Accident Reporting,

Investigation and Analysis

‘ Those who cannot remember the past

are condemned to repeat it’

©Consultnet Ltd
Accident Reporting, Investigation and Analysis
Presentation Contents
 Introduction
 Incident Response
 Incident Investigation
 Incident Analysis
 Remedial Actions
 Incident Report
 Near Miss Reporting
 Cost of incidents
 Incident Statistics
 Summary of Responsibilities
 Types of incident(as %) reported to HSA(>3days lost) 2002
0.1

0.3

0.4
Injured while handling, lifting or carrying
0.4
Slips, trips or falls on same level
1.5
Injured by hand tools
2
Injured by falling objects
10.9
2.1 Fall from height
2.4 32.2 Contact with moving machinery parts
3 Injured by a person – malicious
Transport (excluding road traffic accidents)
Exposure/contact with harmful substance
Road traffic accidents
3.9
Injured by a person – non-malicious
4.6
Struck by something collapsing/overturning
5.3
5.3 Contact with electricity
19.4
6.3
Injured by an animal
Fire or explosion
Drowning or asphyxiation
Miscellaneous or not otherwise classified
 Introduction
Why report and investigate
accidents?
‘PREVENT A RECURRENCE OF THE SAME ACCIDENT’
It is worth doing it well!
 Learn from what went wrong
 Determine the causes
 Prevent recurrence
 Improve the work environment
 Meet regulatory requirements
 Cost of incidents
 Moral Obligation
 Define trends
 Provision of information in case of litigation
 Reduction of operating costs by control of
accidental losses
 Expression of concern by management
 Introduction
Incident Definitions
 ACCIDENT - an undesired event that results in personal
injury or property damage.
 INCIDENT - an unplanned, undesired event that
adversely affects completion of a task.
 NEAR MISS - incidents where no property was damaged
and no personal injury sustained, but where, given a
slight shift in time or position, damage and/or injury
easily could have occurred.
 Lost Time Accident – an accident resulting in time off
work
 Dangerous Occurrence - escape of flammable substance, explosion,
fire, collapse of load bearing apparatus, pipeline ruptures, pressure vessel
ruptures, transport incidents, bursting of reveolving wheel, O/H electric line
contact, building collapse(1993 Safety Health & Welfare at Work( General Application
)Regulations )
 Reportable Incident – injured cannot return to work within 3 days of
incident(1993 Safety Health & Welfare at Work( General Application
)Regulations Form to be submitted to HSA( downloadable at www.hsa.ie )
 Introduction
Incident Classification for Reporting
 Near Miss Incident: a near miss incident where there is no loss be it injury
or property damage however it could have resulted in personal harm/damage
under slightly different circumstances, such incidents are reported to the
Supervisor and formally logged on a Near Miss Report.
 Level 1 - Minor Incident: a level one incident can typically be dealt with by
the person identifying the problem. The supervisor should be informed and
the incident formally logged on an Incident Report; this will permit
assessment of the incident particularly with regard to the possibility of re-
occurrence and the potential for a more serious event. Examples: minor
localised fire, minor first aid injury(less than one day off work)
 Level 2 - Serious Incident: immediate action should be taken where
possible by the person identifying the incident. The supervisor should be
immediately informed and should assess the situation. Thereafter, the
supervisor will contact the necessary emergency services and officials as per
the emergency plan. Examples: injury (person is likely to be out of work for
more than one day but less than three days), containable fire, containable
environmental damage.
 Level 3 - Severe Incident: immediate action should be taken where possible
by the person identifying the incident. The supervisor should be immediately
informed and should assess the situation. The supervisor will contact the
necessary emergency services and necessary personnel as per the site
emergency plan. Examples:persons trapped, serious fire, threat to the safety
of personnel, serious environmental damage, serious injury( person likely to
be out of work > 3days), fatality.
 Level of Incident and Investigation involved
RISK Level 1 Level 2 Level 3
Low Moderate High
Injury Severity First Aid Medical Aid Fatality
Medical Aid (1<days off<3) Lost Time Accident
(<1 day off work) (>3 days)
Serious Incident
Reportable to HSA
Disabling injury

