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Accident Investigation

Help with Unit Assessment. APA Format Throughout to include Reference Page.

Unit Assessment

QUESTION 1

What steps must an organization take before an accident occurs to ensure it is prepared to conduct an effective accident investigation?
Your response must be at least 200 words in length.

QUESTION 2
Explain the four levels of accidents, providing an example of each. How are the categories different from each other?
Your response must be at least 200 words in length.
QUESTION 3
Why is it important to include near misses in the accident investigation process?
Your response must be at least 75 words in length.
QUESTION 4
How do accident investigations help an organization avoid spending money in the future?
Your response must be at least 75 words in length.
QUESTION 5
Describe two characteristics of an effective accident investigation process that you feel are particularly important. Briefly explain your choices.
Your response must be at least 75 words in length.
QUESTION 6
In addition to identifying accident causal factors, what other benefits does an effective accident investigation process provide to a safety and health program?
Your response must be at least 75 words in length.

Course Learning Outcomes for Unit I

Upon completion of this unit, students should be able to:

1. Identify key benefits of conducting accident investigations.

2. Describe the accident investigation process.
2.1 Explain the differences in accident categories.

Reading Assignment

Chapter 1:
What is an Accident?

Chapter 2:
An Accident Happens: What Do You Do? How Long Do You Do It?

Access the resource below, and read pp. 1-5:

Occupational Safety and Health Administration. (2015). Incident [accident] investigations: A guide for
employers. Retrieved from https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015

In order to access the resource below, you must first log into the myWaldorf Student Portal and access the
Business Source Complete database within the Waldorf Online Library. To reduce the amount of results you
receive, it is recommended to search for the article by title and author.

Boraiko, C., Beardsley, T., & Wright, E. (2008). Accident investigations. Professional Safety, 53(9), 26-29.

Unit Lesson

The goal of any safety and health program is to prevent injuries, illnesses, and property damage. When one
of these unwanted events happens, it is no surprise that it may be seen as a failure of the safety program, the
safety manager, or the organization itself. After all, accidents are preventable, right? Think about that for a
moment—do you believe that all accidents are preventable? Was there a time in your life where you tripped
over your own feet for no apparent reason and stumbled or fell? What could you have done to prevent this
from happening? Could you even foresee it happening? Is the solution to pay attention to where/how you are
walking? How would you do that? The reality is that you probably shrugged your shoulders and said, “Well,
that was a dumb thing to do,” and, most likely, you moved on without making any changes to the way you
walked. The reality is that something caused you to stumble and fall; you just cannot identify it (or you do not
want to take the time to identify it).

While it is likely true that all accidents are preventable, finding and correcting the causes is not easy. Some
might even say that accidents are inevitable. We know that we cannot reduce risk to zero, so there is always
a probability, however small, that an accident will happen.

Before we continue, perhaps we should look deeper into what we mean by an accident. A simple definition of
accident would be an unplanned series of events that result in injury, illness, or property damage (Oakley,
2012). Note that the definition does not indicate how serious the injury, illness, or property damage would be
but, rather, includes everything from minor bumps and bruises to fatalities. It includes one dollar’s worth of
property damage to millions of dollars’ worth of damage. The key to the definition is the word “unplanned.” We
could also use the words unexpected, undesired, or unwanted. Some organizations use terms like mishap or

UNIT I STUDY GUIDE

Introduction to Accident Investigation

https://www.osha.gov/dte/IncInvGuide4Empl_Dec2015

UNIT x STUDY GUIDE

Title

incident rather than accident, citing that the word accident implies that nothing can be done to correct the
problem—hence the saying, “it was just an accident.” Different terms are sometimes used to differentiate
injuries from property damage or to discern serious injuries from minor injuries. For consistency in this course,
we will be using the term “accident” for all of these unwanted events, regardless of severity.

Every accident provides an opportunity to identify conditions, processes, or practices that, if corrected, would
aid our overall accident prevention efforts. A well-designed accident investigation process ensures that
causes are identified without bias or blame, and effective measures to eliminate or control the causes are
identified and implemented.

Most safety practitioners divide accidents into categories based on severity. A typical list in order of
decreasing severity might resemble the following (Oakley, 2012):

 fatality or major property damage,

 major injury,

 minor injury, and

 near miss.

Accidents of lower severity are often considered precursors to accidents of greater severity, so there is a
prevention benefit to investigating all accidents. The severity can be used to determine the depth of the
investigation and who will conduct it. You probably would not want to expend the same resources
investigating a near miss as you would a fatality, but you also would not want to completely ignore the near
miss.

The effectiveness of any accident investigation depends on the knowledge and experience of the investigator.
Workplace accidents are, statistically speaking, a rare event, considering the millions of man hours worked
every year. Many safety professionals will never have the opportunity (or misfortune) to investigate a fatality.
This is a good thing, of course, but it creates a dilemma—how does one acquire the necessary knowledge
and experience? Certainly, this course will help, but it does not provide a cookbook or checklist solution.

Each accident scenario is different and can be approached from many different angles. An organization’s
safety culture, or lack of safety culture, may also affect how accidents are investigated. For some
organizations, a team approach to investigation may work best, especially for serious accidents. Supervisors
are often tasked with conducting investigations of accidents that happen within their work crews, but this
approach has some drawbacks. If accidents are rare events at the organizational level, they are even rarer at
the worksite level, so supervisors will get fewer opportunities to improve their skills. In addition, causal factors
may lead back to the supervisor, so there could be a significant bias in how the investigation is conducted.

Accident investigation is a reactive process that happens only after an adverse event, but that does not mean
the process cannot be planned in advance. Having a pre-accident plan that defines roles and responsibilities
in the accident investigation process will reduce the time needed to conduct the investigation and increase the
overall effectiveness. The plan should include the following:

 what accidents are to be investigated,

 who is responsible for the investigations,

 first responder actions,

 lead investigator actions,

 team member actions,

 accident analysis methods,

 documentation and reporting requirements, and

 timeline for the process.

Each individual with responsibilities in the accident investigation process should have a copy of the plan. The
first action to take when notified of an accident should be to refer to the plan. The U.S. Department of the
Interior’s Bureau of Land Management has an excellent example of a pre-accident plan at the following link:
BLM Pre-Accident Plan.

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&cad=rja&uact=8&ved=0CD0QFjAEahUKEwje9MWoweXHAhUTNYgKHV6FD00&url=http://www.ntc.blm.gov/krc/uploads/330/Pre-accident%20plan &usg=AFQjCNGxgieXo0lY4NVenC6NQDdbf3Np9Q&sig2=ql0gJIxK-8Kh

UNIT x STUDY GUIDE

Title
In the next unit, we will examine various theories of accident causation that can be used in the investigation
process. In subsequent units, will we outline the investigation process and use some real-world scenarios to
which the theories can be applied.

Reference

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications
(2nd ed.). Des Plaines, IL: American Society of Safety Engineers.

Suggested Reading

Access the Washington State Department of Labor and Industries at the link below, and download the
PowerPoint presentation on Accident Investigation Basics. This presentation will provide more information on
what an accident is, why they should be investigated, and how they should be investigated.

Washington State Department of Labor & Industries. (2009). Accident investigation basics. Retrieved from
http://www.lni.wa.gov/SAFETY/TRAININGPREVENTION/ONLINE/courseinfo.asp?P_ID=145

Reading this article will provide more insight into how accident investigations can be used as part of an overall
accident prevention program.

Cook, N. (2013). Accident investigation. Rospa Occupational Safety & Health Journal, 43(11), 13-18.

The United Kingdom’s Health and Safety Executive workbook on accident investigation is a good resource to
learn more about how investigations are handled outside of the United States:

Health and Safety Executive. (2004). Investigating accidents and incidents. Retrieved from
http://www.hse.gov.uk/pubns/hsg245

Learning Activities (Non-Graded)

After you complete your reading assignment from the course textbook, answer the review questions on pages
8 and 16. Answer the questions as completely as you can, using concepts and other information learned in
Chapters 1 and 2 of the textbook. Think about what you learned that might apply to your organization and
how it might help you make your organization more safety conscious.

The purpose of this activity is to help you study and learn the concepts taught in this unit. This is a non-
graded activity, so you will not submit it. If you experience difficulty in mastering any of the concepts, contact
your instructor for additional information and guidance.

