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Chapter XVII - Accident Investigation

Goal This program introduces basic accident investigation principles and describes accident analysis techniques.

Objective The employee will demonstrate knowledge of accident investigation principles and techniques.

Background There are four requirements for developing a comprehensive accident prevention program:  identify, control, and/or eliminate worksite hazards;  study operating procedures to identify potential problems;  train employees to recognize unsafe situations and practices; and  investigate accidents and near misses to prevent reoccurrence.

An accident investigation program is designed to uncover the root cause of the accident. An accident is a chance event that brings injury, loss or distress. This occurs when an excess amount of energy or hazardous material is encountered. This energy or hazardous material is the direct cause of the accident. The direct cause is usually the result of one or more unsafe acts and/or conditions. Unsafe acts and conditions are the indirect cause or symptoms. The root cause is the bottom line event that results in an accident.

Accidents that do not result in an injury are considered incidents and should be investigated. An incident is a near miss–an undesirable event–that could have resulted in property damage or personal injury.

Use the Why Principle to determine the root cause. This principle requires that an investigator continue asking Why? until there are no more questions requiring an answer. This end point is the root cause of the accident or event.

Purpose The information obtained from an accident investigation is used to determine the accident’s cause and prevent future accidents. An investigation finds facts, not faults. Most accidents can be prevented by eliminating one or more causes. Accident investigations determine what, how and why an accident occurred.

An accident investigation’s purpose is to:  learn the cause of the accident so that similar accidents can be prevented or controlled;  determine the event(s) which varied from normal procedures and resulted in the accident;  educate employees and supervisors on the hazard(s), and emphasize the importance of accident prevention  in the workplace; and  determine any legal liability that may exist due to the accident or injury.

Remember to investigate contributing factors and, using the Why Principle, search out the root cause.

XVII-1 Procedures  Define the scope of the investigation.  Select the investigators and assign specific tasks to each, preferably in writing.  Present a preliminary briefing to the investigating team, including:  a description of the accident, with damage estimates, using the supervisor’s accident report as the primary source;  normal operating procedures;  maps (local and general);  location of the accident site;  recorder, camera and/or VCR;  list of witnesses; and  events that preceded the accident.  Visit the accident site to get updated information.  Inspect the accident site to:  secure the area. Try not to disturb the site unless a hazard exists; and  prepare the necessary sketches and photographs. Label each carefully and keep accurate records.  Interview each victim and witness. Keep accurate records of the interview, and record the exact words. Conduct interviews as soon as possible after the event. Accurate reporting is directly affected by the time lapse between the accident and the interview.  Determine:  what was not normal before the accident;  where the abnormality occurred;  when it was first noted; and  how it occurred.  Analyze the data obtained and repeat any steps if necessary.  Determine:  why the accident occurred;  a likely sequence of events and probable causes (direct and indirect); and  alternative sequences.  Determine the most likely sequence of events and the most probable causes.  Conduct a post-investigation briefing with management.  Prepare a summary report, including recommended actions to prevent a recurrence.

There are some key facts to look for when conducting an investigation:  nature of injury - the type of physical injury sustained;  body part - the part of the body directly affected by the injury;  injury source - the object, substance, exposure, or bodily movement that directly produced or inflicted the injury;  accident type - the event which directly resulted in the injury;  hazardous condition - the physical condition or circumstance which allowed the accident to occur;  accident source - the object, substance, or part or condition of the environment where the hazardous condition existed;  hazardous object - the specific object/activity that was hazardous; and  unsafe act - the variation from an accepted safe procedure that directly resulted in the accident.

Investigation Techniques Job Safety Analysis (JSA) - is based on the following steps:  select the job to be analyzed;

XVII-2  separate the job into its basic steps;  identify the hazards associated with each step; and  control each hazard.

Fault Tree Analysis (FTA) - is a logic diagram showing all the potential causes of an accident/incident. FTA involves:  defining the undesired event to study;  obtaining an understanding of the system;  constructing the fault tree;  evaluating the fault tree;  controlling the identified hazards.

This information determines the most probable sequence of events leading to the accident/incident.

Investigation Techniques No investigation is complete until the report is made to management. The following useful information should be included in the formal report:  Background Information:  where and when the accident occurred;  who and what were involved; and  operating personnel and other witnesses.  Accident Report (What happened?):  sequence of events;  extent of damage;  accident type (fall, caught, struck, etc.); and  source of energy or hazardous material (electrical, chemical, gas, poison, etc.).  Discussion (Analysis of the Accident - How? Why?):  direct causes (energy sources: hazardous materials);  indirect causes (unsafe acts and conditions);  contributing causes (management policies, personal or environmental factors);  Recommendations (to prevent or control a recurrence):  direct causes (such as reduced quantities of protective equipment or structures);  indirect causes; and  Contributing causes.