Damage Severity Up to E30,000 Up to E100,000 Over E200,000

Production Loss Less than 3 hours 3 hours to one day 1 day or more

Customer Impact Product requires work to Product will not meet Loss of Customer
meet customer standards customer standards Major customer
dissatisfaction

Personnel * Front line supervisor * Front line Supervisor * Front line supervisor
* Worker(s) /Witnesses * Worker(s) /Witnesses * Worker(s)/Witnesses
involved in involved involved involved
investigation * Area Safety Representative * Area Safety Representative * Area Safety Representative
* Safety Manager * Head of Department
* Safety Manager

Investigation Supervisor - Within the Supervisor - Immediately Supervisor -Immediately

same shift after personnel and area after personnel and area
Report are safe are safe
Responsibility
Responsibility for Head of Department Head of Department Head of Department
Remedial Actions
 Accident Initial response Supervisor actions
or as per emergency plan
Safety Manager
Contact insurance
Medical Aid
Incident Prevent secondary accidents
Contact hsa if required
Occurs Notify emergency services

Is the Incident Level 2?

Is the Incident Level 1?
First Aid
Medical Aid (<1 day off work)
Damage < E30,000
Production Loss < 3 hours
Product requires work to meet
customer standards
Medical Aid(1<days off<3)
No E30,000<Damage<E200,000
1 day >Production Loss > 3 hours
Product will not meet customer
standards
Is the Incident Level 3?
No Fatality
Serious Injury - Lost Time(>3 days)
Serious Incident Reportable to HSA
Damage>E200,000
Production Loss < 1 day
Loss of Customer or major customer dissatisfaction

Yes Yes
Yes
Accident Team Accident Team
Accident Team Investigates Investigates
Front line supervisor Front line supervisor
Investigates Worker(s) /Witnesses involved Worker(s) /Witnesses involved
Front line supervisor Area Safety Representative Area Safety Representative
Worker(s)/Witnesses Safety Manager Safety Manager
involved Head of Department
Area Safety
Representative

Analyse
Collect Evidence Response and loss limiting actions
Incident Report Interview witnesses
Supervisor Immediate causes (Substandard acts
Photographs and conditions)
Responsible for Sketches, survey, site maps
completion and Basic causes (personal & job factors)
Relative positions Program management (standards
forward to Safety Examine equipment & machinery
Manager within 24 and compliance)
Failed parts
Hours Examine Materials
Management Examine records
Actions
Managing Director
Management review at next management No Does analyses show what happened,
Actions meeting what should have happened and why?
Head of Department Collect more
track remedial actions evidence and
Head of Yes
Safety Manager re-analyse
Department Issue incident information
track remedial actions add to incident database Analyse causes
Safety Manager Review at next safety
add to incident committee meeting
database
Report findings
Include in incident analysis
Include in incident and actions Develop Remedial Actions
analysis inc. timescales and
Incident Investigation Flowchart responsibilities
Accident Reporting, Investigation and Analysis

 Introduction

Incident Response
 Incident Investigation
 Incident Analysis
 Remedial Actions
 Incident Report
 Near Miss Reporting
 Cost of incidents
 Incident Statistics
 Summary of Responsibilities
 Introduction
Reporting Incidents
 Employee must report to Supervisor

 Supervisor responsible for initiating reporting procedure

 Supervisor responsible for complete of incident report for

near-miss, Level 1 and Level 2 incidents involves Safety
Manager and Area Safety Representative

 Supervisor in conjunction with relevant Head of

Department responsible for completion of Level 3 incident
reports and also involves Safety Manager and Area Safety
Representative

 Head of Department responsible for completion of

corrective actions

 Reports to Senior Manager and Safety Manager

 Initial Response
Typical Procedure
All incidents must be reported immediately by the employee
concerned to their Supervisor:

 If a Near Miss incident the Supervisor shall ensure a Near Miss Report is
completed immediately.
 If a Level 1 incident the Supervisor in conjunction with the area Safety
Representative completes the Incident Report Form and forwards to Safety
Manager within 24 hours.
 If a Level 2 incident immediately after attending to any victim and
minimisation of property damage the Supervisor ensures the accident
scene is secured, prevents access by unauthorised persons and calls the
Safety Manager and the area Safety Representative who will assist the
Supervisor in completing the Incident Report Form, taking witness
statements and completion of the investigation.
 If a Level 3 incident the Supervisor immediately after attending to any
victim and minimisation of property damage ensures the accident scene is
secured, prevents access by unauthorised persons and calls the Safety
Manager, the area Safety Representative and the relevant Head of
Department, who will assist the Supervisor in completing the Incident
Report Form, taking witness statements and completion of the
investigation.
 Initial Response
The Supervisor