Preserve/

Document

Scene

Collect
Information

Determine
Root
Causes

4
Implement
Corrective
Actions

United States Department of Labor

Occupational Safety and Health Administration

December 2015

TABLE OF CONTENTS

PURPOSE OF THE GUIDE – WHY INVESTIGATE? ………………………………………………………………………………….. 1

PRINCIPLES OF INCIDENT INVESTIGATIONS ……………………………………………………………………………………….. 1

The Language of Incident Investigations …………………………………………………………………………………….. 1

Investigate All Incidents, Including “Close Calls” ………………………………………………………………………….. 2

Investigate Programs, Not Behaviors ………………………………………………………………………………………….. 3

Focus on the Root Causes, Not Blame or Fault …………………………………………………………………………….. 4

ESTABLISH AN INCIDENT INVESTIGATION PROGRAM …………………………………………………………………………….. 4

CONDUCT INCIDENT INVESTIGATIONS – A FOUR‐STEP SYSTEMS APPROACH …………………………………………………. 6

Step 1. Preserve/Document the Scene ……………………………………………………………………………………….. 7

Step 2. COLLECT INFORMATION ………………………………………………………………………………………………………. 8

Step 3. DETERMINE ROOT CAUSES …………………………………………………………………………………………………… 9

Step 4. IMPLEMENT CORRECTIVE ACTIONS ……………………………………………………………………………………….. 10

RESOURCES …………………………………………………………………………………………………………………………. 12

REFERENCES ………………………………………………………………………………………………………………………… 14

APPENDIX A: INCIDENT INVESTIGATION FORM ……………………………………………………………………………………….

A‐1

APPENDIX B: INCIDENT INVESTIGATOR’S KIT ………………………………………………………………………………………….

B‐1

APPENDIX C: TIPS FOR VIDEO/PHOTO DOCUMENTATION …………………………………………………………………………..

C‐1

APPENDIX D: SKETCH THE SCENE TECHNIQUES ………………………………………………………………………………………

D‐1

APPENDIX E: COLLECT INFORMATION CHECKLIST …………………………………………………………………………………….

E‐1

APPENDIX F: SAMPLE QUESTIONS FOR IDENTIFYING INCIDENT ROOT CAUSES …………………………………………………..

F‐1

DISCLAIMER:
This guide was developed by OSHA’s Directorate of Training and Education and is intended to assist employers, workers, and others as they
strive to improve workplace health and safety. This guide is advisory in nature and informational in content. It is not a new standard or
regulation and does not create any new legal obligations or alter existing obligations created by OSHA standards or regulations or the
Occupational Safety and Health Act of 1970 (OSH Act). Pursuant to the OSH Act, employers must comply with safety and health standards and
regulations issued and enforced either by OSHA or by an OSHA‐approved state plan. In addition, the OSH Act’s General Duty Clause, Section
5(a)(1), requires employers to provide their workers with a workplace free from recognized hazards likely to cause death or serious physical
harm. Implementation of an incident investigation program in accordance with this guide can aid employers in their efforts to provide a safe
workplace.

Incident [Accident] Investigations: A Guide for Employers

December 2015 1

WHY INVESTIGATE?
Incident investigations
help employers:
 Prevent injuries and
illnesses
 Save lives
 Save money
 Demonstrate
commitment to health
and safety
 Promote positive
workplace morale
 Improve management

Your company experienced an incident that resulted (or almost resulted) in a worker

injury or illness…Now what?

As a responsible employer, you need to react quickly to the incident with a prescribed

investigation procedure for finding the root causes and implementing corrective actions.

Quick and planned actions demonstrate your company’s commitment to the safety and

health of your workers, and your willingness to improve your safety and health

management program to prevent future incidents.

PURPOSE OF THE GUIDE – WHY INVESTIGATE?

The purpose of this Incident Investigation Guide is to provide employers a systems approach to help

them identify and control the underlying or root causes of all incidents in order to prevent their

recurrence.

The Bureau of Labor Statistics reports that more than a dozen

workers died every day in American workplaces in 2013, and nearly 4

million Americans suffered a serious workplace injury. And tens of

thousands are sickened or die from diseases resulting from their

chronic exposures to toxic substances or stressful workplace

conditions. These events cause much suffering and great financial

loss to workers and their families, and also result in significant costs

to employers and to society as a whole. Many more “near misses” or

“close calls” also happen; these are incidents that could have caused

serious injury or illness but did not, often by sheer luck. Practically all

of these harmful incidents and close calls are preventable.

All incidents – regardless of size or impact – need to be investigated. The process helps employers look

beyond what happened to discover why it happened. This allows employers to identify and correct

shortcomings in their safety and health management programs.

OSHA created this Guide to help employers conduct workplace incident investigations using a four‐step

systems approach. This process is supported by an Incident Investigation Form, found in Appendix A,

which employers can use to be sure all details of the incident investigation are covered. Additional tools

to assist with the investigation process are found in Appendices B through F.

PRINCIPLES OF INCIDENT INVESTIGATIONS

The Language of Incident Investigations

Employers will notice this Guide uses the term “incident”, not “accident”, to describe a workplace event.

This is because the word “accident” has come to be considered as a random event that “oh, well, it just

Incident Investigations: A Guide for Employers

December 2015 2

happened” and could not have been prevented. However, the vast majority of harmful workplace

events do not “just happen.” On the contrary, most harmful workplace incidents are wholly preventable.

In short, the basic principle is that incidents do not have to occur; they can be prevented by addressing

the shortcomings in the programs that manage health and safety in the workplace.

The following are the key terms that are used throughout this guide:

 Incident: A work‐related event in which an injury or ill‐health (regardless of severity) or fatality
occurred, or could have occurred.

 Root Causes: The underlying reasons why unsafe conditions exist or if a procedure or safety rule
was not followed in a workplace. Root causes

generally reflect management, design, planning,

organizational or operational failings (e.g., a damaged guard had not been repaired; failure to

use the guard was routinely overlooked by supervisors to ensure the speed of production).

 Close Call: An incident that could have caused serious injury or illness but did not; also called a
“near miss.”

Investigating a worksite incident— a fatality, injury, illness, or close call— provides employers and

workers the opportunity to identify hazards in their operations and shortcomings in their safety and

health programs. Most importantly, it enables employers and workers to identify and implement the

corrective actions necessary to prevent future incidents.

Incident investigations that focus on identifying and correcting root causes, not on finding fault or

blame, also improve workplace morale and increase productivity, by demonstrating an employer’s

commitment to a safe and healthful workplace.

Investigate All Incidents, Including “Close Calls”

OSHA strongly encourages employers to investigate all workplace incidents—both those that cause

harm and the “close calls” that could have caused harm under slightly different circumstances.

Investigations are incident‐prevention tools and should be an integral part of an occupational safety and

health management program in a workplace. Such a program is a structured way to identify and control

the hazards in a workplace, and should emphasize continual improvement in health and safety

performance. When done correctly, an effective incident investigation uncovers the root causes of the

incident or ‘close call’ that were the underlying factors. Most important, investigations can prevent

future incidents if appropriate actions are taken to correct the root causes discovered by the

investigation.

Effective incident investigations are the right thing to do, not only because they help employers prevent

future incidents, but because they help employers to identify hazards in their workplaces and

shortcomings in their safety and health management programs. Investigations also save employers

money, because incidents are far more costly than most people realize. The National Safety Council

estimates that, on the average, preventing a workplace injury can save $39,000, and preventing a

fatality more than $1.4 million, not to mention the suffering of the workers and their families. The more

obvious financial costs are those related to workers’ compensation claims, but these are only the direct

Incident Investigations: A Guide for Employers

December 2015 3

“One central principle…is the

need to consider the

organizational factors that

create the preconditions for

errors as well as the

immediate causes.”

‐Sidney Dekker (2006)

costs of incidents. The indirect costs are less obvious, but very commonly greater, and include lost

production, schedule delays, increased administrative time (for emergency response, investigations,

claim processing and others), lower morale, training of new or temporary personnel, increased

absenteeism, and damaged customer relations and corporate reputation.

