Accident Reporting and

Investigation Training

• What is an accident, what is a near miss?

• What should be reported?

• Why should you investigate?

• What are you looking for?

• How should you investigate?

• What should be the results of the investigation?

Objectives

• Unplanned

• Unwanted

• Controllable event

• Disrupts the work process

• Causes injury to people or damage to property.

What is an Accident?

• Unplanned

• Unwanted

• Controllable event

• Disrupts the work process

• Does not cause injury to people or damage to property.

What is a Near Miss?

Hazardous conditions/acts

Near Miss

Minor incidents

Accidents

Fatalities

• Most are not an “Act of God”

• They are “caused occurrences”– Predictable: the logical

outcome of hazards

– Preventable and avoidable: hazards do not have to exist. They are caused by hazardous conditions or acts.

What is an Accident?

• A 50 lb box falls off the top shelf of a 12’ high rack and lands near a worker.

• Is this event unplanned, unwanted, and have the potential for injury?

• Should this be investigated?

Example – Near Miss

Employees should report all accidents

and near misses regardless of the extent

of injury or damage. Supervisors should

investigate the near misses.

Best Practice for Accident Prevention

• Two weeks later: Another 50 lb box falls off the top shelf of the 12’ high rack –but this time, hits a worker causing a serious head injury.

• Predictable? Yes.

• Preventable? Yes.

• Reporting the previous incident and taking corrective action may have prevented this from becoming an accident.

Why Investigate Near Misses?

Won’t reporting near misses make

our insurance costs go up?

Claims involving no costs are not used in

the calculation of Workers’ Compensation

cost.

If near misses are reported and

investigated, future accidents may be

avoided, and may actually reduce WC

costs.

Employee Accident Report Form

Accident Investigation

Accidents should always be investigated

and reviewed by the injured employee’s

immediate supervisor or designated safety

coordinator. An Accident Investigation Form

provides an outline for the supervisor to

complete the investigation.

Accident Investigation Form

• The goals of accident investigation are to:

– Find the root causes

– Take the appropriate corrective action(s)

– Prevent a similar accident/incident from

happening again

• No accident investigation has ever changed

what has already happened and therefore

should not assign blame, but instead should

identify breakdowns in the safety process

Goals of Accident Investigation

• Prevents future accidents by identifying and eliminating hazards

• Exposes deficiencies in processes and/or equipment

• Reduces injury frequency and workers compensation costs.

• Maintains worker morale

• Promotes greater safety awareness

• Facts are gathered in the event of litigation

Benefits of Accident Investigation

• Direct Cause – Unplanned release of energy

or hazardous materials

• Indirect Cause – Unsafe acts and/or unsafe

conditions

• Root Cause – Policies and decisions,

personal factors, environmental factors

Causes of Accidents

HazardousConditions

HazardousPractices

Accident Weed

Missing guard

Poor housekeeping

Horseplay

Ignored safety rules

Don’t know howNot using PPE

Equipment failure

Lack of safety leadership

Lack of supervision

No formal safety policies

Rules not enforced

Lack of maintenance, unsafe equipment

Poor safety management

Root Causes

Indirect Causes

Does This Meet the Goal?What was the employee doing when injured? Where in the facility/job site did

the accident happen?

Employee was working in the maintenance shop. Employee was working alone.

Describe what happened:

Employee was moving welding gas bottles in the shop. While moving a bottle, felt a

sharp pain in the lower back.

What corrective steps will be taken (or could be taken) to prevent recurrence?

Employee was not lifting correctly. Employee should be reprimanded and re-trained

in proper lifting techniques.

• Basic Question - Keeping asking “What caused or

allowed this condition/practice to occur?” or simply

“Why?” until you find the root cause.

• The “five whys” is probably the simplest of the root

cause analysis methods.

• It is a question-asking method used to explore the

cause/effect relationships that led to the

accident/incident.

Finding Root Causes – The 5 Whys

1. Why did the employee lose

his fingers? The ram on the

press he was working on

“unexpectedly” came down.

2. Why did the ram come

down? Another employee, not

seeing the worker, started up

the machine. The machine was

shut down, but not locked out.

5 Whys – Real Life ExampleInjury - Employee lost four fingers on each hand

during equipment repair.

Direct Cause

Indirect Cause

3. Why didn’t the employee lock the press out? Employee

had never been trained on hazardous energy control.

4. Why hadn’t the employee been trained on hazardous

energy control? Company has no formal lockout/ tagout

program.

5. Why doesn’t the Company have a lockout/ tagout

program? Management does not see safety as a priority

and the use of lockout procedures is not enforced.

5 Whys – Real Life Example

Indirect Cause

Root Cause

Root Cause

• Simplicity. It is easy to use and requires no advanced mathematics or tools.

• Effectiveness. It truly helps to quickly separate symptoms from causes and identify the root cause(s) of a problem.

• Comprehensiveness. It aids in determining the relationships between various problem causes.

• Flexibility. It works well alone and when combined with other quality improvement and trouble shooting techniques.

Benefits of the Five Whys

• Engaging. By its very nature, it fosters and

produces teamwork.

• Inexpensive. It is a guided, team focused

exercise. There are no additional costs.

• Note: You may not need all five whys in

every situation. Sometimes you’ll need

more, often less.

Benefits of the Five Whys

Accident Investigation Process

Being Prepared

Timing

Procedures

Information

Corrective Action

Follow Up

Accident Investigation Kit

Accident Investigation Forms

Clipboard

Diagram Paper

Caution Tape

Flashlight

Tape Measure

Camera

Sample Containers/ Bags

Protective Gloves

It is crucial to collect evidence and

interview witnesses as soon as possible

because evidence will disappear and

people will forget.

Begin Investigation Immediately

• First priority is care for the injured employee.