 Takes control of the scene

 Calls first aid and emergency services
 Controls secondary incidents
 Identifies sources of evidence
 Preserves evidence from alteration or
removal
 Determines the loss potential
 Notifies appropriate management

Discuss you company’s emergency response

procedures in the event of fire, injury,
chemical spill
Accident Reporting, Investigation and Analysis

 Introduction
 Incident Response

 Incident Investigation
 Incident Analysis
 Remedial Actions
 Incident Report
 Near Miss Reporting
 Cost of incidents
 Incident Statistics
 Summary of Responsibilities
 Incident Investigation and Analysis
Tips for investigation and analysis
 Encourage a no-blame reporting culture
 Focus must be to improve working conditions and methods
 Approach with an open and objective mind
 All facts learnt corrective action taken
 Fact finding not fault finding
 An opportunity for employees and management to work together
to correct an unacceptable situation
 An incident will happen again if underlying causes are not
corrected
 Delve deep to establish underlying causes do not accept all
answers given at face value
 Be prepared to look beyong the injured person, his co-workers,
supervisor, manager
 Consider communication skills and language barriers
 Get as much factual information as possible to get the complete
picture
 Incident Investigation
Effective Incident Investigation

 Establish the facts:

Who? What? When? Where? The size?
 Analyse the facts isolating contributary factors:
 Who or what was involved
 What hazards were present?
 What controls failed?
 Identify actions to prevent a recurrence
 Implement the corrective actions
 Incident Investigation
Who should lead investigation?
The Supervisor( ), why? of those involved

 They have a personal interest

 They know the people and conditions
 They know how best and where to get the
information needed
 They will initiate or take any remedial action
 They benefit from investigating

Where there is major loss or loss potential or

where multiple supervisors are involved it is
beneficial that the investigation also involves
the Head of Department for the area. In all
cases it is recommended that the Supervisor
involves the safety professional on his/her site
to assist in the investigation
 Incident Investigation
Collecting evidence and information
Record:
Pre-accident conditions, Accident sequence,
Post-accident conditions

 Position evidence – people(witnesses), equipment, materials &

environment, use sketches maps, photos, video
(Consider plant line up, valve alignment, tools labels, signs)

 People evidence – statements from all involved and witnesses,

interview separately

 Parts evidence – machinery, tools and other equipment that

could have contributed to the incident

 Paper evidence – all relevant records such as training records,

equipment records( maintenance, servicing), MSDS,
procedures, codes of practice, pre-start checklists, permits,
area rules, standards
Consider reconstructing incident from above information
 Initial Response
Typical Procedure
In the event of a Level 2 or Level 3 incident, immediately following the incident the
Supervisor shall ensure the following:
 Photographs of the scene are taken
 If there is a possibility that the accident could become a fatality the
scene must remain undisturbed until viewed by HSA Inspector and
Gardai where required.
 Arrange for survey plans of the site to be prepared. These are to
include the following :
 Locality Plan & details of accident site;
 Detailed plan of view showing details after the accident and include such things as:
Equipment used in rescue operations; Position of materials, ladders, equipment,
etc. involved in the accident; Position from where photographs were taken; Position
of persons involved in the accident; and other relevant information.
 A sectional view (if necessary). Any sections made are to be marked on the detailed
plan.
 Take evidence from witnesses at the scene and make note of any
piece of evidence.
 Check relevant equipment, maintenance and training records
 Analyse condition of equipment materials with specalist input where
necessary
 Prepare a report detailing the circumstances of the accident within
24 hours and submit to the Safety Manager. The report will include
the Incident Report Form and witness incident analysis forms which
provides for systematically identifying immediate causes, basic
causes and lack of control.
 Incident Investigation
Accident Photography
 Photograph the scene from all sides