Investigate Programs, Not Behaviors

As stated previously, incident investigations that follow a systems approach are based on the principle

that the root causes of an incident can be traced back to failures of the programs that manage safety

and health in the workplace. This approach is fundamentally different from a behavioral safety

approach, which incorrectly assumes that the majority of workplace incidents are simply the result of

“human error” or “behavioral” failures. Under a systems approach, one would not conclude that

carelessness or failure to follow a procedure alone was the cause of an incident. To do so fails to

discover the underlying or root causes of the incident, and therefore fails to identify the systemic

changes and measures needed to prevent future incidents. When a shortcoming is identified, it is

important to ask why it existed and why it was not previously addressed.

For example:

 If a procedure or safety rule was not followed, why was the
procedure or rule not followed?

 Did production pressures play a role, and, if so, why were
production pressures permitted to jeopardize safety?

 Was the procedure out‐of‐date or safety training inadequate?
If so, why had the problem not been previously identified, or, if

it had been identified, why had it not

been addressed?

A systems approach always looks beyond the immediate causes of the incident. If a worker suffers an

amputation on a table saw, the investigator would ask questions such as:

 Was the machine adequately guarded? If not, why not?
 Was the guard damaged or non‐functional? If so, why hadn’t it been fixed?
 Did the guard design get in the way of the work?
 Had the employee been trained properly in the procedures to do the job safely?

In a systems approach, investigations do not focus primarily on the behaviors of the workers closest to

the incidents, but on the factors [program deficiencies] that prompted such behaviors. The goal is to

change the conditions under which people work by eliminating or reducing the factors that create

unsafe conditions. This is typically done by implementing adequate barriers and safeguards against the

factors that cause unsafe conditions or actions.

Root causes often involve multiple deficiencies in the safety and health management programs. These

deficiencies may exist, for example, in areas such as workplace design, cultural and organizational

factors, equipment maintenance and other technical matters, operating systems and procedures,

Incident Investigations: A Guide for Employers

December 2015 4

staffing, supervision, training, and others. Eliminating the immediate causes is like cutting weeds, while

eliminating the root causes is equivalent to pulling out the roots so that the weed cannot grow back.

Focus on the Root Causes, Not Blame or Fault

A successful incident investigation must always focus on discovering

the root causes. If an investigation is focused on finding fault, it will

always stop short of discovering the root causes. It is essential to

discover and correct all the factors contributing to an incident, which

nearly always involve equipment, procedural, training, and other safety

and health program deficiencies.

Addressing underlying or root causes is necessary to truly understand

why an incident occurred, to develop truly effective corrective actions, and to minimize or eliminate

serious consequences from similar future incidents.

Moreover, if an investigation is understood to be a search for “someone to blame,” both management

and labor will be reluctant to participate in an open and forthright manner. Workers will be afraid of

retaliation and management will be concerned about recognizing system flaws because of potential

legal and financial liabilities.

Investigations that focus on identifying and correcting the real
underlying causes not only prevent future incidents, but can also
improve workplace morale and productivity, by demonstrating an

employer’s commitment to a safe and healthful workplace.

ESTABLISH AN INCIDENT INVESTIGATION PROGRAM

When a serious incident occurs in the workplace, everyone will be busy

dealing with the emergency at hand. Therefore, it is important to be

prepared to investigate incidents before they occur. An incident

investigation program should include a clearly stated, easy‐to‐follow

written plan to include guidelines for:

 How and when management is to be notified of the incident
 Notifying OSHA, which must comply with reporting

requirements that are:

o All work‐related fatalities within 8 hours
o All work‐related inpatient hospitalizations, all

amputations, and all losses of an eye within 24 hours

 Who is authorized to notify outside agencies (i.e., fire, police,
etc.)

 Who will conduct investigations and what training they should have received
 Timetables for completing the investigation and developing/implementing recommendations
 Who will receive investigation recommendations

Effective Incident
Investigation Programs:

 Clearly state easy‐to‐ follow
written procedures

 Provide for personnel to be
trained on incident
investigation and company
procedures

 Offer collaboration
between workers, worker
representatives, and
management

 Focus on identifying root
cause(s), not on
establishing fault

 Emphasize correcting root
cause(s)

 Implement timely
corrective actions based on
investigation findings

 Provide for an annual
program review to identify
and correct program
deficiencies and identify
incident trends

Eliminating the immediate
causes is like cutting weeds,
while eliminating the root

causes is equivalent to pulling
out the roots so that the weed

cannot grow back.

Incident Investigations: A Guide for Employers

December 2015 5

 Who will be responsible for implementing corrective actions

Although a supervisor sometimes conducts incident investigations, to be most effective investigations

should be conducted by a team in which managers and employees work together, since each brings

different knowledge, understanding, and perspectives to an investigation. Working together will also

encourage all parties to “own” the conclusions and recommendations and to jointly ensure that

corrective actions are implemented in a timely manner.

Where the incident involves a temporary worker provided by a staffing agency, both the staffing agency

and the host employer should conduct an incident investigation. Where the incident involves a multi‐

employer worksite, the incident investigation should be shared with each employer at the worksite. It is

a fundamental principal that temporary workers are entitled to the same protections under the OSH Act

as all other covered workers. Therefore, if a temporary worker is injured and the host employer knows

about it, the staffing agency should be informed promptly, so the staffing agency knows about the

hazards facing its workers. Equally, if a staffing agency learns of an injury, it should inform the host

employer promptly so that future injuries might be prevented, and the case is recorded appropriately.

Both the host employer and staffing agency should track and where possible, investigate the cause of

workplace injuries.

As we now know, investigations are to focus on identifying root causes, not establishing fault. Employers

can reinforce a systems approach by stressing it in their written program as well as their investigation

procedures. Identifying and correcting root causes should always be the key objective.

Incident Investigations: A Guide for Employers

December 2015 6

“Human error is not the

conclusion of an investigation.

It is the starting point.”

‐Sidney Dekker (2006)

“Errors are seen as

consequences rather than

causes”

‐James Reason (2000)

CONDUCT INCIDENT INVESTIGATIONS – A FOUR‐STEP SYSTEMS APPROACH

One of the biggest challenges facing the investigators is to

determine what is relevant to what happened, how it happened,

and especially why it happened. This involves conducting a systems

approach incident investigation

that focuses on the root causes

of the incident to really help prevent them from happening again.

This section of the guide assists the employer to implement a four‐

step approach to conduct a successful incident investigation. Included

is a set of appendices that can serve as tools for employers to use when conducting investigations. They

are:

 Appendix A: Incident Investigation Form – previously introduced; will be used to walk the
employer through the four incident investigation steps

 Appendix B: Incident Investigator’s Kit – lists the equipment recommended to have ready at all
times to be prepared to conduct the investigation

 Appendix C: Tips for Video/Photo Documentation
 Appendix D: Sketch the Scene Techniques
 Appendix E: Collect Information Checklist
 Appendix F: Sample Questions for Identifying Incident Root Causes – Sample questions to ask in

a systems approach process

The four‐step systems approach in this guide is supported by

the Incident Investigation Form [Appendix A] and other tools.

This approach will assist employers through the incident

investigation and help to ensure the implementation of

corrective measures based on the findings.

The steps are:

1. PRESERVE/DOCUMENT THE SCENE [see Appendices A, B, C
and D]

2. COLLECT INFORMATION [see Appendix E]
3. DETERMINE THE ROOT CAUSES – All the ‘Whys’ the incident occurred [see Appendix F]
4. IMPLEMENT CORRECTIVE ACTIONS –Prevent Future Incidents

Safety First
Before investigating, all emergency response needs must be completed and the incident site must be

safe and secure for entry and investigation.

Incident Investigations: A Guide for Employers

December 2015 7

With an effective safety and health management program in place, all the involved parties are aware of

the roles they play during the investigation. This helps the transition from emergency response and site

safety to preserving the scene and documenting the

incident.

Now is the time an employer’s incident investigation program’s written plan goes into effect and the

incident investigation begins.

Step 1. Preserve/Document the Scene

Preserve the Scene:

Preserve the scene to prevent material evidence from being removed or altered; investigators can use

cones, tape, and/or guards.

Document the Scene:

Document the incident facts such as the date of the investigation and who is investigating. Essential to

documenting the scene is capturing the injured employee’s name, injury description, whether they are

temporary or permanent, and the date and location of the incident. Investigators can also document the

scene by video recording, photogaphing and sketching.

