Accident
Investigation
WHAT IS AN ACCIDENT?
• What is an accident?
o
o
Any unexpected event
Some may even be good
• Does an accident always involve an
injury?
• Does an injury always involve an
accident?
What Is An Accident?
Accidents
• Accident
o
Any unplanned event that results in
 Personal injury
 Property damage
Accidents
• Usual causes
o
Failure of people, equipment, supplies, or
surroundings to behave or react as
expected
WHY INVESTIGATE?
• Why investigate?
o
To PREVENT injuries
• Investigations should not be witch
hunts
If results show need for discipline, fine
But.....
o That is not the purpose
o
INVESTIGATIONS
• Include non injury accidents incidents
o
o
Proactive
Preventative
• Investigating only injuries
o
Reactive
INJURY PYRAMID
Fatality
Serious
Recordable
Recordable
1st Aid Cases
Non-injury Accidents
Incident Investigation Plan
• Establish parameters
• Be aware of other requirements
o
ADA, EEO, Union, etc.
• Establish procedures
• Develop forms
• Train employees
First Report
The “First Report of Injury”
sent to Workers’
Compensation Company is
NEITHER an accident report
NOR an investigation.
Incident Report
• Write an incident report
o
As soon as possible
• Start with a supervisor’s report based
on information provided by employees
o
“Employee said......”
Injury Potential
• Investigate based on POTENTIAL
FOR INJURY
• The greater the potential, the more
thorough the investigation
The Investigation
Avoid a “cold trail”
The Investigation
• Be methodical
• Gather as much information as
possible
o
Throw out irrelevant information during the
analysis step
The Investigation
• Beware of preconceived conclusions
• Beware of “jumping the gun”
o
Do not offer solutions before you find the
basic cause
The Investigation
•
•
•
•
•
ASK QUESTIONS
When you get an answer, ask “WHY”
Then ask “WHY” again
And AGAIN
And “who?”, “what?”, and ...”why?”
Basic
Causes
Indirect
Causes
Direct
Causes
Management Safety Policies & Decisions
Personal Factors Environmental Factors
Unsafe Act
Unsafe Condition
Unplanned Release of Energy
and/or Hazardous Material
Incident
The Investigation
• Investigate the scene
o
o
o
o
Take measurements
Take pictures
Evaluate equipment
Be imaginative
The Investigation
• Look for
o
o
o
o
o
o
o
o
Guards off
Lack of PPE
Housekeeping issues
Poor work practices
Faulty equipment
Inadequate training
Poorly written procedures
Etc.
The 4 “Ps”
•
•
•
•
People
Position
Parts
Paper
Interviews
•
•
•
•
Interview employee involved
Interview witnesses
Interview other employees in area
Look for similar incidents
Interviews
• Explain the purpose of the investigation
o
•
•
•
•
Accident prevention
Put at ease
Let speak freely
Take notes without distracting
Only use a tape recorder with the
person’s knowledge and consent.
• Interview as soon as possible
Analysis Techniques
•
•
•
•
•
•
Change analysis
Job Safety Analysis (JSA)
Event and Causal Factors Analysis
Multi linear Events Sequencing (MES)
Project Evaluation Tree (PET)
Combination
Report of Investigation
• 1. Background
information
• 2. Detailed account
of the incident
• 3. Resolution
• 4. Corrective actions
RESOLUTION
• Discuss ways of preventing future
incidents
• Solicit ideas from employees & others
• Be creative
• Make recommendations
Corrective Actions
• Corrective actions
o
Recommendations that are adopted
• Inform and train employees and
supervisors
Follow-Up
• Involve supervisors & employees
• Are solutions:
o
o
Used?
Effective?
• Solicit feedback
Trend Analysis
• Evaluate for incident, accident and
injury trends in order to focus efforts
• Use 300 forms, incident & accident
reports, first aid logs, inspection
reports, etc.
• Analyze by entity, facility, time, job, etc.
• Do at least a 3 year comparison
Resource
• Ask for help from your workers’
compensation carrier
Sandra A. Mihalik, WSO-CST
Safety & Health Specialist
Montana Safety & Health Bureau
Phone: 406.444.6418
E-mail: smihalik@mt.gov