 Use long, medium, close-up sequence

 Accompany with good notes and sketches

 Identify by number, time, date & name of

photographer
 Incident Investigation
Interviewing Witnesses
 Calm, objective, impartial, open mind, search for facts not opinions
 Do not interrogate/cross examine
 As soon as possible( theorising increases as memory decreases)
 Interview separately and privately, use a tape recorder only with
witness permission
 If significant conflict follow up interviews may be necessary
 Assure them the information is being used for accident prevention not
to apportion blame
 Get the individuals version
 Use open questions (cannot be answered with a simple yes or no)
 Do not express an opinion or argue
 Record critical information quickly
 If not at the site of the accident use visual aids, sketches etc.
 End on a positive note and keep the line open
 Review completed statement with witness and have it signed
Helpful Interview Questions
What were you doing? Where were you working? How were you injured? How
do you think the accident occurred? What is the safety procedure for the job? How
were you trained for the job? Have you fully described the circumstances of the
accident as you know them?
Take a look at the Witness Incident Analysis form recommended for Level 2/3 incidents
 Incident Investigation
Parts Examination
Parts – machinery, tools and other equipment that could have contributed
to the incident

 Proper item for task

 Damage - type, extent, pattern
 Previous damage – defects, misuse
 Wear
 Safeguards – machine guards, emergency cut-offs
 Labels, signs, markings
Accident Reporting, Investigation and Analysis

 Introduction
 Incident Response
 Incident Investigation

 Incident Analysis
 Remedial Actions
 Incident Report
 Near Miss Reporting
 Cost of incidents
 Incident Statistics
 Summary of Responsibilities
 Incident analysis
What’s involved?
 Determine what happened –immediate cause –
unsafe practices/conditions ( ask the question would the
accidnet have happened if this particular factor was not present?)

 Determine why it happened basic causes –

personal/job factors
 Cover deficiencies in the management system
WOULD THE ACCIDENT HAVE HAPPENED IF THIS PARTICULAR FACTOR WAS NOT PRESENT?

 Determine appropriate remedial action based on

the immediate and basic causes
 Apportion responsibility to implement corrective
actions
 Report findings to senior management
 Follow-up and monitor corrective actions
 Incident Analysis
THE DOMINO SEQUENCE
How Accidents Happen

The domino described below is a model that will help you

see how accidents happen.

Lack of Control Basic Immediate

Cause Cause Accident Loss

Organizational Lack Of:  Unsafe Act Undesired, Death

Failure to: Training  Unsafe Condition Unplanned  Injury
- Plan Resources Event Which  Property damage
 Direct Belief Disrupts Work  Lost Time
 Organize Activity  Lost Productivity
 Control
 Incident Analysis
Lack of Control
Organisational failure means that the organisation, at one or more
levels, did not effectively/properly plan, direct, organize, control or
combination thereof, its resources
Resources are: Time, Tools, Equipment, Materials, Manpower

 Failure to PLAN means: All aspects of the job, task or operation

were not planned effectively so that an unexpected accident was
not eliminated.
 Failure to DIRECT means: Personnel involved in the job, task or
operation were not instructed and trained as to the potential
hazards involved and means to eliminate or control those
hazards.

 Failure to ORGANIZE means: All resources that were needed to

do the job safely were not present, proper, and/or in safe
operating condition.

 Failure to CONTROL means: Failure to ensure that the job or task

was actually conducted as planned, organized and directed.
 Incident Analysis

Basic
Cause
Personal and job factors - lead a person to commit an unsafe condition or act

 Job factor - Lack of Training/ Lack of Resources

 No training at all
Training that was incomplete or inadequate or not understood
Training that was not repeated frequently enough
Resources (time, tools, equipment, materials, manpower) necessary
to do the job safely are not provided
Resources not proper (skills, size, abilities, type)
Resources not in safe operating condition
Inadequate supervision
Inadequate work standards, procedures, work practices, maintenance

 Personal factor - Lack of Belief

There is a belief that a negative consequence will not result because of their
action. Lack of belief is almost always caused by past experience. Factors that
can contribute to it are:
 Poor morale/low motivation/stress
 Peer pressure
 Productivity pressures
 Inadequate resources
Inadequate capability
 Incident Analysis
Immediate Cause

Immediate causes are the unsafe acts and/or conditions

that lead directly to the accident.