Tools provided to help with Step 1 are:

 Appendix A: Incident Investigation Form [applicable sections pictured at all steps]
 Appendix B: Incident Investigator’s Kit
 Appendix C: Tips for Video/Photo Documentation
 Appendix D: Sketch the Scene Techniques

Incident Investigations: A Guide for Employers

December 2015 8

Step 2. COLLECT INFORMATION

Incident information is collected through interviews, document reviews and other means. Appendix E

provides a checklist to use to help ensure all information pertinent to the incident is collected.

In addition to interviews, investigators may find other sources of useful information. These include:

 Equipment manuals
 Industry guidance documents
 Company policies and records
 Maintenance schedules, records and logs
 Training records (including communication to employees)
 Audit and follow‐up reports
 Enforcement policies and records
 Previous corrective action recommendations

Interviews can often yield detailed, useful

information about an incident. Since memories fade,

interviews must be conducted as promptly as

possible: preferably as soon as things have settled

down a bit and the site is both secure and safe. The

sooner a witness is interviewed, the more accurate

and candid his/her statement will be.

An incident investigation always involves interviewing

and possibly re‐interviewing some of the same or

new witnesses as more information becomes available, up to and including the highest levels of

management. Carefully question witnesses to solicit as much information as possible related to the

incident.

Since some questions will need to be designed around the interviewee, each interview will be a unique

experience. When interviewing injured workers and witnesses it is crucial to reduce their possible fear

and anxiety, and to develop a good rapport. When conducting interviews, investigators should:

 Conduct the interview in the language of the employee/interviewee; use a translator if needed
 Clearly state that the purpose of the investigation and interview is fact‐finding, not fault‐finding
 Emphasize that the goal is to learn how to prevent future incidents by discovering the root

causes of what occurred

 Establish a climate of cooperation, and avoid anything that may be perceived as intimidating or
in search of someone to blame for the incident

 Let employee know that they can have an employee representative (e.g., labor representative),
if available/appropriate

 Ask the individuals to recount their version of what happened
 Not interrupt the interviewee

Incident Investigations: A Guide for Employers

December 2015 9

 Take notes and/or record the responses; interviewee must give permission prior to being
recorded

 Have blank paper and or sketch available for interviewee to use for reference
 Ask clarifying questions to fill in missing information
 Reflect back to the interviewees the factual information obtained; correct any inconsistencies
 Ask the individuals what they think could have prevented the incident, focusing on the

conditions and events preceding the injury

Step 3. DETERMINE ROOT CAUSES

The root causes of an incident are exactly what the

term implies: The underlying reasons why the

incident occurred in a workplace. Root causes

generally reflect management, design, planning,

organizational and/or operational failings (e.g.,

employees were not trained adequately; a

damaged guard had not been repaired).

 Determining the root cause is the result of persistently asking “why”
 Determining the root cause is the most effective way to ensure the incident does not happen again

Finding the root causes goes beyond the obvious proximate or immediate factors; it is a deeper

evaluation of the incident. This requires persistent “digging”, typically by asking “Why” repeatedly.

Conclusions such as “worker was careless” or “employee did not follow safety procedures” don’t get at

the root causes of the incident. To avoid these incomplete and misleading conclusions in the

investigative process, investigators need to continue to ask “why?” as in, “Why did the employee not

follow safety procedures?” If the answer is “the employee was in a hurry to complete the task and the

safety procedures slowed down the work”, than ask “Why was the employee in a hurry?” The more and

deeper “why?” questions asked, the more contributing factors are discovered and the closer the

investigator gets to the root causes. If a procedure or safety rule was not followed, why was the

procedure or rule not followed? Did production pressures play a role, and, if so, why were production

pressures permitted to jeopardize safety? Was the procedure out‐of‐date or safety training inadequate?

If so, why had the problem not been previously identified, or, if it had been identified, why had it not

been addressed?

It cannot be stressed enough that a successful incident investigation must always focus on discovering

the root causes. Investigations are not effective if they are focused on finding fault or blame. If an

investigation is focused on finding fault, it will always stop short of discovering the root causes, because

it will stop at the initial incident without discovering their underlying causes. The main goal must always

be to understand how and why the existing barriers against the hazards failed or proved insufficient, not

to find someone to blame.

Incident Investigations: A Guide for Employers

December 2015 10

The questions listed below are examples of inquiries that an investigator may pursue to identify

contributing factors that, in turn, can lead to root causes:

 If a procedure or safety rule was not followed, why was the procedure or rule not followed?
Was the procedure out of date or safety training inadequate? Was there anything encouraging

deviation from job procedures such as incentives or speed of completion? If so, why had the

problem not been identified or addressed before?

 Was the machinery or equipment damaged or fail to operate properly? If so, why?
 Was a hazardous condition a contributing factor? If so, why was it present? (e.g., defects in

equipment/tools/materials, unsafe condition previously identified but not corrected,

inadequate equipment inspections, incorrect equipment used or provided, improper substitute

equipment used, poor design or quality of work environment or equipment)

 Was the location of equipment/materials/worker(s) a contributing factor? If so, why? (e.g.,
employee not supposed to be there, insufficient workspace, “error‐prone” procedures or

workspace design)

 Was lack of personal protective equipment (PPE) or emergency equipment a contributing
factor? If so why? (e.g., PPE incorrectly specified for job/task, inadequate PPE, PPE not used at

all or used incorrectly, emergency equipment not specified, available, properly used, or did not

function as intended)

 Was a management program defect a contributing factor? If so, why? (e.g., a culture of
improvisation to sustain production goals, failure of supervisor to detect or report hazardous

condition or deviation from job procedure, supervisor accountability not understood, supervisor

or worker inadequately trained, failures to initiate corrective actions recommended earlier)

Additional examples of questions to ask to get to the root causes are listed in Appendix F.

Step 4. IMPLEMENT CORRECTIVE ACTIONS

The investigation is not complete until corrective actions are implemented that address the root causes

of the incident. Implementation should entail

program level improvements and should be

supported by senior management.

Note that corrective actions may be of limited

preventive value if they do not address the

root causes of the incident. Throughout the

workplace, the findings and how they are

presented will shape perceptions and

subsequent corrective actions. Superficial

conclusions such as “Bob should have used

common sense,” and weak corrective actions such as “Employees must remember to wear PPE”, are

unlikely to improve the safety culture or to prevent future incidents.

Incident Investigations: A Guide for Employers

December 2015 11

In planning corrective actions and how best to implement them, employers may find that some root

causes will take time and perseverance to fix. Persisting in implementing substantive corrective actions,

however, will not only reduce the risk of future incidents but also improve the company’s safety, morale

and its bottom line.

Specific corrective actions address root causes directly; however, some corrective actions can be

general, across‐the‐board improvements to the workplace safety environment. Sample global corrective

actions to consider are:

 Strengthening/developing a written comprehensive safety and health management program
 Revising safety policies to clearly establish responsibility and accountability
 Revising purchasing and/or contracting policies to include safety considerations
 Changing safety inspection process to include line employees along with management

representatives

Implementing a systems approach will help ensure all incident investigations are successful.

Thank you for your commitment to the safety and health of the American workforce!

Incident [Accident] Investigations: A Guide for Employers

December 2015 12

RESOURCES

OSHA Training Institute Education Centers: http://www.osha.gov/otiec

The OSHA Training Institute (OTI) Education Centers are a national

network of non‐profit organizations authorized by OSHA to deliver

occupational safety and health training to public and private sector

workers, supervisors and employers on behalf of OSHA. Relevant

courses are:

 OSHA #7500 Introduction to Safety and Health Management
Description: This course covers the effective implementation of a company’s safety and health

management system. The course addresses the four core elements of an effective safety and health

management system and those central issues that are critical to each element’s proper management.

