Accident Investigations

Part I
 Accident Investigation -
Objectives
By the end of this lecture the students will:
Understand the importance of the need for
effective and thorough investigation of an accident

Understand practical skills required to respond

and investigate an incident/accident in a
consistent manner

Make meaningful recommendations for

preventive actions to reduce potential risks that
may contribute to accidents
 Effective Accident Investigations -
Objectives (cont.)

Understand critical role in the accident

investigation and the accident reporting
process

Determine the cause(s) of the accident and

make recommendations to help prevent a
recurrence of this type of incident
 What is an Accident ?

“An accident is an undesired event that results

in physical harm to a person or damage to
property.”
 Purpose of an Accident Investigation

The purpose of an accident investigation is to

prevent the recurrence of the accident. The focus
should be on the accident , not the injury .
 Effective Accident Investigations

What to Look for:

Policies/Procedures Equipment Materials

Environment Task People/Operators

Accidents generally have more than one cause

 Critical Injury Defined

For the purpose of the Act and Regulations, “critically injured”

means an injury of serious nature that,

a) places life in danger; e) involves the amputation

of a leg, arm, hand or
b) produces foot but not a finger or
unconsciousness; toe;

c) results in substantial f) consists of burns to a

loss of blood; major portion of the
body; or
d) involves the fracture of a
leg or arm but not a finger g) causes the loss of sight
or toe; in an eye.
 Who Investigates Accidents?

Supervisors

They have a personal interest to protect.

They know their people, the conditions and the
job.
They know how to get the information needed.
They will take action in any case.
 Who Investigates Accidents?
Joint Health and Safety Committee (JHSC)
Representative

They are familiar with the people and

workplace.
They have a legal requirement in Critical
Injuries
They have been trained in Accident
Investigation
 Who Investigates Accidents?

Government and Business

Ministry of Labor (MOL)

Ministry of the Environment (MOE)
Workplace Safety & Insurance Board
 Before an Accident Occurs…

Create an accident “action plan”

Create an Accident Investigation Policy

Develop Investigation Procedures

Practice
 When To Investigate An Accident

Immediately or ASAP
( If a Critical Injury or Immediately Reportable
Accident, secure the scene and advise the
ministry of labor (MOL )

Accident Investigation Procedures should be in

writing to ensure a consistent response to all
accidents.
 At the Accident Scene

Control the Scene

People are the first priority; send for help;
make sure area is safe; administer first aid
Stop Ongoing Hazards
Get personal protective equipment; provide
emergency lighting, power, air, etc.
Collect Evidence
Take notes, pictures, sketches of tools,
equipment, layout, etc.
 At the Accident Scene

Contributing Factors:
Housekeeping
Floor/surface conditions
Noise
Air quality/temperature
Equipment malfunction
Supervision
Employee morale/attitude/health
Alcohol/drug abuse
 What Equipment Is Required?

Personal Protective Camera (battery and

Equipment film)
Caution Tape Flashlight (with
Measuring Tape batteries)
Graph Paper Emergency Phone
Numbers
Pencils
Accident Investigation
Lockout / Tag out Forms
Clipboard Optional - tape recorder,
photo log, flares, etc.
 Immediate Causes

Struck By Contact with

Struck Against - Electricity
Caught In, On, - Heat or Cold
Between, or Under
- Radiation
Fall On, In, or From
- Noise
Scraped / Rubbed
Against - Caustics
Overexertion or Body - Toxic Substances
Strain
 Basic Causes

Lack of preventative Unsafe Working or

maintenance Travelling Speed
Servicing, Moving or Unsafe Working
Live Equipment Posture or Position
Failure To Warn or Incorrect Equipment or
Secure Body Use
Tampering or Poor or Improper Work
Removing Safety Practices
Devices

Personal Factors Job Factors
Poor Motivation
Labor Relations
Lack of Skill or Knowledge
Physical and/or
Psychological Problems
Root Causes
Poor Purchasing Standards
Poor Work Standards
Poor Maintenance or
Design
Abnormal Usage
Excessive Wear and Tear
Lack of Programs and
Procedures
 Equipment or Conditions
Involved

Equipment Conditions
Metal Lab cart water on floor
Specimen Blender damaged equipment
Metal work counter running water
electrical appliance
plug-ins (cart &
counter)
metal sink
leather shoes
eyeglasses
 Accident Scene

• view accident scene at

https://www.youtube.com/watch?v=YjVOJUrhrJ
M

• What happened?
 Flip Chart Layout

Who was injured?

What happened?

How to prevent a recurrence?