 Unsafe acts account for 85% of accidents; unsafe

conditions account for 14% of accidents.

 However, 85% of the unsafe conditions were caused

by an unsafe act.

 Therefore, we can say that 97% of all accidents are

caused directly or indirectly by an unsafe act.
 Incident Analysis

Accident

 An accident is:

“An unplanned, undesirable event which

disrupts work activity”

 An accident always results in a loss.

 Incident Analysis
Loss
 The loss is the result of an accident. (Disruption of
work activity).

 Approximately 30 different losses have been identified

as potential results of accidents, for example:

Death Lost Productivity

Injury Civil Penalties
Lost Time Replacement Costs
Damaged Morale Economic Loss
Damaged Tools Loss of Client Goodwill
Damaged Equipment Lost Competitiveness
Lost Materials
 Human Element of Accident Causation
Organisational Local Working Conditions Active Failures Defences
Process

Latent Failures Latent Failures Latent Failures Active Failures Active & Latent

Psychological Inadequate
Line Precursors Unsafe Acts
Fallible Communication
Defences
Decisions Management of Tools &
Person Factor
Training & Skills Deficiencies Unsafe Acts Equipment
Work Atmosphere Planning Communication
Supervision Job Factor
Team Work

Operators
Senior Line Frontline Safety
Maintenance
Management Management Supervisor Equipment
Crews

Casual Sequence

Human Elements of Accident Causation (Reason 1990)

 Incident analysis
Loss Causation Model
Lack of Basic Immediate Incident Loss
Control Causes Causes

Unintended
Inadequate Personal Substandard harm or
Acts/practices Event
Factors damage
•Systems
Contact
Substandard •People
•Standards Job/system with
factors Conditions energy or •Property
•Compliance
surface
•Processes

Problem Solving Model

In an incident analysis situation use this model and write down
the loss, incident event, immediate, basic causes and relevant lack
of controls under each heading in list form as per the Incident
Report Form
This makes it possible to identify the causes and relevant
corrective actions to prevent a reoccurrence.
Incident Form: Immediate Causes
Immediate Causes (What sub standard actions &
Conditions caused the event):
Tick all applicable below and explain here:
SUBSTANDARD ACTIONS
 Operating equipment without
authority
 Failure to warn
 Failure to secure
 Operating at improper speed
 Making safety devices inoperable
 Removing safety devices
 Using defective equipment
 Using equipment improperly
 Failure to use PPE properly
 Improper loading
 Improper placement
 Improper lifting
 Improper position for task
 Servicing equipment in operation
 Horseplay
 Under influence of alcohol or drugs
 Working in dangerous situation
 Non-adherence to rules/standards
SUBSTANDARD CONDITIONS
 Inadequate guards or barriers
 Inadequate or improper protective
equipment
 Defective tools equipment or
materials
 Congested or restricted action
 Inadequate warning system
 Fire and explosion hazard
 Poor housekeeping disorder
 Hazardous environmental
conditions(gas, dust etc.)
 Noise exposures
 Radiation exposure
 High or low temperature exposures
 Inadequate or excess illumination
Inadequate ventilation
 Defective PPE
Incident Form: Basic Causes
Basic Causes (What personal factors & job factors
caused the event):
Tick all applicable below and explain here:

Personal factors Job Factors

 Inadequate capability
Lack of knowledge
 Lack of skill
 Stress
 Improper motivation
 Inadequate Leadership
 Inadequate engineering
 Inadequate purchasing
 Inadequate maintenance
 Inadequate tools &
equipment
 Inadequate work standards
 Wear & Tear
 Abuse or misuse
Accident Reporting, Investigation and Analysis

 Introduction
 Incident Response
 Incident Investigation
 Incident Analysis

 Remedial Actions
 Incident Report
 Near Miss Reporting
 Cost of incidents
 Incident Statistics
 Summary of Responsibilities
 Incident analysis
Remedial Actions
 Temporary Actions – correct
substandard actions and conditions

 Permanent Actions – remedy personal

factors and job factors

Remedial Actions must be:

 Communicated clearly
 Responsible person identified and timescale
established for their completion
 Follow-up conducted by Investigation Team
 Department Manager responsible to ensure
completion
Accident Reporting, Investigation and Analysis