This course is an interactive training session focusing on class discussion and workshops. Upon course

completion students will have the ability to evaluate, develop, and implement an effective safety and

health management system for their company. Minimum student contact hours: 5.5

 OSHA #7505 Introduction to Incident [Accident] Investigation
Description: This course covers an introduction to basic incident investigation procedures and describes

analysis techniques. Course topics include reasons for conducting incident investigations, employer

responsibilities related to workplace incident investigations, and a four‐step incident investigation

procedure. The target audience is the employer, manager, employee or employee representative who is

involved in conducting incident and/or near‐miss or close call investigations. Upon course completion

students will have the basic skills necessary to conduct an effective incident investigation at the

workplace. Minimum student contact hours: 7.5

OSHA Website: www.osha.gov

Incident Investigation Webpage

http://www.osha.gov/dcsp/products/topics/incidentinvesti

gation/index.html

Injury and Illness Prevention Programs Webpage

http://www.osha.gov/dsg/topics/safetyhealth/index.html

 This webpage provides information relevant to Injury and Illness Prevention Programs in the
workplace. To learn more about Injury and Illness Prevention Programs, refer to:

http://www.osha.gov/Publications/OSHA3665 and

http://www.osha.gov/dsg/topics/safetyhealth/OSHAwhite‐paper‐january2012sm

Incident Investigations: A Guide for Employers

December 2015 13

OSHA’s “$afety Pays” program

 This online tool can help employers assess the impact of
occupational injuries and illnesses on their profitability. To

learn more about OSHA’s “$afety Pays” program, visit

http://www.osha.gov/dcsp/smallbusiness/safetypays/

Other: UK Health and Safety Executive

Investigating Accidents and Incidents: A Workbook for employers, unions, safety representatives,

and safety professionals. 2004. http://www.hse.gov.uk/pubns/hsg245

Incident Investigations: A Guide for Employers

December 2015 14

REFERENCES

 Center for Chemical Process Safety publication, Guidelines for Preventing Human Error in
Process Safety, Center for Chemical Process Safety (CCPS), 1994.

 Conklin, T., Pre‐Accident Investigations: An Introduction to Organizational Safety, Ashgate
Publishing Company; 1 edition (September 28, 2012), ISBN‐10: 1409447820, ISBN‐13: 978‐

1409447825

 Dekker, S., The Field Guide to Understanding Human Error, Ashgate Publishing Company; 1
edition (June 30, 2006), English, ISBN‐10: 0754648265; ISBN‐13: 978‐0754648260

 National Safety Council, http://www.nsc.org/pages/home.aspx
 Reason, J., Human error: models and management, BMJ 2000;320:768

Incident Investigations: A Guide for Employers
A‐1

APPENDIX A: INCIDENT INVESTIGATION FORM
Form Section Systems Approach

Section A: Information Step 1

Company Name: _______________________________________ Date: ____________

Investigator (or) Team Name (s) and Titles:

Name Title

_________________________________ _____________________________________

Section B: Incident Description/Injury Information Step 1 and Step 2

1) Name and Age of Injured Employee: _______________________________________________

Employee’s first language: ________________________________________________________

Employees Job Title: _____________________________________________________________

Job at time of injury: ____________________________________________________________

Type of employment:  Full‐time  Part‐time Temporary  Seasonal  Other: ________

Length of time with Company: ____________________________________________________

Length in current position at the time of the incident: _________________________________

Description and severity of injury: _________________________________________________

2) Date and time of incident: _______________________________________________________
3) Location of Incident: ____________________________________________________________

NOTE: Items 4, 5, and 6 are used for both Step 1 and Step 2

4) Detailed description of incident: Include relevant events leading up to, during, and after the
incident. (It is preferred that the information is provided by the injured employee.)

__________________________________________________________________________________

Use additional pages if needed

Incident Investigations: A Guide for Employers

A‐2

5) Description of incident from eye witnesses, including relevant events leading up to, during and
after the incident. Include names of persons interviewed, job titles and date/time of interviews.

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

__________________________________________________________________________________

Use additional pages if needed

6) Description of incident from additional employees with knowledge, including relevant events
leading up to, during and after the incident. Include names of persons interviewed, job titles and

date/time of interviews.

Incident Investigations: A Guide for Employers

A‐3

Section C: Identify the Root Causes: What Caused or Allowed the Incident to Happen? Step 3

The Root Causes are the underlying reasons the incident occurred, and are the factors that need to

be addressed to prevent future incidents. If safety procedures were not being followed, why were

they not being followed? If a machine was faulty or a safety device failed, why did it fail? It is

common to find factors that contributed to the incident in several of these areas:

equipment/machinery, tools, procedures, training or lack of training, and work environment. If

these factors are identified, you must determine why these factors were not addressed before the

incident.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Use additional pages if needed

Section D: Recommended Corrective Actions to Prevent Future Incidents Step 4

Section E: Corrective Actions Taken/ Root Causes Addressed Step 4

Incident Investigations: A Guide for Employers
B‐1

APPENDIX B: INCIDENT INVESTIGATOR’S KIT

Sample list of items to use to conduct the investigation:
 Camera

 Charged Batteries (for phones, cameras, equipment, etc.)

 Video / Audio recorder

 Measuring devices in various sizes

 Leveling rod

 Clipboard and writing pad

 Pens, pencils, markers

 Graph paper

 Straight‐edge ruler (Can be used as a scale reference in photos)

 Incident investigation forms

 Flashlight

 Strings, stakes, warning tape

 Photo marking cones

 Personal protective equipment: Gloves, hat, eyewear, ear plugs, face mask, etc.

 Magnifying glass

 High visibility plastic tapes to mark off area

 First aid kit

 Latex gloves

 Sampling [holding] containers with seals (Various types: bags, jars, containers, etc.)

 Identification tags

 Variety of tape: Scotch, masking, duct

 Compass

 Carpenters ruler

 Hammer

 Paint stick (yellow/black)

 Chalk (yellow/white)

 Protractor

 Clinometer

Incident Investigations: A Guide for Employers
C‐1

APPENDIX C: TIPS FOR VIDEO/PHOTO DOCUMENTATION

Note: Interviewees must be aware that they are being video recorded and/or photographed. It
is recommended that investigators obtain permission from the interviewee prior to the
interview.

Tips for Video Documentation:

 Video the scene as soon as possible; doing this early on will pick up details that may
later add valuable information to the investigation

 Scan slowly 360 degrees left and right to establish location
 Narrate what is being taped, and describe objects, size, direction, location, etc.
 If vehicles were involved, record direction of travel, going and coming

Tips for Photograph Documentation:

 Always make notes about the photos taken
 Start by taking distance shots first then move in to take closer photos of the scene
 Take photos at different angles (from above, 360 degrees of scene, left, right, rear)

to show the relationship of objects and minute and/or transient details such as ends
of broken rope, defective tools, drugs, wet areas, or containers

 Take panoramic photos to help present the entire scene, top to bottom ‐ side to side
 Take notes on each photo; these should be included in the incident investigation file

with the photos
 Identify and document the photo type, date/time/location taken, subject, weather

conditions, measurements, etc.
 Place an item of known dimensions in the photo to add a frame of reference and

scale (e.g., a penny, a pack of cards)
 Identify the person taking the photo
 Indicate the locations where photos were taken on sketches (See Appendix D)

Incident Investigations: A Guide for Employers
D‐1

APPENDIX D: SKETCH THE SCENE TECHNIQUES

1. Make sketches large; at least 8” x 10” and clear, be sure to print legibly
2. Include “Incident Details” (i.e., time, date, injured, location, conditions, etc.)
3. Include measurements (i.e. distances, heights, lengths, etc.) and use permanent points (e.g.,

telephone pole, building) to clearly present the measurements
4. Indicate directions – N= North; E= East; W= West; S= South
5. Make notes on sketch to provide additional information such as the photo location and/or

where people were at the time of the incident
Note: The sketch can be used during interviews to help interviewees identify their location before,
during or after the incident

Incident Investigations: A Guide for Employers
E‐1

APPENDIX E: COLLECT INFORMATION CHECKLIST
Investigators should be sure their investigation answers the following questions:

WHO? WHERE?

 Who was injured?
 Who saw the incident?
 Who was working with the employee?
 Who had instructed/assigned the employee?
 Who else was involved?
 Who else can help prevent recurrence?

 Where did the incident occur?
 Where was the employee at the time?
 Where was the supervisor at the time?
 Where were fellow workers at the time?
 Where were other people who were involved at

the time?
 Where were witnesses when incident occurred?

WHAT? WHY?

