidentsCost of incidents
Incident StatisticsIncident Statistics
 Summary of ResponsibilitiesSummary of Responsibilities

45. Accident StatisticsAccident Statistics
AnalysisAnalysis
 Accident data base should be establishedAccident data base should be established
 Identify trends and focus systems where they canIdentify trends and focus systems where they can
produce the greatest return on invested time andproduce the greatest return on invested time and
energyenergy
 Accident analysis statistics should be:Accident analysis statistics should be:
 produced regularly by the Safety Departmentproduced regularly by the Safety Department
 reviewed at regular management and safety committee meetingsreviewed at regular management and safety committee meetings
 summary available to all employeessummary available to all employees
 Identify repetitive or signifcant itemsIdentify repetitive or signifcant items

46. Accident Statistics AnalysisAccident Statistics Analysis
 Statistics may include:Statistics may include:
 Number of near-miss, property damage, first aid, medical aid, lost timeNumber of near-miss, property damage, first aid, medical aid, lost time
incidents, fire, environmental eventsincidents, fire, environmental events
 Lost time injury frequency rates and severity ratesLost time injury frequency rates and severity rates
Lost Time Incident Frequency Rate(LTIFR)=(Total Lost Time Incidents/Total Hours Worked) x 100,000Lost Time Incident Frequency Rate(LTIFR)=(Total Lost Time Incidents/Total Hours Worked) x 100,000
Lost Time Incident Severity Rate(LTIFR)=(Total hours lost/Total Hours Worked) x 100,000Lost Time Incident Severity Rate(LTIFR)=(Total hours lost/Total Hours Worked) x 100,000
 CostsCosts
 Cause and control analysisCause and control analysis
Type of accidents by department, work section, occupationType of accidents by department, work section, occupation
Equipment/substances involvedEquipment/substances involved
Activity at time of injuryActivity at time of injury
Age of person/length of serviceAge of person/length of service
Time of dayTime of day
Immediate causes(substandard acts and conditions)Immediate causes(substandard acts and conditions)
Basic causes( Personal and job factors)Basic causes( Personal and job factors)
Lack of control(inadequate programme standards or compliance with standards)Lack of control(inadequate programme standards or compliance with standards)
Remedial action completion by departmentRemedial action completion by department
Problem solving project teams to address critical problems identifiedProblem solving project teams to address critical problems identified

47. Accident Reporting, Investigation and AnalysisAccident Reporting, Investigation and Analysis
 IntroductionIntroduction
 Incident ResponseIncident Response
 Incident InvestigationIncident Investigation
 Incident AnalysisIncident Analysis
 Remedial ActionsRemedial Actions
 Incident ReportIncident Report
 Near Miss ReportingNear Miss Reporting
 Cost of incidentsCost of incidents
 Incident StatisticsIncident Statistics
Summary of ResponsibilitiesSummary of Responsibilities

48. IncidentsIncidents
Summary of ResponsibilitiesSummary of Responsibilities
 All Employees must report all incidents to their SupervisorAll Employees must report all incidents to their Supervisor
 All Supervisors responsible for initiaiting accident investigationsAll Supervisors responsible for initiaiting accident investigations
 All Heads of Department are responsible for taking appropriate action on theAll Heads of Department are responsible for taking appropriate action on the
conclusions and results of any incident investigation within theirconclusions and results of any incident investigation within their
Department.Department.
 All Heads of Departments are responsible to ensure that the supervisors inAll Heads of Departments are responsible to ensure that the supervisors in
their department are fully aware of, understand and initiate the Incidenttheir department are fully aware of, understand and initiate the Incident
Reporting and Investigation Policy and attendReporting and Investigation Policy and attend relevantrelevant training.training.
 The Safety Manager will be responsible forThe Safety Manager will be responsible for providing technical support to theproviding technical support to the
Supervisor in the course of the incident investigation, issuing incidentSupervisor in the course of the incident investigation, issuing incident
information for communication to all employees, producinginformation for communication to all employees, producing the incidentthe incident
statistics and presentation to monthly managementstatistics and presentation to monthly management and safety committeeand safety committee
meetingmeeting
 The Safety Manager will ensure that management, employees and theirThe Safety Manager will ensure that management, employees and their
representatives are adequately consulted and informed on the incidentrepresentatives are adequately consulted and informed on the incident
investigation policy and provision of training as regards implementation ofinvestigation policy and provision of training as regards implementation of
the policythe policy
 In the event that a Level 2 or Level 3 incident meets the requirement ofIn the event that a Level 2 or Level 3 incident meets the requirement of
reporting to the Health & Safety Authority, the Safety Manager contacts thereporting to the Health & Safety Authority, the Safety Manager contacts the
relevant Inspector, submits the completed statutory report form and co-relevant Inspector, submits the completed statutory report form and co-
ordinates any subsequent investigation with the Inspector.ordinates any subsequent investigation with the Inspector.
 The Safety Manager is responsible for reporting Level 2 & 3 incidents to theThe Safety Manager is responsible for reporting Level 2 & 3 incidents to the
Company Loss Adjuster and Company Insurance Co-ordinator and co-Company Loss Adjuster and Company Insurance Co-ordinator and co-
ordinating any subsequent follow-up investigation.ordinating any subsequent follow-up investigation.