A successful accident investigation determines not only what happened, but also finds how and why the accident occurred. Comprehensive documentation and recordkeeping of all incidents and accidents can be a valuable tool in the investigation and accident prevention process. The ultimate goal of an investigation is to prevent a similar or perhaps more disastrous sequence of events from occurring in the future.

Disclaimer: Information contained in this training program is considered accurate. For complete information on rules and regulations on accident investigation procedures, please consult OSHA’s “Voluntary Guidelines for Effective Safety & Health Programs”.

XVII-3 XVII-4 Accident Prevention Plan

Review Checklist

Company Name: ______Jobsite Address: ______Supervisor: ______Date/Time: ______Inspector(s): ______

Check Items Inspected Yes No N/A Date Corrected Worksite General • OSHA (or other required) posters displayed in prominent location? [ ] [ ] [ ]______• Are safety signs/warnings posted where appropriate? [ ] [ ] [ ]______• Are emergency telephone numbers posted where they can be found readily? [ ] [ ] [ ]______• First aid kit available and adequately stocked? [ ] [ ] [ ]______• Substance abuse policy in-place? [ ] [ ] [ ]______• Summary of Occupational Injuries and Illnesses posted? [ ] [ ] [ ]______• Emergency evacuation traffic routes identified? [ ] [ ] [ ]______• Written drug/substance abuse policy established and distributed to employees? [ ] [ ] [ ]______

Management Component • Written policy statement? [ ] [ ] [ ]______• Policy statement signed by management? [ ] [ ] [ ]______Current? [ ] [ ] [ ]______• Are copies of the policy provided to new employees? [ ] [ ] [ ]______• Individual(s) responsible for development, implementation, and enforcement of accident prevention plan? [ ] [ ] [ ]______• Employee/Supervisor responsibilities and authority assigned? [ ] [ ] [ ]______• Safety team established to monitor safety and health program? [ ] [ ] [ ]______• Established procedure for handling employee safety and health complaints? [ ] [ ] [ ]______

Recordkeeping Component • OSHA 200 (or other required logs) being maintained as required? [ ] [ ] [ ]______• Procedures in place to maintain records and logs? [ ] [ ] [ ]______a. Safety inspections [ ] [ ] [ ]______b. Safety meeting minutes [ ] [ ] [ ]______c. Accident investigations [ ] [ ] [ ]______d. Emergency response drills [ ] [ ] [ ]______• Employee medical records up-to-date and in accordance with OSHA standards? [ ] [ ] [ ]______• Employee exposure records to hazardous substances or harmful physical agents maintained? [ ] [ ] [ ]______• Employee training records maintained and available for employee review? [ ] [ ] [ ]______Yes No N/A Date Corrected XVII-5 • Are records being maintained for time frame as required? [ ] [ ] [ ]______

• Are operating permits and records current? [ ] [ ] [ ]______• Responsible person designated? [ ] [ ] [ ]______

Analysis Component • Has a job safety analysis been conducted? [ ] [ ] [ ]______• Has a trend analysis been conducted? [ ] [ ] [ ]______• Is there an established time frame for analysis (monthly, quarterly, semi-annually, annually)? [ ] [ ] [ ]______• Are analysis records maintained and current? [ ] [ ] [ ]______• Safety program documentation reviewed for completeness? [ ] [ ] [ ]______• Identified discrepancies corrected? [ ] [ ] [ ]______• Insurance loss run information matches records? [ ] [ ] [ ]______• Safety program current for all employer operations and employee activities? [ ] [ ] [ ]______• Accident prevention program documentation reviewed for completeness? [ ] [ ] [ ]______• Hazard assessments conducted, current and controls established? [ ] [ ] [ ]______• Responsible person designated? [ ] [ ] [ ]______

Health & Safety Training Component • Have new employees received orientation training? [ ] [ ] [ ]______• Employees participate in regularly scheduled safety meetings? [ ] [ ] [ ]______• Management provides resources and participates in employee training? [ ] [ ] [ ]______• Have employees received and documented required training? [ ] [ ] [ ]______a. Work area hazards [ ] [ ] [ ]______b. Emergency action plan [ ] [ ] [ ]______c. Equipment operation [ ] [ ] [ ]______d. Personal protective equipment [ ] [ ] [ ]______e. Location and use of emergency equipment [ ] [ ] [ ]______f. Hazard communication/MSDS [ ] [ ] [ ]______g. Hearing conservation [ ] [ ] [ ]______• Do all employees receive refresher training at least annually? [ ] [ ] [ ]______• Have employees received instruction on reporting procedures to report unsafe conditions, defective equipment, and unsafe acts? [ ] [ ] [ ]______• Have supervisors received instruction in accident investigation and hazard abatement? [ ] [ ] [ ]______• Employees received required OSHA training, as needed? a. Emergency action plan? [ ] [ ] [ ]______b. Fire prevention plan? [ ] [ ] [ ]______c. Operation of powered platform? [ ] [ ] [ ]______d. Hearing protection? [ ] [ ] [ ]______e. Ionizing radiation? [ ] [ ] [ ]______f. Storage of Flammable and Combustible Liquids? [ ] [ ] [ ]______e. Explosives or blasting agents? [ ] [ ] [ ]______g. Storage and Handling of LP gases? [ ] [ ] [ ]______h. Process safety management of highly hazardous chemicals? [ ] [ ] [ ]______i. Hazardous waste operations and emergency response? [ ] [ ] [ ]______

