Course 162 Accident Investigation: Basic

Gathering the Facts

What is an Accident?

An accident is the final event in an unplanned process that results in injury or illness to an employee and possibly property damage. It is the final result or effect of a number of surface and root causes.

  • An "event," occurs when one "actor" (one person/thing) performs an "action" (does something).
  • A person or thing (equipment, tools, materials, etc.) will do something that results in a change of state.
  • An accident may be the result of many factors (simultaneous, interconnected, cross-linked events) that have interacted in some dynamic way.

Reporting Accidents to OSHA

injury
This flowchart explains when you need to report an injury to OSHA.
Click to enlarge.

If your company is in the private sector, and a serious accident or fatality occurs, you may be required to report it to your State or Federal OSHA office.

OSHA Standard 1904.39, Reporting fatalities, hospitalizations, amputations, and losses of an eye as a result of work-related incidents to OSHA, details the specific requirements.

Basic Requirements

Within eight (8) hours after the death of any employee as a result of a work-related incident, you must report the fatality to the Occupational Safety and Health Administration (OSHA), U.S. Department of Labor.

Within twenty-four (24) hours after the in-patient hospitalization of one or more employees or an employee's amputation or an employee's loss of an eye, as a result of a work-related incident, you must report the in-patient hospitalization, amputation, or loss of an eye to OSHA.

1. How soon must an employer report a work-related fatality to OSHA?

a. Within 30 hours
b. Within 24 hours
c. Within 16 hours
d. Within 8 hours

Accident Types

Safety Memo - The Accident Cascade

An accident isn't just an event that you can lump into one big category. In reality, there are many different types of accidents. Let's take a look at a partial list.

  • Struck-by: A person is forcefully struck by an object. The force of contact is provided by the object.
  • Struck-against: A person forcefully strikes an object. The person provides the force or energy.
  • Contact-by: Contact by a substance or material that, by its very nature, is harmful and causes injury.
  • Contact-with: A person comes in contact with a harmful substance or material. The person initiates the contact.
  • Caught-on: A person or part of his/her clothing or equipment is caught on an object that is either moving or stationary. This may cause the person to lose his/her balance and fall, be pulled into a machine, or suffer some other harm.
  • Caught-in: A person or part of him/her is trapped, or otherwise caught in an opening or enclosure.
  • Caught-between: A person is crushed, pinched or otherwise caught between a moving and a stationary object, or between two moving objects.
  • Fall-to-same-surface: A person slips or trips and falls to the surface he/she is standing or walking on. This is the second-most common accident causing injuries in the workplace.
  • Fall-To-below: A person slips or trips and falls to a level below the one he/she was walking or standing on. This is the third-most common accident in the workplace (NSC).
  • Overexertion: A person over-extends or strains himself/herself while performing work. This is the most common accident in the workplace (NSC).
  • Bodily reaction: Caused solely from stress imposed by free movement of the body or assumption of a strained or unnatural body position. A leading source of injury.
  • Over-exposure: Over a period of time, a person is exposed to harmful energy (noise, heat), lack of energy (cold), or substances (toxic chemicals/atmospheres).

2. According to the National Safety Council (NSC) this is the most common accident type in the workplace.

a. Falls-to-same-surface
b. Bodily reaction
c. Overexertion
d. Falls-to-below

Effective Accident Investigation Program

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Everyone knows what to do when the program is effective.

An effective accident investigation program will be guided by standard written procedures. It's important to make sure procedures are clearly stated and easy to follow in a step-by-step fashion. The effective program will include the following elements:

  • Joint Investigation: Usually a supervisor, safety manager, or management/labor team conducts the investigation. Usually, two heads work better than one, especially when gathering and analyzing material facts about the accident. We recommend a team approach.
  • Training: All accident investigators will be formally trained on accident investigation techniques and procedures.
  • Fact-Finding vs. Fault-Finding: The accident investigation must be perceived as separate from any potential disciplinary procedures resulting from the accident. The purpose of the accident investigation is to get at the facts, not find fault. The accident investigator must be able to state with all sincerity, that he or she is conducting the investigation only for the purpose of determining cause, not blame.
  • Recommendations: The accident investigation report will make recommendations to correct hazardous conditions, work practices, and those underlying contributing factors that allowed them to exist. In many instances, the surface causes for the accidents are corrected on the spot, and will be reported as such. But the investigator must make recommendations for long-term corrections in the safety and health system to make sure those surface causes do not reappear.
  • Formal Report: The accident investigation report will be in writing and will make sure that the surface causes and root causes of accidents are addressed. Most accident reports are ineffective precisely because they neglect to uncover the underlying reasons or factors that contribute to the accident.
  • Follow-up: Assignment of responsibilities and follow-up procedures to make sure short and long-term corrective actions are completed.
  • Review: An annual review of accident reports. A couple of safety committee members evaluate accident reports for consistency and quality. They must make sure root causes are being addressed and corrected. Information about the types of accidents, locations, trends, etc., can be gathered.

3. What is the purpose of an accident investigation?

a. To determine legal liability
b. To find facts, not fault
c. To prevent OSHA investigations
d. To establish who is at fault

The Six Step Investigation Process

In this episode of "Safe in 60 Seconds" InterAct Safety Solution's president, Bart Spence, shares some tips on incident investigation and defining the problem.

The accident investigation process we will discuss in this course will make sense if you understand that ultimately, the purpose of the investigation is to improve the safety management system. Conducting the investigation for any other reason will likely result in ineffective solutions. In this course, we'll introduce a six-step process for conducting accident investigations.

Step 1: Secure and Document the Accident Scene

Securing the Scene

The first step in an effective accident investigation procedure is to secure the accident scene as soon as possible so that we can accurately gather facts. At this point, you are not yet interested in what "caused" the accident. Instead, you should focus on making the accident scene secure so that you can gather as much pertinent information as possible.

To secure the accident scene, simply use yellow caution tape, place warning cones, or post a guard to keep people away.

Starting the Investigation

Don't start documenting the scene until it is safe to do so. As the accident investigator, you don't want to get in the way of emergency responders. It's also not safe to start if hazards have not been properly mitigated.

4. When should the accident investigation be initiated?

a. Within 8 hours of the accident
b. Immediately after the event
c. When it is safe to do so
d. When OSHA requires it

Documenting the Accident Scene

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Take photos from all directions, distance and close-ups.

Once the accident scene has been roped off, it's important to immediately begin gathering evidence from as many sources as possible during an investigation. You want to gather data that will help you determine what happened, how it happened, and why it happened.

You won't be able to document the scene effectively unless you come prepared, so make sure you have put together an accident investigation kit for use during the investigation. As you'll learn, there are many ways to document the scene, so it may become quite difficult for one person to effectively complete all actions.

The most effective strategy is to document as much as possible, even if you don't think the information may be relevant. It's easy to discard clues or leads later if they prove to not be useful to the investigation. It's not at all easy to dig up material evidence late into the investigation.

  • Make personal observation: With clipboard in hand, take notes on personal observations. Try to involve all of your senses (sight, hearing, smell, etc.).
  • Get initial written statements: If you are fortunate, there will be one or more eyewitnesses to the accident. Ask them for an initial statement giving a description of the accident.
  • Take photos and videos: When taking photos, make sure you start with distance shots, and gradually move in closer as you take the photos. Take photos from different angles. Use rulers to size objects. Identify what is being photographed. When taking video, try to get witnesses to describe what happened.
  • gsg photo Overhead sketch of an accident scene
    Triangulation Method
    Click to enlarge.
  • Sketch the scene: Sketches are very important because they compliment the information in photos, and are good at indicating distances between the various elements of the accident. This is important to do because it establishes "position evidence." It is important to be as precise as possible when making sketches. The sketch to the right illustrates the Triangulation Method which makes it possible to later pinpoint the exact location of an object. Notice the small circles with horizontal lines through them. These circles indicate where photos were taken. Also, North is indicated and all major objects are identified.
  • Interview records: That's right. Don't just review the records. Ask questions and they will give you answers. Records include training records, preventive/corrective maintenance reports, Job Hazard Analyses, standard operation procedures, work schedules, and previous hazard reports, etc.