Accident Investigation
Part II
 Effective Accident Investigations

What to Look for:

Policies/Procedures Equipment Materials

Environment Task People/Operators

Accidents generally have more than one cause

 Accident Investigation Process

Response Interview Witnesses

Assess Scene / Identify Analysis and

Witnesses Conclusions
Preserve Evidence
Recommendations
Notification
Follow up
 Accident Investigation Forms

Internal Accident Report

Investigator’s Checklist

Witness Interview Form

JHSC Accident Investigation Report

Accident Findings Recommendation Form

 At the Accident Scene

Contributing Factors:
Housekeeping
Floor / surface conditions
Noise
Air quality / temperature
Equipment malfunction
Supervision
Employee morale / attitude / health
Alcohol / drug abuse
 Basic Causes

Preventative Unsafe Working

Maintenance Posture or Position
Servicing Moving or Incorrect Equipment
Live Equipment or Body Use
Failure To Warn or Poor or Improper
Secure Work Practices
Tampering or Removing
Safety Devices
Unsafe Working or
Travelling Speed
 Root Causes

Personal Factors Job Factors

Poor motivation and/or Poor purchasing
labour relationship Standards
Lack of skill or Poor work standards
knowledge Poor maintenance or
Physical and/or design
psychological problems Abnormal usage
Excessive wear and
tear
 Who Are The Witnesses ?

Eye Witness
First Person (s) at the scene Witness
Surrounding Events Witness
Person Having Knowledge
 Interview Process

 First - Get The Big Picture

 Separate All Witnesses
 Interview Each Witness Alone and In Private
 Interview Eye Witnesses First
 Interview At Accident Scene (when advisable)
 Effective
Interview Technique

 Put person at ease  Always thank person for

 Explain purpose of accident
investigation
 Listen to the individual’s
version
 Ask the right questions at the
right time
 Repeat the information given  Keep the door open for
back to the individual
their cooperation
 Immediately document
critical information
 Provide drawings and
photos where useful
 Probe for Basic Causes
further information
 Interviewing
Questions To Ask

• Where were you at the time of the accident ?

• What were you doing at the time ?

• What did you see, hear ?

• What were the environmental conditions ?

• What was the injured worker doing at the time ?

• In your opinion, what caused the accident ?

• How might similar accidents be prevented in the future ?

 Interviewing
Questions to Ask

• Ask “WHY” 5 times

• “He was lying on the floor” - Why?
• “Because there was water on the floor” - Why?
• “Because there was a leak in the sink” - Why?
• “Because maintenance hadn’t fixed it” - Why?
• “Because they’re short-staffed” - Why?
• “Because of the hiring freeze”
 Typical Investigation

• Who was injured? John Doe

Slipped on spill on floor

• What happened? and struck their head.

• How to prevent a We should clean up spills

recurrence? right away or put sign up
saying wet floor.
Hot link to poster 2
 At the Accident Scene

• Contributing Factors:
• Housekeeping
• Floor/surface conditions
• Noise
• Air quality/temperature
• Equipment malfunction
• Supervision
• Employee morale/attitude/health
• Alcohol/drug abuse
 Investigation Begins
• Individual shots of accident scene

• Click link(s)

• Lab cart - first view

• Lab cart - second view
• Plug
• Water
• Feet
 Investigation Begins

Examples…

Immediate Causes?

Basic
Causes?

Root Causes?
 Effective Investigation
Examples…

Immediate Causes? Contact with live equipment

Fall to the floor
Struck head

Basic Tampering / removal of safety device

( insulating rubber feet
Causes? Water on floor

Poor maintenance / housekeeping

Root Causes? Poor labour relations
Poor health
 Accident Scene
Re-visited

• View accident scene and identify and

reconfirm again following queries.

• What really happened?


 Have intermediate control
measures been
implemented prior to final
corrective measure ?
 Have the intermediate or
final corrective measures
resulted in further
hazards?
 How adequate are the
control measures ?
Recommendations
& Follow - Up
 How effective are the
control measures ?
 Has there been follow-up
and an analysis of the
corrective measures to
ensure they have been
implemented and are
effective ?
Thank You
OPTIONAL SCENARIO:
OFFICE ACCIDENT
OPTIONAL SCENARIO:
OFFICE ACCIDENT
 OFFICE ACCIDENT

Contributing Factors:

Policies/Procedures Equipment Materials

Environment Task People/Operators

 Office Accident Investigation

Immediate Causes?

Basic
Causes?

Root Causes?
 Office Accident Investigation

Immediate Causes? Fall to the floor

Struck back

Basic Using improper procedure / equipment

Standing on cabinet
Causes?

Root Causes? Working alone

Training
 OFFICE ACCIDENT
CONCLUSION

Accidents generally have more than one

cause
Keep asking WHY until you determine the root
cause
Thank You