 What was the incident?
 What was the injury?
 What was the employee doing?
 What had the employee been told to do?
 What tools was the employee using?
 What machine was involved?
 What operation was the employee performing?
 What instructions had the employee been given?
 What specific precautions were necessary?
 What specific precautions was the employee given?
 What protective equipment should have been

used?
 What protective equipment was the employee

using?
 What had other persons done that contributed to

the incident?
 What problem or questions did the employee

encounter?
 What did the employee or witnesses do when the

incident occurred?
 What extenuating circumstances were involved?
 What did the employee or witnesses see?
 What will be done to prevent recurrence?
 What safety rules were violated?
 What new rules are needed?

 Why was the employee injured?
 Why and what did the employee do?
 Why and what did the other person do?
 Why wasn’t protective equipment used?
 Why weren’t specific instructions given to the

employee?
 Why was the employee in the position?
 Why was the employee using the tools or machine?
 Why didn’t the employee check with the supervisor

when the employee noted things weren’t as they
should be?

 Why did the employee continue working under the
circumstances?

 Why wasn’t the supervisor there at the time?

WHEN? HOW?

 When did the incident occur?
 When did the employee start on that job?
 When was the employee assigned on the job?
 When were the hazards pointed out to the

employee?
 When was the employee’s supervisor last check on

job progress?
 When did the employee first sense something was

wrong?

 How did the employee get injured?
 How could the employee have avoided it?
 How could fellow workers have avoided it?
 How could supervisor have prevented it ‐ could it

be prevented?

Incident Investigations: A Guide for Employers
F‐1

APPENDIX F: SAMPLE QUESTIONS FOR IDENTIFYING INCIDENT ROOT CAUSES
QUESTIONS

1. Did a written or well‐established procedure exist for employees to follow?
2. Did job procedures or standards properly identify the potential hazards of job performance?
3. Were there any hazardous environmental conditions that may have contributed to the incident?
4. Were the hazardous environmental conditions in the work area recognized by employees or

supervisors?

5. Were any actions taken by employees, supervisors, or both to eliminate or control environmental
hazards?

6. Were employees trained to deal with any hazardous environmental conditions that could arise?
7. Was sufficient space provided to accomplish the job task?
8. Was there adequate lighting to properly perform all the assigned tasks associated with the job?
9. Were employees familiar with job procedures?
10. Was there any deviation from the established job procedures?
11. Were the proper equipment and tools available and being used for the job?
12. Did any mental or physical conditions prevent the employee(s) from properly performing their jobs?
13. Were there any tasks in the job considered more demanding or difficult than usual (e.g., strenuous

activities, excessive concentration required, etc.)?

14. Was there anything different or unusual from normal operations? (e.g., different parts, new or
different chemicals used, recent adjustments/maintenance/cleaning on equipment)

15. Was the proper personal protective equipment specified for the job or task?
16. Were employees trained in the proper use of any personal protective equipment?
17. Did the employees use the prescribed personal protective equipment?
18. Was personal protective equipment damaged or not properly functioning?
19. Were employees trained and familiar with the proper emergency procedures, including the use of

any special emergency equipment and was it available?

20. Was there any indication of misuse or abuse of equipment and/or materials at the incident site?
21. Is there any history of equipment failure, were all safety alerts and safeguards operational and was

the equipment functioning properly?

22. If applicable, are all employee certification and training records current and up‐to‐date?
23. Was there any shortage of personnel on the day of the incident?
24. Did supervisors detect, anticipate, or report an unsafe or hazardous condition?
25. Did supervisors recognize deviations from the normal job procedure?
26. Did supervisors and employees participate in job review sessions, especially for those jobs

performed on an infrequent basis?

27. Were supervisors made aware of their responsibilities for the safety of their work areas and
employees?

28. Were supervisors properly trained in the principles of incident prevention?
29. Was there any history of personnel problems or any conflicts with or between supervisors and

employees or between employees themselves?

30. Did supervisors conduct regular safety meetings with their employees?
31. Were the topics discussed and actions taken during the safety meetings recorded in the minutes?
32. Were the proper resources (i.e., equipment, tools, materials, etc.) required to perform the job or

task readily available and in proper condition?

33. Did supervisors ensure employees were trained and proficient before assigning them to their jobs?

Part I

INTRODUCTION TO THE
ACCIDENT SEQUENCE

Accidents do not just happen-they are caused, and the key to accident
investigation is to find the causes. The first step in finding the cause of an
accident is to examine the sequence of events that led up to it. Discovering
this sequence is the goal of many of the analytical techniques discussed later
in the book. This part of the book includes many theories that have been
developed to determine how accidents occur. Many have been and continue
to be used, and many others have been disproven. This book will mention
many theories, but will focus on those that are based on the accident sequence.

The objective of this book is to present an analytical approach to
accident investigations-gathering evidence, using analytical techniques and
~e analytical process to determine the accident sequence, and using this
Info .

rmatton to discover the causes and to recommend changes to prevent
future accidents.

Ob· Jectives for Part I:

• Dnderstand that accidents have a sequence of events and be able to
deter · thi mine · s sequence.

• Be familiar with several accident causation theories and know how each
applies to the accident sequence.

Part I: Introduction to the Accident Sequence

• Be aware that most accidents have multiple causes.

• Be able to break down accidents and use an analytical approach to
investigate them.

CHAPTER1

What is An Accident?

Nobody wants to answer the phone and hear the words, “There’s been
an accident.” But what is an accident? There are many different ways in which
that term is to describe something that should not have occurred. A child
would say, “It was an accident. I didn’t mean to break that window with my
ball.” However, in the realm of investigations, an accident is an occurrence in a
sequence of events that produces unintended injury, death,

or property damage.

Definition of Terms

Accident

There are many definitions for accident. Most books agree that an accident
is an undesired event that causes injury or property damage (Bird and
Germain 1985). Many companies use the term incident rather than accident
because accident implies human error, whereas, according to the National
Safety Council, “an incident is an unintentional event that may cause personal
harm or other damage” (National Safety Council 2009, viii). The definition of
accident that best captures the analytical approach to accident investigation is:
“Th at occurrence in the sequence of events that produces unintended injury,

Part I: Introduction to the Accident Sequence

death, or property damage” (National Safety Council 2009, viii). Accidents
are sequences of events. There are normal (positive) sequences where there
is no accident and accident sequences, also called negative sequences. An
accident is a result of a negative sequence of events. These definitions and
others are listed in Exhibit 1.1.

Near Miss

The difference between an accident and a near miss is usually luck or chance.
A near miss is an occurrence in a sequence of events that had the potential
to produce injury, death, or property damage but did not. Near misses can
and should be investigated the same way accidents are.

Accident Investigation

An accident investigation is a structured process that attempts to uncover
the sequence of events that produced or had the potential to produce
injury, death, or property damage so that causal factors can be determined
and corrective actions can be taken. Any occurrence that has a sequence
of events can be investigated by analytical techniques-first-aid cases,
OSHA-recordable injuries or illnesses, fatalities, property damage, or near
misses. The steps in an accident investigation are: analyzing the facts,
developing an accident sequence, finding the causes, and recommending
corrective action.

The next definitions have to do with the accident itself. Safety professionals
use various terms for the basic terminology of the profession (Sorrell 1998);
this book simplifies the definitions.

Causal Factors

The causes of the accident are called the causal factors. A causal factor is
an event or circumstance that produced an accident. Other books may use
the term root cause to mean something similar. Causal factors can be at the
basic (worker or equipment) level, the intermediate (supervisory) level, and
the upper management level. The causal factors of an accident answer the
question, ”What happened?” After causal factors are determined through an

Chapter 1: What is An Accident?

analytical process, con-ective actions are developed to prevent similar types of
accidents.

Corrective Actions

Corrective actions are the actions taken to prevent recurrence of the accident.
Causal factors link to corrective actions to address all levels of causes and
accountability ( see Exhibit 1.1, Definitions).

Exhibit 1.1
DEFINITIONS

Accident-The occurrence in a sequence of events that produces unintended
injury, death, or property damage.

Incident-An unintentional event that may cause personal harm or other damage.

Near Miss-An occurrence in a sequence of events that had the potential to
produce injury, death, or property damage but did not.

Accident Investigation-A structured process of uncovering the sequence of
events that produced or had the potential to produce injury, death, or property
damage to determine the causal factors and corrective actions.

Causal Factors-Events and circumstances that produced the accident. Causal
factors incorporate “root causes,” “basic causes,” “immediate causes,” lower
level causes, upper level causes, and management causes. When discovering
causal factors, it is important to analyze all causes at all levels.