5. Each of the following activities is part of documenting the accident scene, EXCEPT _____.

a. placing warning tape around the accident scene
b. making personal observations
c. taking initial written statements
d. taking photographs and video

Step 2: Interview Witnesses

Good Interview Techniques

After you have initially documented the accident scene, the next step is to start digging for additional details by conducting interviews. This activity is perhaps the most difficult part of an investigation. The purpose of the accident investigation interview is to obtain an accurate and comprehensive picture of what happened. Remember, you're conducting an accident investigation, not a criminal investigation. The last thing to do in the interview is to come down hard (be accusatory) on an interviewee.

So let's take a look at some effective techniques that will assure you get the facts. An important aspect of your job, as the interviewer, is to construct a composite story or "word picture" of what happened using the various accounts of the accident and other evidence. So, let's review some effective interviewing techniques:

  • Tell the interviewee the purpose of the interview is to get facts, not place blame.
  • Do not interview more than one person at a time. The facts change when others are listening.
  • Ask for background information. Then, simply have the witness tell you what happened. Let them talk, and you just listen.
  • Don't ask them "if" they can explain what happened, because they may respond with a simple "no," and that's that.
  • Go to the scene to interview if you can. If you can't, find an office or meeting room that the interviewee considers a "neutral" location.
  • Put the person at ease. Explain the purpose and your role. Sincerely express concern regarding the accident and desire to prevent a similar occurrence.
  • Be friendly, understanding, and open minded. Be calm and unhurried.
  • Don't ask leading questions; don't interrupt; and don't make expressions (facial, verbal of approval or disapproval).
  • Do ask open-ended questions and avoid closed-ended questions that require a simple yes and no answer.
  • Avoid asking "why-you" questions as these type of questions tend to make people respond defensively.
  • Repeat the facts and sequence of events back to the person to avoid any misunderstandings.
  • Take notes. Let the individual read your notes so that they can correct inaccuracies.
  • Don't record the interview unless you get permission.
  • If the interviewee wants to have someone witness the interview, that's fine.
  • Ask for the interviewee's opinion about what can be done to prevent another accident.
  • Thank the interviewee and ask them to contact you if they think of anything else that might be helpful.

6. What is the purpose of the accident investigation interview?

a. To establish who is primarily at fault
b. To determine the degree of involvement of the interviewee
c. To get an accurate picture of what happened
d. To determine extent of injuries and damage to equipment

Step 3: Conduct Event Analysis

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Analyze the data to develop a sequence of events.

So far, you have collected a lot of factual data and it's strewn all over your desk. The task now is to turn that data into useful information. You've got to somehow take this data and make some sense of it.

Assessment vs. Analysis

It's important to know that you're not gathering all of this information just to conduct an assessment of what was and was not present immediately prior to the accident. You're actually conducting an analysis to determine specifically how surface causes (behaviors and conditions), and the underlying root causes (system weaknesses) contributed to the accident. To better understand this, let's take a closer look at what the process of "analysis" is.

Analysis Defined

Webster defines analysis as the, "separation of an intellectual or substantial whole into its parts for individual study."

The accident is a complicated process of individual events leading up to and including the main event. When an accident occurs, we need to separate or "break down" the "whole" accident into its component "parts" for study to determine how they contributed to the accident: the main event.

The accident investigator's challenge is to effectively assess each event to identify the presence or absence of behaviors and conditions, and then analyze those behaviors and conditions in each event to determine if and how they contributed to the accident. To do this we need to make some basic assumptions about the factors that cause or contribute to accidents.

7. What is the definition of analysis?

a. Assessing the need for improvements in processes
b. Judging the effectiveness of a process or procedure
c. Separating the whole into its individual parts for study
d. Determining how the whole contributes to its individual parts
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Each event has an actor and an action.

Analyzing Each Event

In developing a sequence of events, the challenge is to take the information gathered and arrange it so that we can accurately determine what initial conditions and/or actions transformed the planned work process into an unintended accident process.

The two components of an event: The Actor and the Action

Each event in the unplanned accident process is composed of an actor and an action, so let's take a look at each.