XVII-6 Yes No N/A Date Corrected

j. Respiratory protection? [ ] [ ] [ ]______k. Accident prevention signs and tags? [ ] [ ] [ ]______l. Permit required confined space? [ ] [ ] [ ]______m. Control of hazardous energy - lockout/tagout? [ ] [ ] [ ]______n. Medical service and first aid? [ ] [ ] [ ]______o. Fire brigades? [ ] [ ] [ ]______p. Portable fire extinguishers? [ ] [ ] [ ]______q. Fire extinguishing system? [ ] [ ] [ ]______r. Servicing multi-piece and single-piece rim wheels? [ ] [ ] [ ]______s. Powered industrial trucks? [ ] [ ] [ ]______t. Mechanical power presses? [ ] [ ] [ ]______u. Welding? [ ] [ ] [ ]______v. Electrical safety related work practices? [ ] [ ] [ ]______w. Toxic and hazardous substances? [ ] [ ] [ ]______x. Bloodborne pathogens? [ ] [ ] [ ]______y. Hazard communication? [ ] [ ] [ ]______• Responsible person designated? [ ] [ ] [ ]______Yes No N/A _ Date Corrected Audit/Inspection Component • Regularly scheduled and conducted inspections? [ ] [ ] [ ]______a. Facilities [ ] [ ] [ ]______b. Worksite locations [ ] [ ] [ ]______c. Vehicles [ ] [ ] [ ]______d. Equipment and tools [ ] [ ] [ ]______e. Personnel protective equipment [ ] [ ] [ ]______f. Housekeeping [ ] [ ] [ ]______• Fire suppression equipment inspection current? [ ] [ ] [ ]______• First-aid equipment and sharps kit adequately supplied? [ ] [ ] [ ]______If medical/first-aid facilities are not in proximity, is at least one employee on each shift qualified to render first-aid? [ ] [ ] [ ]______• Are medical personnel readily available for advice and consultation? [ ] [ ] [ ]______• Are quick drenching and/or flushing areas available where corrosive liquids or materials are handled? [ ] [ ] [ ]______• Are inspection checklists utilized? [ ] [ ] [ ]______• Procedures established to ensure inspection deficiencies are corrected? [ ] [ ] [ ]______• Responsible person designated? [ ] [ ] [ ]______

Accident Investigation Component • Have accident investigation guidelines been established? [ ] [ ] [ ]______• Are responsibilities assigned for all phases of investigation process? [ ] [ ] [ ]______a. Who is responsible for conducting investigation? [ ] [ ] [ ]______b. Who completes records/logs? [ ] [ ] [ ]______c. What forms are used? [ ] [ ] [ ]______e. Who completes accident investigation report? [ ] [ ] [ ]______f. Who ensures corrective actions are implemented and effective? [ ] [ ] [ ]______• Are all accidents and “near misses” investigated? [ ] [ ] [ ]______

XVII-7 Yes No N/A Date Corrected

• Accident investigation recommendations implemented? [ ] [ ] [ ]______• Personnel involved in investigation process trained in investigation techniques and procedures? [ ] [ ] [ ]______• Responsible person designated? [ ] [ ] [ ]______

Periodic Review and Revision Component • Accident prevention plan reviewed at least annually? [ ] [ ] [ ]______• Results documented and shared with management/supervisors/employees? [ ] [ ] [ ]______• Are professional safety services or other sources utilized in revising or updating safety program? [ ] [ ] [ ]______• Who conducts the review? [ ] [ ] [ ]______• Follow-up procedures in-place? [ ] [ ] [ ]______• Responsible person designated? [ ] [ ] [ ]______

Corrective Actions • Are deficiencies of this review, proposed corrective actions, and commitment dates described in attached documents? [ ] [ ] [ ]______

Note This Accident Prevention Plan review checklist is not designed to supersede existing safety inspection checklists, rather it should be used only as a general guideline to assess your accident prevention plan. You are encouraged to customize this general guideline to accommodate your specific accident prevention plan.

References • 29 Code of Federal Regulations, 1910, General Industry, U.S. Department of Labor, Washington D.C., 1994. • 29 Code of Federal Regulations, 1926, Construction Industry, U.S. Department of Labor, Washington D.C., 1994. • Training Requirements in OSHA Standards and Training Guidelines, U.S. Department of Labor, Washington D.C., OSHA 2254, 1992.

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