 Introduction
 Incident Response
 Incident Investigation
 Incident Analysis
 Remedial Actions

 Incident Report
 Near Miss Reporting
 Cost of incidents
 Incident Statistics
 Summary of Responsibilities
 Incident Report
Typical Contents
 Title, date and time
 Location of the accident
 Type of injury or damage/who and what was involved
 Cost of losses
 Description of what happened including emergency
response sequence
 How the accident occurred/extent of damage
 Immediate(direct(energy sources, haz. materials etc.) &
indirect causes(unsafe acts and conditions) & basic
causes (personal/environmental factors)
 Lack of control(management policies)
 Remedial actions temporary & permanent
 Management review
 Other
Note:
 Timeliness of report is critical, best reports are written
promptly
 Accident reports are usually ‘discoverable’ this means they
can be used by parties to an action for damages or criminal
charges
 Incident Report
Where to?
Incident reports forwarded to the Safety Manager are
processed as follows :
 All incident reports are analysed and the summary
information is presented at the next monthly
management meeting and safety committee meeting
 All Level 2 and Level 3 incidents are reviewed at the
next weekly management meeting. Any lessons
learned are communicated to management and
employees from information distributed to all
Supervisors(for inclusion in tool box talk ) and on
Company Notice Boards
 Incident reports are copied to the relevant Head of
Department and General Manager in the case of Level
2 and Level 3 incidents
Accident Reporting, Investigation and Analysis

 Introduction
 Incident Response
 Incident Investigation
 Incident Analysis
 Remedial Actions
 Incident Report

 Near Miss Reporting

 Cost of incidents
 Incident Statistics
 Summary of Responsibilities
 Near Miss Reporting

Reporting of Near Miss Incidents is critical

1
Serious or Major Injury
Accident
Ratio
Study 10
Minor Injuries

30
Property Damage

600
Incidents with no visible
injury or damage
Near miss

 Near misses provide a much larger base for more effective control of accidental loss
 Eliminate the causes of near misses, reduce the potential for more serious accidents,
this is the basis of any proactive safety management system
 High potential incidents should be analysed thoroughly
Accident Reporting, Investigation and Analysis

 Introduction
 Incident Response
 Incident Investigation
 Incident Analysis
 Remedial Actions
 Incident Report
 Near Miss Reporting

 Cost of incidents
 Incident Statistics
 Summary of Responsibilities
 Analysis of costs
Consider the following:
 Cost of dealing with incident( such as first aid,
emergency supplies, staff downtime)
 Costs of incident investigation( such as staff time,
consultants time)
 Cost of getting back to business( such as re-
scheduling, clean-up, hire of equipment)
 Business Costs( such as cost of injured persons
salary, replacement salary, lost orders)
 UK HSE useful incident cost calculator template –
next slide
©Consultnet Ltd
Accident Reporting, Investigation and Analysis

 Introduction
 Incident Response
 Incident Investigation
 Incident Analysis
 Remedial Actions
 Incident Report
 Near Miss Reporting
 Cost of incidents

 Incident Statistics
 Summary of Responsibilities
 Accident Statistics
Analysis
 Accident data base should be established
 Identify trends and focus systems where they can
produce the greatest return on invested time and
energy
 Accident analysis statistics should be:
 produced regularly by the Safety Department
 reviewed at regular management and safety committee meetings
 summary available to all employees
 Identify repetitive or signifcant items
Accident Statistics Analysis

 Statistics may include:

 Number of near-miss, property damage, first aid, medical aid, lost time
incidents, fire, environmental events
 Lost time injury frequency rates and severity rates
Lost Time Incident Frequency Rate(LTIFR)=(Total Lost Time Incidents/Total Hours Worked) x 100,000
Lost Time Incident Severity Rate(LTIFR)=(Total hours lost/Total Hours Worked) x 100,000
 Costs
 Cause and control analysis
Type of accidents by department, work section, occupation
Equipment/substances involved
Activity at time of injury
Age of person/length of service
Time of day
Immediate causes(substandard acts and conditions)
Basic causes( Personal and job factors)
Lack of control(inadequate programme standards or compliance with standards)
Remedial action completion by department