  1. Actor: The actor is an individual or object that directly influenced the flow of the sequence of events. An actor may participate in the process or merely observe the process. An actor initiates a change by performing or failing to perform an action.
  2. Action: An action is "the something" that is done by an actor. Actions may or may not be observable. An action may describe a behavior that is accomplished or not accomplished. Failure to act should be thought of as an act, just as much as an act that is accomplished.

It's important to understand that when describing an event in writing, first identify the actor and then tell what the actor did. Remember, the actor is the "doer," not the person or object being acted upon or otherwise having something done to them. For instance, take a look at the event statement below:

"Bob unhooked the lifeline from the harness."

In the example above, "Bob" is the actor and "unhooked" describes the action. First we describe the actor...Bob. Next, we describe the action...unhooking. The lifeline and harness, although "objects" are not actors because they are not performing an action. Rather, something is being done to them. Also note that the statement is written in active tense.

8. Each event in the sequence of events leading up to an accident will contain _____.

a. a combination of actors and events
b. one actor and one action
c. actors and related events
d. actors, actions, and consequences
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The challenge is to properly sequence the events resulting in the accident event.

Developing the sequence of events

Our challenge at this point in the investigation process is to accurately arrange the events to determine their correct sequence leading up to the accident so that we can more effectively understand why the accident event, itself, happened. Once the sequence of events is developed, we can then study each event in the sequence to determine the related causal factors below.

  • Hazardous conditions: Objects and physical states that directly caused or contributed to the accident.
  • Unsafe behaviors: Actions taken/not taken that directly caused or contributed to the accident.
  • System weaknesses: Underlying inadequate or missing policies, programs, plans, processes, procedures and practices that contributed to the accident.

Sample Sequence of Events

To get a good idea of what the sequence of events looks like, review the short example below:

  1. At approximately 12:45 PM employee #1 began dumping accumulated sand from an irrigation mainline pipe.
  2. Employee #1 oriented the pipe vertically and it contacted a high voltage power line directly over the work area.
  3. Employee #2 heard a ' zap' and turned to see the pipe falling and employee #1 falling into an irrigation ditch.
  4. Employee #2 ran to employee #1 and pulled him from the irrigation ditch.
  5. Approximately one minute later, paramedics arrived and began to administer CPR on employee #1.
  6. At approximately 1:10 PM an ambulance arrived and transported employee #1 to the hospital where he was pronounced dead at 1:30 PM.

9. What must be completed before the accident investigator can analyze events to determine surface and root causes?

a. Only keep those events that establish liability
b. Determine the total number of events
c. Accumulate all relevant events
d. Arrange events into their proper sequence

Paint a Word Picture

It's important the sequence of events clearly describe what occurred so someone who is unfamiliar with an accident is able to "see it happen" as they read the narrative.

gsg photo
You can use cards to develop the sequence of events.
Click to enlarge.

Sample Sequence of Events

Click on the image to the right to see how you can use cards to visually develop the sequences of events. Describe each single event on the front of the card and any additional source information on the back. Each card will indicate the actor and action. Attach any photos you take to the card. Arrange the cards on your desk or a wall in the proper sequence.

Construct One Event Only

If an event is hard to understand, it may be that the description is too vague or general. The solution to this problem is to increase the detail. We can use two strategies to increase detail:

  1. Look around: Determine if anything else was said/done before or after the event you' re currently assessing.
  2. Separate the actors: Remember, an actor may be a person or a thing accomplishing a given action. If an event includes actions by more than one actor, break the event down into two events. If the event contains the conjunction, "and," the event is likely to be a combination of two events. If you look at the sample sequence of the events from 5.9 and 5.10, I'm sure you can spot a few combined events.

Well, that was a short, but informative, introduction to the idea of constructing the sequence of events. Just remember, the accuracy of your investigation will be greater by following this procedure. It is now time to answer your final quiz question and check your answers below.

10. What is a clue that you have included too much information in an event?

a. All actions are stated in the past tense
b. The event description is too long
c. The event includes multiple actors or actions
d. The actor and action are not directly related

Check your Work

Click on the "Check Quiz Answers" button to grade your quiz and see your score. You will receive a message if you forgot to answer one of the questions. Any questions you missed will be listed below. To correct your answers, go back to the question, change your answer, and come back to this section and click on the "Check Quiz Answers" button again.

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