49. Accident
or
Incident
Occurs
Initial response Supervisor
actions as per emergency plan
Medical Aid
Prevent secondary accidents
Notify emergency services
Safety Manager
Contact insurance
Contact hsa if required
Is the Incident Level 1?
•First Aid
•Medical Aid (<1 day off work)
•Damage < E30,000
•Production Loss < 3 hours
•Product requires work to meet
customer standards
Is the Incident Level 2?
•Medical Aid(1<days off<3)
•E30,000<Damage<E200,000
•1 day >Production Loss > 3 hours
•Product will not meet customer
standards
Is the Incident Level 3?
•Fatality
•Serious Injury - Lost Time(>3 days)
•Serious Incident Reportable to HSA
•Damage>E200,000
•Production Loss < 1 day
•Loss of Customer or major customer dissatisfaction
Accident Team
Investigates
•Front line supervisor
•Worker(s)/Witnesses
involved
•Area Safety
Representative
Accident Team
Investigates
•Front line supervisor
•Worker(s) /Witnesses involved
•Area Safety Representative
•Safety Manager
Accident Team
Investigates
•Front line supervisor
•Worker(s) /Witnesses involved
•Area Safety Representative
•Safety Manager
•Head of Department
Incident Report
Supervisor
Responsible for
completion and
forward to Safety
Manager within 24
Hours
Management
Actions
•Head of
Department
track remedial actions
•Safety Manager
add to incident
database
Include in incident
analysis
Collect more
evidence and
re-analyse
Does analyses show what happened,
what should have happened and why?
Collect Evidence
•Interview witnesses
•Photographs
•Sketches, survey, site maps
•Relative positions
•Examine equipment & machinery
•Failed parts
•Examine Materials
•Examine records
Analyse
•Response and loss limiting actions
•Immediate causes (Substandard
acts and conditions)
•Basic causes (personal & job
factors)
•Program management (standards
and compliance)
Analyse causes
Develop Remedial Actions
inc. timescales and
responsibilities
Management
Actions
•Managing Director
review at next management
meeting
•Head of Department
track remedial actions
•Safety Manager
Issue incident information
add to incident database
Review at next safety
committee meeting
Include in incident analysis
Report findings
and actions
No
Yes
Yes Yes
Yes
No
No
Incident Investigation FlowchartIncident Investigation Flowchart

50. Accident InvestigationAccident Investigation
Case StudyCase Study
 Form teams for the investigating andForm teams for the investigating and
reportingreporting
 Analyse the factsAnalyse the facts
 Identify the immediate and basic causesIdentify the immediate and basic causes
 Recommend remedial actionsRecommend remedial actions
 Complete Incident ReportComplete Incident Report
 Present findingsPresent findings
Remember Rudyard Kipling'sRemember Rudyard Kipling's
I keep six honest serving men,I keep six honest serving men,
They taught me all I knew,They taught me all I knew,
Their names are What and Why and HowTheir names are What and Why and How
and Where and When and Whoand Where and When and Who

51. Accident Reporting,Accident Reporting,
Investigation and AnalysisInvestigation and Analysis
ConclusionConclusion
WHEN AN ORGANIZATION REACTS SWIFTLYWHEN AN ORGANIZATION REACTS SWIFTLY
AND POSTIVELY TO ACCIDENTS AND INJURIES,AND POSTIVELY TO ACCIDENTS AND INJURIES,
ITS ACTIONS REAFFIRM ITS COMMITMENT TOITS ACTIONS REAFFIRM ITS COMMITMENT TO
THE SAFETY AND WELL-BEING OF ITSTHE SAFETY AND WELL-BEING OF ITS
EMPLOYEESEMPLOYEES

52. Accident Reporting &Accident Reporting &
InvestigationInvestigation
Further informationFurther information(click to follow link):(click to follow link):
 Irish HSAIrish HSA Accident NotificationAccident Notification information andinformation and accident statisticsaccident statistics
 UK IChemE comprehensive information source on majorUK IChemE comprehensive information source on major incidentsincidents
 UK HSE Report onUK HSE Report on Accident InvestigationAccident Investigation
 UK guidance on use ofUK guidance on use of digital images as evidencedigital images as evidence
 EU research onEU research on work related accidentswork related accidents
 US site onUS site on injury research and controlinjury research and control
 TheThe Investigation ProcessInvestigation Process Research LibraryResearch Library
 US basedUS based OSHA accident investigationOSHA accident investigation information,information, safety payssafety pays software andsoftware and fatal factsfatal facts
informationinformation
 CHEMSAFETY.govCHEMSAFETY.gov is the US Chemical Safety and Hazard Investigation Board's site, itis the US Chemical Safety and Hazard Investigation Board's site, it
investigates major chemical accidentsinvestigates major chemical accidents
 US basedUS based OSHA Studies of Occupational FatalitiesOSHA Studies of Occupational Fatalities. Links to OSHA reports of. Links to OSHA reports of
fatality/catastrophe investigationsfatality/catastrophe investigations
 United StatesUnited States Chemical Safety & Hazard InvestigationChemical Safety & Hazard Investigation BoardBoard
Australian guidance onAustralian guidance on learning from accidentslearning from accidents
 Canadian based information onCanadian based information on reporting and investigating accidentsreporting and investigating accidents
 New Zealand information on Aftermath -New Zealand information on Aftermath -
The Social and Economic Consequences of Workplace Injury and IllnessThe Social and Economic Consequences of Workplace Injury and Illness
 Investigation ProcessInvestigation Process Research LibraryResearch Library