Accident Investigation

“If you think safety is expensive, try an accident” !

Dr. Muhammad Usman Farooq

(CH-161)
Ghulam Ishaq Khan Institute Of Engineering Sciences & Technology
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What is an accident ?
An unwanted, unplanned event that causes injuries, illnesses, or property
damage.

o Bad event caused by error or by chance.

o Unintentional, results in some damage or injury.
o Result of the failure of people, equipment, materials or environment to

react as expected.
• A car crash is one example of an accident.
• If some equipment malfunctions in a factory and injures the workers, that is
also an accident
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What is an Incident ?

o Big or small, good

or bad, intentional
or unintentional. A
bank robbery, a
funny or
controversial
situation etc.
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• Undesired circumstance: a set of conditions or circumstances that have the potential to

cause injury or ill health, e.g. untrained operators working on heavy machinery.
• Near miss: an event that, while not causing harm, has the potential to cause injury or ill
health.

  

Unsafe Condition Near Miss Accident

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Types of Accidents
FAC (First aid case):
An accident occurring while on the job and which is treated at site by the qualified first aider
(one time treatment) or any minor industrial injury which normally do not need medical
intervention. The injured person resume his work .
MTC (Medical treatment case):
Medical treatment case an accident occurring in plant, and which required intervention of
qualified medical professional. The injured person required medication more than a day and he
may or may not resume duty on same day.
LTA or LTI (Lost time accident or incident ):
A lost time injury (LTI) is an injury sustained by an employee that will ultimately lead to the loss
of productive work time in the form of worker delays. An injury is considered a lost time injury
only when the worker is unable to perform the regular duties of the job, takes time off for
recovery, or is assigned modified work duties for the recovery period.
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Reasons for Incident/Accident Investigation

1. Logic and understanding

2. Legal reasons

3. Benefits
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Reasons for Incident/Accident Investigation
1- Logic and Understanding
• All incidents/accidents have causes … eliminate the cause and eliminate
future incidents.
• The direct and indirect causes of an incident/accident can be discovered
through investigation.
• Corrective action indicated by the causation can be taken to eliminate
future incidents/accidents.
• Valuable information and understanding can be gained from carrying out
accident/incident investigations.
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Reasons for Incident/Accident Investigation
2- Legal Reasons

• To ensure that the organization is operating in compliance with legal

requirements.

• Company has a positive attitude to health and safety.

• The investigation will also provide essential information for insurers in the

event of an employer’s liability or other claim.

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Reasons for Incident/Accident Investigation
3- Benefits
• The prevention of similar events occurring again.

• The prevention of business losses due to disruption immediately after the

event, loss of production, loss of business through a lowering of reputation or

inability to deliver, and the costs of criminal and legal actions.

• Improvement in employee morale and general attitudes to HS

• Improving management skills to improve health and safety performance

throughout the organization.

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When Should the Investigation Be Conducted?
Immediate information from the person suffering the accident often proves to be
most useful.

• Factors are fresh in the minds of witnesses

• Witnesses have had less time to talk

• Physical conditions have had less time to change

• More people are likely to be available,

• Take immediate action to prevent a recurrence and to demonstrate management

commitment to improvement
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INVESTIGATION PROCESS

(1). Immediate
Action (5). Analyse
Information
(2). Plan the
Investigation
(6). Recommend
(3). Collect Solution
Information
(7). Report
(4). Organize Outcomes
Information
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1- Immediate Action

• Does anyone require medical attention.

• How can the incident scene be secured and taken control of?

• Are there any hazards, that pose a danger to yourself or other persons, that

need removing?

• Was any equipment involved in the incident?

• Were any departmental vehicles involved in the incident?

• Does any individual or organisation need to be informed of the incident?

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2- Plan The Investigation

• What is the time frame for the investigation?

• Who do I need to speak to?

• Does anything need to be photographed?

• Do you need to draw a sketch plan of the incident scene?

• What other documents need to be collected or sighted?

• Who do I report the investigation findings to?

