This document provides an overview of accident investigation procedures. It discusses the purpose of investigations as preventing recurrence, complying with policies, and maintaining employee awareness. The key steps in conducting an investigation are to: immediately secure the accident scene and ensure treatment of injured; gather information from witnesses, physical evidence, and records; analyze the facts to identify direct and root causes; and make recommendations for corrective actions and follow up. Accident investigations aim to understand why unsafe acts or conditions were present in order to prevent future accidents.

1. Accident /Incident
Investigation

6. Overview
 Purpose of Investigation
 Managing the Accident Scene
 Steps in Conducting Investigation

7. Investigations are conducted to:
Prevent recurrence
Comply with policies and regulatory
requirements
Maintain employee awareness

8. ACCIDENT
An undesired event that results
in harm to people, damage to
property, or loss to process

9. ILO Accident Report
• Accidents - 250 M/year or 685 T/day or
475/minute or 8/second
• Working children - 12 M (recorded),
12,000 are fatal
• Working Adults - 3,000/day = 2/min.

10. Types of Accident
1. Personal injury or illness
2. Property damage
3. Combination of items 1 & 2
4. Near-miss (actually an
incident)

11. INCIDENT
An undesired event which,
under slightly different
circumstances, could have
resulted in harm to people,
damage to property, or loss to
process

12. Accidents are the result of: :
 Unsafe Acts
 Unsafe Conditions

13. UNSAFE ACTS
Behaviors which could permit
the occurrence of an accident or
incident
Deviation from standard
procedures or practices

14. UNSAFE CONDITIONS
Circumstances which could
permit the occurrence of an
accident or incident
Deviation from
standard conditions
(equipment, materials,
or environment)

15. Unless the unsafe acts/conditions are:
Prevention is the reason for
conducting an Accident
Investigation
 Identified and
 Eliminated or controlled
… similar mishaps will occur

16.  LTI
 Non-LTI
 Near Miss
 Chemical Spill
 Property Damage
 Fire and Explosion
All accidents must be
investigated:

17. Accident Investigations are
usually considered a
Supervisor’s responsibility

18.  More familiar with the people
involved
 Better understanding of the
operations
 Personal interest in investigations
Advantages of Supervisors
over other investigators:

19. Team Effort
All employees should
understand :
 What to report
 How to report

20.  LTI
 Non-LTI
 Near Misses
 Property Damage
 Chemical Spill
 Fire or Explosion
What to Report

21.  Medical
 Safety
 Environmental Control
 Management
Whom to Report to:

22. Managing the Accident Scene
Two Priorities:
 Care & treatment of the injured
 Elimination or control of
remaining hazards

23.  Training in First Aid
 Drills under normal and abnormal
conditions
 Liaison with hospitals
Care & Treatment of Injured
Supervisors can increase their
ability to respond to Medical
Emergencies by:

24.  Notify necessary personnel
 Provide PPE to potentially
exposed
 Refer to MSDS
Controlling Remaining Hazards
If a hazardous environment or toxic
materials exist:

25. Isolate the site
 To protect people from further
injury
 To preserve evidence and
valuable clues

26. Successful investigation is
done ...
 Immediately
 Completely
 Thoroughly

27. Investigate immediately,
because:
 Operations are disrupted
 Memories fade
 Employees are at risk

29. Conducting the Investigation
 Gather information
 Analyze the facts
 Make recommendations

30. ACCIDENT INVESTIGATION
Guidelines:
1. Investigate immediately
2. Ensure immediate treatment
3. Secure the area
4. Record details of event (photo, sketch, etc.)
5. Collect physical evidence
6. Review other sources (victim’s record, friends, etc.)
7. Interview witnesses (5Ws + 1H)
8. Write causal factors (man, machine, material, method)
9. Make recommendations (effective/reliable results)

31. Gathering Information
 NOI, POI, DOI, TOI
 personnel involved
 property damage
 environmental harm
Preliminary Facts:

32. Accident Investigation
Equipment
 Report form
 Notebook or pad of
paper
 Tape recorder
 Camera (instant or
digital)
 Measuring equipment

33. Sources of Information
 Witnesses
 Physical evidence at the
scene
 Existing records

34. Victim and onlookers
Those who heard what happened
Saw area prior to incident
Others with info about involved
individuals, equipment or
circumstances
Witnesses

35. Interviewing Witnesses
1. Reassure the witness
2. Let the witness tell the story
3. Begin with open-ended questions
4. Don’t ask leading questions

36. Interviewing Witnesses
5. Summarize
6. Ask for recommendations
7. Get written statements
8. Close on a positive note

37. ACCIDENT INVESTIGATION
Questions for reporting: WHO
- was injured?
- saw the accident?
- was working with the injured?
- had instructed/assigned the job to the injured?
- else was involved?
- has the information of events prior to the accidents?

38. ACCIDENT INVESTIGATION
Questions for reporting: WHAT
- is the injury?
- is the damage or loss?
- was the injured doing?
- had the injured been
instructed to do?
- tools/equipment/machinery
were being used?
- did the injured & any
witnesses saw?
- training had been given?
- were the contributory causes
of the accident?
- communication system was
used?
- is the state of health of the
injured?
- safety rules were violated?
- safety system and procedures
were there?

