Accident Investigation

Accident investigation is the systematic process of examining the causes, circumstances, and consequences of an accident to determine what happened, why it happened, and how similar incidents can be prevented in the future. It involves gathering evidence, analyzing contributing factors, and recommending corrective actions to improve safety.

Course Content

Contents
Fundamentals of Accidents Investigation Steps Investigation Report Recommendations Corrective Actions Summary

Contents

Definitions
Accident An accident is an unplanned event that results in harm to people, loss of company assets or damage to the environment. Near-miss A near-miss is an event that has the potential to result in an accident but for particular reasons this potential is never realized. Normally there will be no property loss or injuries.

Why Accident Investigation?
To learn what happened and why. To evaluate potential risks and prevent recurrence. To determine, communicate and implement improved work methods.

Causes of Accidents
Unsafe acts Unsafe conditions

Human Factors
Lack of skills or knowledge Improper motivation Stress Inadequate capabilities

Job Cause Factors
Inadequate engineering Inadequate specifications in purchasing Inadequate maintenance and inspection Inadequate tools or equipment Wear and tear

Pyramid Concept

Cause Analysis
Immediate Cause An immediate cause is a human error or equipment failure that directly led to the incident or made the incident’s consequences worse. Root cause A root cause is an underlying reason why the incident occurred; it is virtually always a specific deficiency in a management system.

Management Systems
Standards & procedures Emergency planning Work permit system Training & communication Design maintenance & inspection

Applicable Standards
Instructions (company) Regulation (government) Forms & notification

Who Investigates Accidents?
Supervisor/foreman Safety personnel Special committee (pool) Government agencies Specialist or experts

Investigator’s Kit
Camera & tape recorder Tape measure & flashlight Accident reporting forms Personal protective equipment High-visibility tape or cord

Investigation Steps
Respond to the site. Preserve the site. Collect information/evidence. Analyze causes. Recommend corrective actions. Prepare report. Follow up on recommendations.

Initial Response
Survey the accident scene. Aid the injured. Prevent secondary accidents. Preserve evidence.

Survey the Accident
P --- People E --- Equipment M --- Materials E --- Environment

Interviewing Witnesses
Interview promptly and separately. Put witness at ease and get his statement. Ask for details and make brief notes. Ask open-ended questions. Give witness time to think. Review key points and end on positive note. Always thank the witness for assistance.

Equipment Examination
Tools, clothing, & PPE Extent of damage Wear & tear Labels, signs, markings Modifications

Records Examination
Job procedures or instructions Employee training Maintenance & inspection Purchasing

Investigation Report
Identifying details Description of accident Cause analysis Conclusions & recommendations

Recommendations
List alternatives and evaluate each one. Consider cost and practicality. Select best alternative.

Corrective Action
Modify standards and procedures. Discuss report with personnel. Check completion of recommendations. Ensure problem correction. Enforce corrective action continuity Communicate findings widely

Summary
Familiarity with fundamentals Following investigation steps Preparing the report Recommendations Ensuring correction Communication

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Course Content

Contents Fundamentals of Accidents Investigation Steps Investigation Report Recommendations Corrective Actions Summary

Contents

Definitions

Why Accident Investigation? To learn what happened and why. To evaluate potential risks and prevent recurrence. To determine, communicate and implement improved work methods.

Why Accident Investigation

Causes of Accidents Unsafe acts Unsafe conditions

Causes of Accidents

Human Factors Lack of skills or knowledge Improper motivation Stress Inadequate capabilities

Human Factors

Job Cause Factors Inadequate engineering Inadequate specifications in purchasing Inadequate maintenance and inspection Inadequate tools or equipment Wear and tear

Job Cause Factors

Pyramid Concept

Concept

Cause Analysis

Management Systems Standards & procedures Emergency planning Work permit system Training & communication Design maintenance & inspection

Management Systems

Applicable Standards Instructions (company) Regulation (government) Forms & notification

Applicable Standards

Who Investigates Accidents? Supervisor/foreman Safety personnel Special committee (pool) Government agencies Specialist or experts

Who Investigates Accidents?

Investigator’s Kit Camera & tape recorder Tape measure & flashlight Accident reporting forms Personal protective equipment High-visibility tape or cord

Investigator’s Kit

Investigation Steps Respond to the site. Preserve the site. Collect information/evidence. Analyze causes. Recommend corrective actions. Prepare report. Follow up on recommendations.

Investigation Steps

Initial Response Survey the accident scene. Aid the injured. Prevent secondary accidents. Preserve evidence.

Initial Response

Survey the Accident P --- People E --- Equipment M --- Materials E --- Environment

Survey the Accident

Interviewing Witnesses Interview promptly and separately. Put witness at ease and get his statement. Ask for details and make brief notes. Ask open-ended questions. Give witness time to think. Review key points and end on positive note. Always thank the witness for assistance.

Interviewing Witnesses

Equipment Examination Tools, clothing, & PPE Extent of damage Wear & tear Labels, signs, markings Modifications

Equipment Examination

Records Examination Job procedures or instructions Employee training Maintenance & inspection Purchasing

Records Examination

Investigation Report Identifying details Description of accident Cause analysis Conclusions & recommendations

Investigation Report

Recommendations List alternatives and evaluate each one. Consider cost and practicality. Select best alternative.

Recommendations

Corrective Action Modify standards and procedures. Discuss report with personnel. Check completion of recommendations. Ensure problem correction. Enforce corrective action continuity Communicate findings widely

Corrective Action

Summary Familiarity with fundamentals Following investigation steps Preparing the report Recommendations Ensuring correction Communication

Summary

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