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2- Plan The Investigation
Preparation for investigation

 Seal the accident area.

 Interview witnesses.

 Draw and take measurements of the

accident area.

 Take samples.
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3- Collect Information

• The date, time and location of the incident

• The people involved

• Any known events leading up to the incident

• What was happening at the time of the incident

• Weather conditions.
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3- Collect Information (Conducting Interviews)

• Purpose for investigating the incident is to find out why it happened

• If any witnesses are reluctant to speak to you, assure them that your
investigation is not attempting to apportion blame or liability.
• If possible, speak to witnesses at the scene.
• Speak to people separately.
• Always use simple language and avoid acronyms.
• Most importantly, close each interview on a positive
note.
Who, what, when where and how
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3- Collect Information (Conducting interviews)

• Open questions
• What did you see?
• Who else was there?
• When did it happen?
• Closed questions
• Are you feeling better today?
• Are you happy?
• Multiple questions
• Did you see the staircase tread break and the
teacher walking down the staircase carrying a box?
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3- Collect Information (Recording Statements )

• The oral information people provide needs to be recorded in some sort of

written document.
• This is commonly known within investigation circles as ‘taking a statement’.
Because there is no blame in a health and safety investigation, and liability is
attached to the investigation outcome,
• The information you gather will not be presented as evidence in a court of
law.
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3- Collect Information (Recording the Scene)

• As Napoleon Bonaparte has been credited with saying, ‘A picture is worth a thousand words.

• Photographs are one of the most useful investigation tools,

• Taking photographs can eliminate the need to write descriptions.

• Photographs assist the investigation by providing a permanent record of:

 The original scene and as things change

 Any scratches, dents and perishable evidence (e.g., Tyre marks, bruises)

 Before and after views (e.g., Scene, equipment).

 They also enable comparison between damaged and undamaged equipment

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4- Organise Information

• Put it into some order

• Timeline chart
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5- Analyse Information

• To determine the cause of the incident, the events on the timeline need to
be analysed or examined. To do this, you need to ask ‘why’ an event
occurred and keep asking ‘why’ until you know why the event occurred.
• Identify the possible causes, identify which are within the control of
workplace.
• Can you apply a solution to a possible cause if it is outside the control of
the workplace ?
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5- Analyse Information
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 Say what happened step-by-step.

 Analyze the events with the 6 key questions:
Who saw the crash?
◦ Who?
What happened to the brakes?
◦ What?
When did the brakes fail?
◦ When? Where were the replacement brakes?

◦ Where? Why wasn’t the mechanic told?

◦ Why? How did the crash happen?

◦ How?
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5- Analyse Information
• Immediate Causes:
• Unsafe acts Unsafe conditions
• Underlying or Root Causes: Reasons behind the immediate causes Often
failures in the management system
 No supervision
 No PPE provided
 No training
 No maintenance
 No checking or inspections
 Inadequate or no risk assessments
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6- Recommended Solutions
Sometimes it is easier to look for solutions by using a table or columns.
• In one column, list the possible causes you found during your analysis of the
timeline.
• In the next column, indicate whether the possible causes are within the control of
the workplace. In the third column, write all the possible solutions.
• Dangerous conditions must be dealt with immediately Interim actions may be
possible.
• Underlying causes will require more complex actions.
→ will take time, effort, disruption, money
→ need for prioritisation
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6- Recommended Solutions

• Elimination – Complete elimination of the risk.

• Substitution – Replace the risk with a less dangerous one.

• Engineering – Redesign the work process or equipment.

• Administration – Provide training and/or procedures.

• Personal protective equipment – Use personal protective equipment.

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7- Report Outcomes

• Report the investigation findings.

• Include all collected information.
• Finally, it must includes an executive summary.

“Remember, to have an incident in the workplace is regrettable but to have

an incident and not learn from it is unforgivable, so if you are aware of it
take care of it.”
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• Say what happened.

• Say which were the surface causes.
• Say which were the root causes.
• Say what needs to be done so the accident doesn’t happen again.
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Thank you !