The prime objective of accident investigation is prevention. Finding the causes of an accident and taking steps to control or eliminate it can help prevent similar accidents from happening in the future.
Accidents can rarely be attributed to a single cause. Work environment, job constraints, and supervisory or worker experience can all play a part. These factors must be examined to determine what role each had in causing the accident. Once the causes are established, precautions must be identified and implemented to prevent a recurrence.
Investigators must always keep in mind that effective accident investigation means fact-finding, not fault-finding. To explain why and how an accident happened, investigators must collect information on the events that took place before and during the event.
Investigators can then determine accident conditions by examining physical evidence and interviewing witnesses. Both of these steps are of equal importance and should be done as soon as possible to ensure complete accident investigation. Was the worker trained? First: Report the incident occurrence to a designated person within the organization.
Provide first aid and medical care to injured person s and prevent further injuries or damage. The incident investigation team would perform the following general steps: Scene management and scene assessment secure the scene, make sure it is safe for investigators to do their job. Witness management provide support, limit interaction with other witnesses, interview.
Investigate the incident, collect data. Analyze the data, identify the root causes. Report the findings and recommendations. The organization would then: Develop a plan for corrective action. Implement the plan. Evaluate the effectiveness of the corrective action. Make changes for continual improvement. Figure 1: Incident Categories Task Here the actual work procedure being used at the time of the incident is explored.
Members of the investigation team will look for answers to questions such as: Was a safe work procedure used? Had conditions changed to make the normal procedure unsafe? Were the appropriate tools and materials available? Were they used? Were safety devices working properly? Was lockout used when necessary? For most of these questions, an important follow-up question is "If not, why not? What caused it to fail?
Was the machinery poorly designed? Were hazardous products involved? Were they clearly identified? Was a less hazardous alternative product possible and available? Was the raw material substandard in some way? Should personal protective equipment PPE have been used? Was the PPE used? Were users of PPE properly educated and trained? Work Environment The physical work environment, and especially sudden changes to that environment, are factors that need to be identified.
For example, investigators may want to know: What were the weather conditions? Was poor housekeeping a problem? Was it too hot or too cold? Was noise a problem? Was there adequate light?
Were toxic or hazardous gases, dusts, or fumes present? Personnel The physical and mental condition of those individuals directly involved in the event must be explored, as well as the psychosocial environment they were working within.
Some factors will remain essentially constant while others may vary from day to day: Did the worker follow the safe operating procedures? Were workers experienced in the work being done? Had they been adequately educated and trained? Can they physically do the work? What was the status of their health? Were they tired? Was fatigue or shiftwork an issue? Were they under stress work or personal? Was there pressure to complete tasks under a deadline, or to by-pass safety procedures?
Management Management holds the legal responsibility for the safety of the workplace and therefore the role of supervisors and higher management and the role or presence of management systems must always be considered in an incident investigation.
Ask questions such as: Were safety rules or safe work procedures communicated to and understood by all employees? Were written procedures and orientation available? Were the safe work procedures being enforced? Was there adequate supervision? Were workers educated and trained to do the work? Had hazards and risks been previously identified and assessed? Had procedures been developed to eliminate the hazards or control the risks?
Were unsafe conditions corrected? Was regular maintenance of equipment carried out? Were regular safety inspections carried out? Had the condition or concern been reported beforehand? Was action taken? Physical Evidence Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses. Based on your knowledge of the work process, you may want to check items such as: positions of injured workers equipment being used products being used safety devices in use position of appropriate guards position of controls of machinery damage to equipment housekeeping of area weather conditions lighting levels noise levels time of day You may want to take photographs before anything is moved, both of the general area and specific items.
Witness Accounts Although there may be occasions when you are unable to do so, every effort should be made to interview witnesses. Interviewing The purpose of the interview is to establish an understanding with the witness and to obtain his or her own words describing the event: DO The actual questions you ask the witness will naturally vary with each incident, but there are some general questions that should be asked each time: Where were you at the time of the incident?
What were you doing at the time? What did you see, hear? What were the work environment conditions weather, light, noise, etc. What was were the injured worker s doing at the time? In your opinion, what caused the incident? How might similar incidents be prevented in the future? Other Information Data can be found in documents such as technical data sheets, health and safety committee minutes, inspection reports, company policies, maintenance reports, past incident reports, safe-work procedures, and training reports.
Each conclusion should be checked to see if: it is supported by evidence the evidence is direct physical or documentary or based on eyewitness accounts, or the evidence is based on assumption. This list serves as a final check on discrepancies that should be explained. If so, what was it?
Why did it fail this time? Is there a new method that should be used to correct the problem? Is there a way to eliminate the cause s of the incident? Employers should document any actions they have taken to secure an unsafe worksite. Next, organizations should contact their insurance carriers and file a work-related injury report. All work-related claims must be recorded on the OSHA log. The employer should follow up with the employee after the accident investigation has concluded to see how the employee is doing.
If the employee is hospitalized, someone from the organization should visit the employee in the hospital. A get-well card signed by co-workers, a fruit basket or flowers will send the message that the company really cares about its employees and will encourage the employee to return to work.
If the employee initially declined medical treatment, the employer should confirm with the employee that no medical treatment related to the accident has been necessary. Corrective action should be identified in terms of how to prevent a recurrence and improve the overall operations of the company.
If an employee violated a major or minor safety rule, the employer will need to follow its company work rule violation policy and take the corrective action necessary. Taking immediate corrective action will ensure workplace safety and help reduce or eliminate work-related injuries.
If a company has a safety committee, members should review investigations of all accidents to help form recommendations for appropriate corrective action to prevent future reoccurrence.
Thorough investigations will help employers identify causes of accidents and will reveal any accident trends. You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page. Reuse Permissions. Page Content. Step 1: Assess the Injury When a workplace accident occurs, the first thing to do is to identify any injured employees and assess the severity of the injury.
Step 2: Obtain Medical Treatment if Necessary If no medical attention or only first-aid is required, the employer may proceed to Step 3.
This could include some or all of the following forms: Medical treatment consent form. Questions to ask during the investigation might include: What was the employee doing at the time of the accident? Was the employee qualified to perform this operation? Were company procedures being followed? Is the job or process new? Were proper tools or equipment being used?
Was the proper supervision being provided?
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