• Also, remove any danger that still exists, if it is safe to do so.

• Secure the scene, if necessary.

• Gather the facts.

– Complete accident investigation form

– Diagram the scene including location of injured worker, witnesses

– Take photos of the scene and related area

Performing the Investigation

Record all observations made at the scene, such as:

• Environmental conditions

– temperature very high or very low, chemicals being used, inadequate lighting or

ventilation, excessive noise, poor housekeeping practices, etc.

• Date and time of the accident

– near the beginning or end of the shift, overtime involvement, usual shift the employee

works, etc.

• Condition of the worker

– fatigued, stressed, strained, experienced, supervised, any indication of drug or alcohol

use, past medical conditions and prescription medications, etc., that may be relevant

and may have played a role in or contributed to the accident.

• Machine, tool, or equipment involved

– was the worker wearing appropriate personal protective equipment, trained on how to

use the equipment, any apparent malfunctions with the equipment, etc.

• Task employee was performing

– repetitive motions being used, materials being handled by the worker (number of

pounds, ease of handling, etc.).

Performing the Investigation

• Interview promptly after the incident

• Choose a private place to talk

• Keep conversations informal

• Talk to witnesses as equals

• Ask open ended questions

• Listen. Don’t blame, just get facts

• Ask some questions you know the answers

to

If You Need to Interview Witnesses

Corrective Actions

When deficiencies are discovered,

corrective actions should be taken.

There is no better way to ruin moral

than to investigate then do nothing.

• Hierarchy of hazard control (HHC) is used to recommend the most appropriate measure for controlling an observed hazard

• Always start from the top, and work your way towards the bottom

Best Method For Hazard Control

Elimination

Substitution

Engineering Controls

Administrative Controls

Personal Protective Equipment

Elimination

• Where no hazard exists, no chance of injury or illness exists.

• The hazard is often eliminated through job, part, or workstation redesign.

• Example

– Employees are experiencing shoulder and back injuries due to repetitions tasks of manually stripping floor.

– Risk factors are eliminated by purchase and use of a riding floor scrubber.

Substitution

• If it’s not feasible to eliminate a hazard, the next

most effective approach is substitution by removing

something that produces a hazard and replacing it

with a lesser hazard.

• Examples

– Replace a larger parts container (70 lbcapacity)\with a smaller part containers (20 lbcapacity) to reduce lifting risk

– Substitute a “natural” pesticide for a pesticide that is a known carcinogen

Engineering Controls

• Use engineering controls when you cannot

eliminate the hazard or provide a less

hazardous substitute.

• Examples:

– Use mechanical aids (lift tables, hoists) to

minimize bending, lifting, etc.

– Provide adjustable workstations to accommodate

employees of different heights.

– Providing machine guarding.

Administrative Controls

Administrative controls are the management procedures

that do not actually eliminate or reduce the hazard, but

try to reduce the employee’s exposure to the hazard.

• Examples

– Training employees on safe lifting techniques.

– Job rotation for intense jobs.

– Requiring workers in hot environments to take

breaks in cool rest areas and providing fluids for

re-hydration.

– Posting Danger, Warning, Caution, signs.

• Devices used by employees who must work in hazardous environments

• Does not eliminate the hazard and success relies on proper use of the equipment

• Common PPE includes protection for the: head, eyes and face, hands, feet, breathing zone

Personal Protective Equipment

Personal Protective Equipment

PPE should only be used after all other steps in

the hierarchy have been investigated. Many

organizations make the mistake of starting with

PPE, allowing the hazard to exist and in many

cases leaving it up to the employees to protect

themselves from hazards.

Accident Investigation Example

A food service worker for Yourtown School District was injured

while cleaning filters in the exhaust hood system. The injury

was serious and resulted in a torn rotator cuff, surgery, and

extended time away from the job. The cost of the claim was

$149,678.

What was this employee doing to get so severely injured?

If no investigation of this incident occurs, could a similar

accident happen in the future?

Let’s investigate!

Accident Investigation Example

Interview the injured worker

Interview the supervisor

Determine:

•Direct causes - Unplanned release of energy or

hazardous materials

•Indirect causes - Unsafe acts and/or unsafe

conditions

•Root causes - Policies and decisions, personal

factors, environmental factors

Accident Investigation ExampleDirect Cause(s)

•Cart Moved resulting in loss

of balance and fall

Indirect Cause(s)

•Use of an inappropriate

climbing device

•Why? Because that’s the way

we have always done this

Root Cause(s)

•Appropriate climbing device

not provided

•No procedure in place

•No training on proper

procedure

Accident Investigation ExampleRoot Causes: Inappropriate climbing device, No procedure, No training

What corrective actions would you recommend?

1. Is there a way to eliminate the hazard?

2. Are there engineering controls that could be applied?

3. Are there administrative controls needed?

4. Would PPE help?

Task probably cant be eliminated, hood must be cleaned.

A proper climbing device should be provided.

Training should be provided including use of proper device, the task should be

supervised.

PPE may reduce other exposures to injury while performing the task.

• Follow-up is crucial

• If changes are to be made, communicate the

plans to employees (for example, in Toolbox

meetings)

• A great way to reduce morale is for an

accident to occur, but the hazard to remain

Follow-up

• Make sure that the corrections are doing as

they are designed – to eliminate the hazards

that caused the injury

• If similar injury occurs, review previous

accident investigation report

– Were corrective actions implemented?

– Why did a similar accident still occur?

– What more can be done to prevent another

similar accident?

Check Effectiveness

• Goal of accident investigation is to determine

the root cause(s) so you can take steps to

prevent similar accidents in the future

• When investigating, consider direct, indirect,

and basic causes of accidents

• Emphasize future prevention, not current

blame

• Always follow through with corrective actions!

Summary

Questions?