Corrective Actions-The actions taken to prevent recurrence of the accident.
Corrective actions are the “fixes” to prevent future accidents. These fixes should
be performed at the appropriate level.

Accidents versus Incidents

There has been much debate from safety professionals on the relevance of the
terms accident and incident. Many companies use the term incident to lessen
the impact of human error or fault in the meaning. Many companies and even
governmental agencies have switched to the term incident and thus perform

Part I: Introduction to the Accident Sequence

incident investigations. Other companies use the concept of an incident as
more of property or equipment damage. There is not much use in trying to
contemplate the differences, and just embrace whichever one works for your

company or industry.

The same accident investigation processes and analytical techniques can
be used no matter what term is used to describe the unintended injury, death,

or property damage.

Near Misses
How do near misses fit into the accident investigation process? A near miss is
an occurrence in a sequence of events that had the potential to produce injury,
death, or property damage but did not. In aeronautical terms, when airplanes
almost collide or fly too close to each other, then it is a near miss or you could
say a near hit-they nearly hit each other. In these instances you want a far hit.

The concept of a near miss is widely confused among employees and
these instances usually do not get properly reported. The best concept that
can be used to describe a near miss is when someone sees you do something
and says, ”You were lucky,” or ‘”( ou dodged a bullet on that occasion. That
almost got you that time.” These are all instances that resulted in a near miss.

What is the difference in an accident and a near miss? Again, sometimes the
only difference in a near miss and an accident is a matter of inches or seconds
and luck or chance. If the blade was one inch to the left, then it would have
been a fatality. According to the definitions, the only difference between these
two terms is the severity that one was hurt, or damage was done. The moSt

important issue is to determine the potential of injury, death, or property damage
for these instances. The biggest problem with near misses is the procedure for
how these near misses are reported. If near misses are not reported, then they
cannot be investigated; thus, the potential for an accident still exists.

These near misses are extremely important to understand and ensure
that all employees understand the importance of prompt reporting of these
instances. Near misses usually fall into the categories that will eventually ruro
into an accident. How companies handle and react to near misses is the keY
to preventing these hazards and issues before they become accidents. Praise

Chapter 1: What is An Accident?

and recognition for reporting near misses, instead of fault-finding accusations,
will start a trend in more reporting of near misses, thus making near misses
a proactive management tool to ensure a sincere message of trying to fix
problems and prevent accidents (Clark 2010).

Property Damage and Equipment Damage Accidents

Property damage and equipment damage accidents are also sometimes as
confusing as near misses and also often unreported. One of the issues with
this type of accident is the monetary damage. Similar to near misses, how
much monetary damage is enough to prompt a response or reporting? A
broken hand tool might not get reported; however, a vehicle crash might get
reported. These are also based on potential, in that even though there was
no injury or death, there was still loss, but there was potential for injury as
well. Just take a look at forklifts in plants: how many do you see that are all
scratched and dented? I wonder how many of those were reported.

Small versus Big Accidents

Many professionals get bogged down by the issue of big accidents versus
small accidents. All accidents, no matter how big or small, can and should
be investigated. It starts with a hazard or a hazardous situation. The bigger
the hazard or hazardous situation or act/ omission, then the more likelihood
of loss. There are instances where a near-miss accident had more potential
than an injury accident; however, through chance and luck it was just a small
accident or a near miss. That near miss must be investigated, causal factors
found, and corrective actions taken to prevent a much bigger accident and
loss the next time, if conditions remained the same. Just because the accident
was a small one this time, if conditions and acts are not corrected, then a big
accident will come later. Near misses, property damage, and injury accidents
can all be investigated.

Risk and Accidents

There has been much debate over these terms over the years. There is risk in
everything we do. Risk is the amount of probability of occurrence and severity
of occurrence that is inherent in everything we do. There are also hazards

Part I: Introduction to the Accident Sequence

that increase the amount of risk in our everyday life. Zero accidents is a goal
that every company and every person should strive to meet. While most
companies strive to reduce hazards and hazardous situations and reduce the
amount of risk, there are risky situations that arise every day at the workplace.

Summary

There are many types of accidents, near misses, and even property damage
events that need to be investigated. The type of accident makes no difference.
First aid injuries or fatalities and catastrophes are basically all the same. The
theories apply to both the small accident and the large accident and even
near misses. There is a sequence of events for all, and while some are more
complicated than others, they are basically the same. Many of the near misses
are categorized as a near miss because of luck more than safety controls. No
matter what size of the accident (even near misses), they all have causal factors
that caused the accident. They key to accident investigation is to identify the
causal factors and correct them to prevent accident recurrence.

REVIEW QUESTIONS
I

1. What is an accident?

2. Why should near misses b~ investigated?

3. What is the difference in an accident, near miss, and property damage
accident? ,

4. What are causal fac;tors?

CHAPTER2 – ..•

An Accident Happens
What D o You Do?
How Long D o You Do It?

These two questions are major issues of accident investigation that
must be addressed and answered. Answering the first is simple: p1,;ovide
emergency response, protect the employees involved from further harm, and
try to determine what happened so that measures can be taken to prevent
its happening again. Answering the second question is more difficult. Some
companies commit a specific amount of time to an accident investigation-a
day, two weeks, or a month, for example-depending on the severity
of the accident. In a perfect world, there is no time limit-an accident
investigator investigates an accident until he or she is reasonably certain
of what happened and why. This book answers the first question-it tells
you what to do-and it provides ways to decrease the amount of time it
takes to do it.

Accident investigations are a dreadful part of a safety professional’s job.
Accident outcomes may include injuries, fatalities, and property or equipment
damage. It is sometimes difficult to “get over” the outcome of an accident,
especially if there is a fatality or an employee is hospitalized because of it.
However, accident investigations are a necessary and critical part of the

Part I: Introduction to the Accident Sequence

occupational safety process. A thorough acciden~ investigation can be of ~eat
benefit to your organization, not only by preventmg ~e same type of accident
from happening again, but also by finding syste~c problems that ~ould
cause more severe accidents in the future. The main purpose of an accident
investigation is to find the causes (what happened) and _fix the problems to
prevent the accident from recurring. “Accidents do not )USt happen, but are
caused” (Marshall 2000, 29).

Goals of Accident Investigation

Determine the Accident Sequence without Placing Blame
An accident investigation determines the accident sequence and finds the
causal factors of an accident. Its purpose is not to find fault or assign
blame.

How do you keep from finding fault when an individual disregards a
major safety policy? The answer is to be fair and consistent with your policy.
If there is no accountability for violating a safety policy or disregarding the
safety program, then the safety program will eventually fail. The main issue
is to find out why the individual violated the safety policy. The accident
investigator must determine why the safety program allowed the individual
to disregard the rule and why supervisors did not enforce the rule. While
these types of situations are rare, it is imperative for companies to correct
problems with their safety programs to keep accidents from happening
(Sorrell 1998).

Recommend Corrective Actions

Accident investigations determine corrective actions so that future accidents
are prevented and the overall safety program is improved.

Update the Overall Safety Program
By identifying hazards from th k
1 1 h

e wor er level up to the management systerns
eve , t e safety progr b

. am can e updated and improved. An accident is afl
opporturuty to find and fix problems wi·th th £

e sa ety program.

Chapter 2: An Accident Happens

Accident Reporting

Thorough Reporting Is Necessary
Accidents cannot be investigated if they are not properly reported. All accidents,
including fatalities, injuries, and property damage, as well as potential accidents
(near misses), should be reported. Formal company policy and employee
training must spell out how to properly and consistently report accidents, near
misses, and property damage (Vincoli 1994). Individuals must have no fear
of repercussions for informing the company or the safety department of an
accident or near miss. If people fear punishment or repercussion (accusation
of fault or blame) for accidents, they are less likely to report them (Speir
1998). It is crucial to a company’s safety program and to the prevention of
future accidents that all accidents and near misses be reported so that all of
the problems in the safety program can be found.

Incentive Programs Must Reward Reporting
Incentive programs have been developed to reward safe behaviors.
Unfortunately, many of them do not actually reward safe behavior
but instead inhibit the reporting of accidents and near misses because
employees fear losing their incentives. Such incentives do not improve
safety programs. Reporting accidents and near misses, finding causal
factors, and determining corrective actions, however, will improve them.
Reporting accidents and near misses should be rewarded, and incentive
programs should be designed to reward the reporting of all accidents and
near misses.