Problem solving project teams to address critical problems identified

Accident Reporting, Investigation and Analysis

 Introduction
 Incident Response
 Incident Investigation
 Incident Analysis
 Remedial Actions
 Incident Report
 Near Miss Reporting
 Cost of incidents
 Incident Statistics

 Summary of Responsibilities
 Incidents
Summary of Responsibilities
 All Employees must report all incidents to their Supervisor
 All Supervisors responsible for initiaiting accident investigations
 All Heads of Department are responsible for taking appropriate action on the
conclusions and results of any incident investigation within their
Department.
 All Heads of Departments are responsible to ensure that the supervisors in
their department are fully aware of, understand and initiate the Incident
Reporting and Investigation Policy and attend relevant training.
 The Safety Manager will be responsible for providing technical support to the
Supervisor in the course of the incident investigation, issuing incident
information for communication to all employees, producing the incident
statistics and presentation to monthly management and safety committee
meeting
 The Safety Manager will ensure that management, employees and their
representatives are adequately consulted and informed on the incident
investigation policy and provision of training as regards implementation of
the policy
 In the event that a Level 2 or Level 3 incident meets the requirement of
reporting to the Health & Safety Authority, the Safety Manager contacts the
relevant Inspector, submits the completed statutory report form and co-
ordinates any subsequent investigation with the Inspector.
 The Safety Manager is responsible for reporting Level 2 & 3 incidents to the
Company Loss Adjuster and Company Insurance Co-ordinator and co-
ordinating any subsequent follow-up investigation.
 Accident Initial response Supervisor actions
or as per emergency plan
Safety Manager
Contact insurance
Medical Aid
Incident Prevent secondary accidents
Contact hsa if required
Occurs Notify emergency services

Is the Incident Level 2?

Is the Incident Level 1?
First Aid
Medical Aid (<1 day off work)
Damage < E30,000
Production Loss < 3 hours
Product requires work to meet
customer standards
Medical Aid(1<days off<3)
No E30,000<Damage<E200,000
1 day >Production Loss > 3 hours
Product will not meet customer
standards
Is the Incident Level 3?
No Fatality
Serious Injury - Lost Time(>3 days)
Serious Incident Reportable to HSA
Damage>E200,000
Production Loss < 1 day
Loss of Customer or major customer dissatisfaction

Yes Yes
Yes
Accident Team Accident Team
Accident Team Investigates Investigates
Front line supervisor Front line supervisor
Investigates Worker(s) /Witnesses involved Worker(s) /Witnesses involved
Front line supervisor Area Safety Representative Area Safety Representative
Worker(s)/Witnesses Safety Manager Safety Manager
involved Head of Department
Area Safety
Representative

Analyse
Collect Evidence Response and loss limiting actions
Incident Report Interview witnesses
Supervisor Immediate causes (Substandard acts
Photographs and conditions)
Responsible for Sketches, survey, site maps
completion and Basic causes (personal & job factors)
Relative positions Program management (standards
forward to Safety Examine equipment & machinery
Manager within 24 and compliance)
Failed parts
Hours Examine Materials
Management Examine records
Actions
Managing Director
Management review at next management No Does analyses show what happened,
Actions meeting what should have happened and why?
Head of Department Collect more
track remedial actions evidence and
Head of Yes
Safety Manager re-analyse
Department Issue incident information
track remedial actions add to incident database Analyse causes
Safety Manager Review at next safety
add to incident committee meeting
database
Report findings
Include in incident analysis
Include in incident and actions Develop Remedial Actions
analysis inc. timescales and
Incident Investigation Flowchart responsibilities
 Accident Investigation
Case Study
 Form teams for the investigating and
reporting
 Analyse the facts
 Identify the immediate and basic causes
 Recommend remedial actions
 Complete Incident Report
 Present findings
Remember Rudyard Kipling's
I keep six honest serving men,
They taught me all I knew,
Their names are What and Why and How
and Where and When and Who
 Accident Reporting,
Investigation and Analysis
Conclusion

WHEN AN ORGANIZATION REACTS SWIFTLY

AND POSTIVELY TO ACCIDENTS AND
INJURIES, ITS ACTIONS REAFFIRM ITS
COMMITMENT TO THE SAFETY AND WELL-
BEING OF ITS EMPLOYEES
Thanks and take care