39. ACCIDENT INVESTIGATION
Questions for reporting: WHEN
- did the accident occur?
- did the damage become evident?
- did the injured start the job?
- was the explanation of hazard given?
- did the supervisor last see the injured?
- did the persons involved last have food & rest?

40. ACCIDENT INVESTIGATION
Questions for reporting: WHY
- did the injury occur?
- did the communication fail?
- was the training not given?
- were the unsafe condition
permitted?
- was the hazard not spotted at
previous inspection?
- was PPE not provided?
- was PPE not used?
- was there no safe system of
work?
- was there no safety
instruction given?
- was the supervisor not
consulted when things
started go wrong?
- was the supervisor not there
at the time?

41. ACCIDENT INVESTIGATION
Questions for reporting: WHERE
- did the accident occur?
- did the damage occur?
- was the supervisor at that time?
- was the witnesses at that time?

42. ACCIDENT INVESTIGATION
Questions for reporting: HOW
- did the injury occur?
- could the accident have been avoided?
- could have been the injury avoided?
- could the supervisor have prevented the
accident?
- could better design help?

43. Physical Evidence
Provides information about an
accident that witnesses may
overlook or take for granted

44. Sketches
To record important details at the
accident site for later study

45. Electrocution
victim
Comfort
Room

46.  Floor plan from overhead view
 Location of involved man,
machine, tool
 Size and location of transient
evidences (spills, dust,
footprints, skid marks)
Include everything that
could be important:

47. AHU
X
X

48. Photographs
 detail
 color differences
 complex shapes
difficult to recall

50. Photographs
 General area
 Detailed shots
 Show scale on small objects
 Indicate reference point
 Better to take too many than
too few

56. Materials
Tools
Machines EXAMINING
Examining Physical Evidence

57.  Physical condition
 Position of switches/levers
 Reading of gauges
 Safeguards
 Warning devices
Machines & Tools

58.  Misuse
 Abuse
 Disuse
 Improper handling
 Damage
Material
Position and condition can indicate

59. If chemicals are involved:
 correct item used
 correct concentration
 expired
 contaminated
 MSDS availability
Material - Chemical

60.  Log and label
 Secure storage & transport
 Avoid contamination
 Guard against tampering and loss
 Appropriate HSE warnings
If items have to be
removed from the scene
for detailed examination:

61. Environment (Work)
 Weather condition
 Illumination
 Noise
 Housekeeping

62. Existing Records
 Employee records
 Equipment records
 Job or Task records
 Previous Accident Investigation
reports

63. Workshop I - Gathering of Facts
I. Actual Accident or Simulated Accident
- Nature of Accident
- Parties involved/responsible person(s)
- Place of Accident
- Time and Date of Accident
II. Interview witnesses/victims
- 5W’s and 1 H develop at least 20 questions
III. Collected evidences, photographs, records review
15 minutes
IV. Presentation: Dramatization
10 minutes

64. Analyzing the Facts
 Cause Analysis (root)
 Change analysis

65. UNAWARE
UNABLE
UNMOTIVATED
HAZARDOUS
ACTS
UNNOTICED
UNCORRECTED
HAZARDOUS
CONDITIONS
ACCIDENT / ILLNESS
Immediate and Basic Causes

66.  Look beyond the direct causes of
the accident …
 Find out what can be done to
eliminate the underlying reason for
the hazardous behaviors and
conditions that led to the mishap

67. Direct
Causes
Basic
(root)Causes

68. Direct Causes
• caught in, between, or under
• struck against or struck by
• fall from or fall on
• overexertion or stress

69. Basic (Root) Causes
• inadequate maintenance of equipment
• inadequate codes and standards
• insufficient employee safety training
• safe work practices inadequately followed
• faulty design of work area
• supervisors not performing duties

70. Change Analysis
Compares how a job was
actually performed with the way
it should have been performed

71. Change Analysis
ACTUAL
BEHAVIORS or
CONDITIONS
STANDARD
BEHAVIORS or
CONDITIONS
SAFE
BEHAVIORS or
CONDITIONS
ACTUAL
BEHAVIORS or
CONDITIONS
STANDARD
BEHAVIORS or
CONDITIONS
UNSAFE
BEHAVIORS or
CONDITIONS

72. Recommending Corrective
Actions
 Specific
 Measurable
 Attainable
 Realistic
 Time-bound

73. Follow-up
It’s the best way to ensure that
recommendations are carried
out

74.  General information
 A Summary
 An Analysis
 Recommendations
Report forms require four
basic types of information

75. Reports should be
 Clear
 Detailed
 Neat
 Legible

81. Management Approach
 Training
 Inspections
 Hazard analysis
 Safety Meetings

82. Not just for incidents
involving serious injury, its
for ANY occurrence that has
the POTENTIAL of causing
harm
Accident Investigation...

83. Review
 Purpose of Investigation
 Managing the Accident Scene
 Steps in Conducting Investigation

84. ACCIDENT INVESTIGATION
(General Process Flow)
Secure
the area
Document
the facts:
hard
evidence,
witness
Ensure
immediate
medical
treatment
Gather
facts
about the
accident:
witnesses
Identify
the root
cause
(causal
factors)
Corrective
action
Follow-
up