Documentation versus Investigation
When accidents occur, it is not just meant to document the occurrence. The
purpose of an accident investigation is to ask questions, interview, analyze,
probe, and discover what happened. It is not just to take witness statements
and document what happened. Many companies’ accident investigation forms
and record-keeping forms are just a documentation tool. The purpose is to
use these forms and tools to investigate and determine the causal factors and
prevent these instances from occurring.

Part I: Introduction to the Accident Sequence

Why Do We Need Accident Investigations?

To Avoid Spending Money on Accidents in the Future

Accidents are a major expense for companies. According to the 2011 edition
of I,gury Facts, in 2009 the total cost of unintentional injuries at work Was
$168.9 billion dollars (National Safety Council 2011). This monetary figure
does not reflect the cost of human pain and suffering as a result of accidents.
In 2009, 3,582 fatal occupational injuries occurred and 5.1 million injuries
were reported (National Safety Council 2011).

Bird and Germain compare the costs of an accident to an iceberg-like
an iceberg, most of the costs of an accident are not obvious and are not
seen. For every dollar of medical and insurance costs an injury or illness
incurs, the uninsured costs are $5 to $50 and miscellaneous costs are $1 to
$3. The uninsured costs include damage to equipment, tools, and products;
production delays; and legal expenses. The miscellaneous costs include
accident investigation expenses, hiring replacement workers, and loss of
business (Bird and Germain 1985).

As expensive as an accident may be, the resulting investigation can
ultimately save money by helping to prevent future accidents and update safety
programs. Future savings will be found in identifying systemic problems in the
safety program and correcting them. Near misses are excellent opportunities
to prevent costly accidents and identify and deal with systemic problems in
the safety program.

Accident costs come directly from a company’s bottom line. While saving
money is a great motivator for improving safety procedures, a bigger motivator
is avoiding the pain and suffering accidents produce. The field of occupational
safety is very dynamic, with theories and concepts that change over cirn_e.
However, most people would agree that “the ultimate goal of all efforts 1~

. safety engineering should be to reduce accidents and harmful exposures
(.Marshall 2000, 6).

To Prevent Future Accidents
A ‘d . . . d . 1·ured, n acc1 ent 1nvest1gat1on cannot do anything for the person alrea Y U1 . .
the machine already damaged, or the product already destroyed. Its value is JJl

Chapter 2: An Accident Happens

preventing future accidents. Although investigations are performed reactively,
they allow companies to be proactive in improving their safety programs.

To Comply with the Law and
Detennine the Total Cost of an Accident

Accident investigations must also be performed to complete workers’
compensation claims, to comply with legal requirements and Occupational
Safety and Health Administration (OSHA) regulations, and to determine the
total costs of accidents.

Decisions to Be Made
Before an Investigation Begins

Determine the Level of Investigation
Companies define levels of accidents and levels of accident investigations
to help answer questions about how an investigation will be conducted-
such as how much detail the investigation should uncover and how long the
investigation should take. In general, the more serious an accident is, the more
detailed the investigation will be and the longer it will take. The philosophy of
this book is that whether an accident is minor or catastrophic, the investigation
process still follows the same steps—develop the accident sequence, analyze
it, determine causal factors, and recommend corrective actions. The levels of
accidents and types of accident investigations are listed in Exhibit 2.1.

Decide Who Will Investigate
Once the accident level and the depth of investigation are determined, your
company must decide whether to use an individual or a team to do the
investigation. Many people from throughout your organization may be able
to perform adequate accident investigations. The key is to choose the person
(or persons) who is in the best position to discover what really happened and
determine how to prevent it from happening again. Foremen and supervisors
are excellent choices if they are able to look beyond their departments to

Part I: Introduction to the Accident Sequence

Exhibit 2.1
CATEGORIZATION OF ACCIOENTS

LEVELS OF ACCIDENTS TYPES OF ACCIDENT INVESTIGATIONS

1. Near miss Near misses can range from potentially minor to
potentially catastrophic accidents. At the least,
document the near miss on a form, determine its
causes, and recommend corrective actions.

2. Minor injury or
first-aid case

3. Major injury or
recordable injury

4. Catastrophic injury
(fatality, many
injured, or major
property damage)

Investigate, interview injured employee, determine
causes, and recommend corrective actions.
Document on a form.

Investigate, interview the injured employee and
witnesses, use analytical techniques, determine
causes, and recommend corrective actions. Write a
short report.

Team investigation. Interview injured, eyewitnesses,
and other employees; use analytical techniques;
determine causes; and recommend corrective
actions. Write a full report explaining the analytical
techniques used.

· • c gernent,
system1c causes-problems with the overall system of sa1ety mana d

· shoul
They usually understand the workers’ jobs and the roles supervisors
play. Safety professionals can do investigations, but usually they do;;
fully understand all of the workers’ job functions, so they must spen~ .is
1 · · b d · fessionai earruog JO uttes and sequences. A more useful role for safety pro . aJs
· ·din · . fession is prov1 g assistance to accident investigators, since safety pro (11

. d t syste
are trame to uncover and analyze systemic causes and managernen
causes.

The Team Approach
. cioD

For large or comple “d th “d , … vestlgi1 x acci ents, e team approach to acc1 ent ,,, . Jess
seems loo-ical beca · . d th n with

. i:,· use more 10format1on must be analyze a ,vbO
senous accidents Th al . . }eade! · e usu team approach is to appoint a team tbe
oversee~ and manages the investigation. The number of individuals o:)•ect
team will vary dep din -ny s1.1 en g on the accident’s complexity. NortnaJ.L ‘

Chapter 2: An Accident Happens

matter experts will be used to lend expertise about the complex issues that
will be uncovered in the accident investigation.

In order for a team investigation to work effectively, the team leader must
assign each subject matter expert to work in his or her area of expertise.
Having the subject matter experts work separately on the overall investigation
rather than concentrating on their own areas is a waste of time. Each subject
matter expert should have a separate area to focus on, such as a technical
or engineering issue, training, management systems, supervision, emergency
response, etc. The team leader coordinates all of the efforts and ensures that
all of the subject matter experts are working toward a common goal- finding
out what happened and how to prevent it.

Decide How Much Time Will Be
Allotted to the Investigation
Deciding how much time the investigators will be given to perform the
investigation and document the findings is a difficult decision. Many
companies allot a set amount of time based on the level of the accident and
the type of investigation to be performed. Ideally, the company should allow
enough time to find out what happened and determine how to prevent it from
recurring. In most cases, a first-aid case or an OSHA-recordable case will take
a few days, while a major injury, fatality, or other complex accident may take
anywhere from a couple of days to a month. Investigations of catastrophes
with multiple fatalities and involving complex systems (plant explosions, plane
crashes, etc.) usually take from a month to several years. The time needed to
perform investigations at any level depends on the amount of data collected,
the number of interviews, the number of people helping with the investigation,
the analytical methods used, the complexity of the systems involved, and the
length of the final report or form.

Determine Whether Additional
Resources Will Be Needed
For the most part, this book discusses nonproprietary investigation techniques
that do not require extra expenses. However, in many investigations,
consultants (subject matter experts, medical doctors, lawyers) or special

Part I: Introduction to the Accident Sequence

equipment (testing equipment, external testing, laboratory work, computer
software) may be needed. Coordinating these resources will extend the tune
needed to perform an investigation.

Summary

The basic requirement for a successful accident investigation program is a
formal accident-reporting policy with proper and consistent reporting of all
accidents and near misses from employees who do not fear repercussions. In
the past, most accident investigations began with the question ”Who did it?”
In a mod~m investigation, the accident investigator must concentrate on causal
factors and corrective actions and not place blame. Accident investigations
should be conducted by a qualified individual or team. The purpose of the
investigation is to find the causal factors of the accident and determine the
corrective actions to prevent recurrence of the accident as well as to find
systemic causes and thus prevent other types of accidents in the future.

Accident investigations are a necessary part of the occupational safety
process. Although proactive accident prevention and loss control strategies
are the main purpose of a safety program, accidents will occur. The company
and the accident investigator must learn from each accident and revise the
safety program as needed.

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