Accident and Incident

Investigation
 Objectives of this Section

• Learning Outcome:
• Students should be able to explain the
processes & procedures for
investigating & reporting accidents at
work
• Students should be able to understand
the importance of proactive & reactive
health & safety monitoring measures
 Accident Investigation
Purpose
• To investigate why accidents happen.
• improve health and safety performance by:
 Find out the cause of accidents;
 Find a solution to overcome the accidents
 What to Investigate?
• All accidents whether major or minor.

• Serious accidents and minor accidents can be

caused for the same cause. Therefore the root cause
of the accidents needs to studies
Some studies show that the non injury accidents are an
important indication as shown below

1
Major injury
Or illness

7
Minor injuries or illnesses

189
Non Injury Accidents/Illnesses
 Accident Studies
• In all cases the ‘non injury’ incidents had the potential
to become events with more serious consequences.

• Such ratios clearly demonstrate that safety effort

should be aimed at all accidents
• Peterson (1978) in defining the principles of safety
management says that “an unsafe act, an unsafe
condition, an accident are symptoms of something
wrong within the management’s system.”
 Stages in an Accident/Incident
Investigation
The stages in an accident/incident investigation are
shown in the following diagram.

Deal with immediate

risks.

Select the level of

investigation.

Investigate the event.

Record and analyse the

results.

Review the process.

 Dealing with Immediate
Risks
Deal with immediate • When accidents and incidents occur
risks.
immediate action may be necessary
to:
Select the level of
investigation. Make the situation safe and
prevent further injury.
Investigate the event.
Help, treat and if necessary
rescue injured persons.
Record and analyse the
results.
Immediate help could be given
only if there is proper
Review the process.
documentation to handle the
situation. Therefore planning
is important
 Selecting the level of
investigation
The greatest effort should be put into:
Deal with immediate  Those involving severe injuries, ill-
risks.
health or loss.
 Those which could have caused much
Select the level of
investigation.
greater harm or damage.
These types of accidents and incidents
Investigate the event. demand more careful investigation and
management time. This can usually be
Record and analyse the
achieved by:
results.  Looking more closely at the
underlying causes of significant
Review the process. events.
 Assigning the responsibility for the
investigation of more significant
events to more senior managers.
 Investigating the Event

Deal with immediate

risks.
The purpose of investigations is
to establish:
Select the level of
investigation.
• The way things were and how they came to
be.
Investigate the event.
• What happened – the sequence of events
that led to the outcome.
• Why things happened as they did analysing
Record and analyse the
results. both the immediate and underlying causes.
• What needs to be done to avoid a repetition
Review the process. and how this can be achieved.
A few sources should give the investigator all that is
needed to know.
Observation
Information from physical
sources including:
 Premises and place of
work
 Access & egress
 Plant & substances in use
 Location & relationship of
physical particles
 Any post event checks,
sampling or
reconstruction
Documents
Information from:
 Written instructions;
Procedures, risk
assessments, policies
 Records of earlier
inspections, tests,
examinations and
surveys.
 Checking reliability, accuracy
 Identifying conflicts and resolving differences
 Identifying gaps in evidence
Interviews
Information from:
 Those involved and
their line
management;
 Witnesses;
 Those observed or
involved prior to the
event e.g. inspection
& maintenance staff.
 Interviews
• Interview is an important process to gather
information.
• Ideally the persons involved in the accident or
the persons who were there at the scene of
accident will be the best persons to be
interviewed
• The interview should be held in a private
place
• Information provided should be kept
confidential
 Interviews

• Interviews should be held at different times

and places to stop people from influencing
each other.
• Questions asked should not be aggressive or
blame anyone, instead it should be carried
out in a fact finding manner.
 Observation
The accident site should be inspected as
soon as possible after the accident. Particular
attention should/must be given to:

• Positions of people.
• Personnel protective equipment (PPE).
• Tools and equipment, plant or substances in
use.
• Orderliness/Tidiness.
 Documents
Documentation to be looked at includes:
• Standard operating procedures
• Risk assessment
• Procedures in carrying out an investigation
Other documents include
• Records of inspections, tests, examination and
surveys undertaken before the event. These will
provide more information towards what could have
caused the accident.
 Determining Causes
• Collect all information and facts which surround the
accident from the interview and documentations.

• Immediate causes could be found that relates to the

accident. Unsafe acts show poor safety attitudes and
indicate a lack of proper training.

• These needs to be addressed immediately

Determine the changes

• Determine the current control measure

• Is the control measure inadequate or not
• Create remedies to control this situation
 Remedial action

• Eliminate Risks - try to substitute the dangerous

situation with a lesser dangerous situation
• Combat risks by having more controls have
protective measures
• Minimise risk by designing suitable systems of
working.
• Use personal protective equipments
 Recording & Analysing the
Results
• Recorded in a similar and systematic
manner.
Deal with immediate
risks. • Provides a historical record of the accident.
• Analysis of the causes and recommended
Select the level of preventative protective measures should be
investigation. listed.
• Completed as soon after the accident as
Investigate the event. possible.
• Information on the accident and remedial
actions should be passed to all supervisors.
Record and analyse the
results. • Appropriate preventative measures may
also have to be implemented by such
Review the process. supervisors.
• Investigation reports and accident statistics
should be analysed from time to time to identify
common causes, features and trends not be
apparent from looking at events in isolation.
 Reviewing the Process
The entire process should be
Deal with immediate reviewed to assess its reliability
risks.
 Line managers and supervisors
Select the level of should be in charge of evaluating
investigation.
 New risk should be assessed
Investigate the event.  Check if the system is working well
according to different time frame
Record and analyse the
results.

Review the process.

 QUESTION

In a construction site a worker was killed as a

falling concrete fell on the worker. It resulted
in immediate death. Using the process of
investigation what are your further actions in
investigating this accident.