Occupational Health and Safety Section Department of Environmental Health 133 Environmental Health Building Fort Collins, CO 805

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Guide to Accident/Incident Investigations

(Including a Sample Investigation Form)
(ourse '&%) (Text Adopte d f r o m O U p d a t e d # O S H A !" $ " % & & '

Introduction
Accidents occur )hen ha*ards escape detection during preventive measures+ such as a ,o- or process safety analysis+ )hen ha*ards are not o-vious+ or as the result of com-inations of circumstances that )ere difficult to foresee. A thorough accident investigation may identify previously overloo/ed physical+ environmental+ or process ha*ards+ the need for ne) or more extensive safety training+ or unsafe )or/ practices. The primary focus of any accident investigation should -e the determination of the facts surrounding the incident and the lessons that can -e learned to prevent future similar occurrences. The focus of the investigation should 0121 -e to place -lame. The process should -e positive and thought of as an opportunity for improvement. 3ost accidents in the )or/place result from unsafe )or/ -ehaviors. According to the latest research+ they represent the direct cause for a-out 456 of all )or/place accidents. Ha*ardous conditions represent the direct cause for only a-out 76 of )or/place accidents. 8Acts of 9od8 account for the remaining %6. All these statistics imply that management system )ea/nesses account for fully 4$6 of all )or/place accidents. 1ffective accident investigation identifies these root causes and recommends strategies to eliminate management system )ea/nesses.

When do you conduct an investigation?

As a general rule+ investigations should -e conducted for: ; All in,uries (even the very minor ones) ; All accidents )ith potential for in,ury ; <roperty and"or product damage situations ; All =0ear 3isses> )here there )as potential for serious in,ury 0ear miss and incident reporting and investigation allo) you to identify and control ha*ards -efore they cause a more serious incident. Accident"incident investigations are a tool for uncovering ha*ards that either )ere missed earlier or ha*ards )here controls )ere defeated. Ho)ever+ it is important to remem-er that the investigation is only useful )hen its o-,ective is to identify root causes. In other )ords+ every contri-uting factor to the incident must -e uncovered and recommendations made to prevent recurrence.

Have a plan!
?hen a serious accident occurs in the )or/place+ everyone )ill -e too -usy dealing )ith the emergency at hand to )orry a-out putting together an investigation plan+ so the -est time to develop effective accident investigation procedures is -efore the accident occurs. The plan should include procedures that determine: ; ?ho should -e notified of accident. ; ?ho is authori*ed to notify outside agencies (fire+ police+ etc.) ; ?ho is assigned to conduct investigations. ; Training re@uired for accident investigators: ; ?ho receives and acts on investigation reports. ; Timeta-les for conducting ha*ard correction.

Secure the accident scene

For a serious accident+ the first action the accident team needs to ta/e is to secure the accident scene so material evidence is not moved or removed. 3aterial evidence has a tendency to )al/ off after an accident. If the accident is

@uite serious+ OSHA may inspect and re@uire that all material evidence -e mar/ed and remain at the scene of the accident.

Gather information
The next step is to gather useful information a-out )hat directly and indirectly contri-uted to the accident. The follo)ing tools should -e used to gather as much information as possi-le: ; Intervie) eye )itnesses as soon as possi-le after the accident. Intervie) )itnesses separately+ never as a group. ; Intervie) other interested persons such as supervisors+ co#)or/ers+ etc. ; evie) related records such as: ; Training records ; Aisciplinary records ; 3edical records (as allo)ed) ; 3aintenance records ; OSHA %&& Bog (past similar in,uries) ; Safety (ommittee records ; Aocument the scene )ith photographs+ videotape+ or s/etches A0A appropriate measurements.

Develop a sequence of events

Use the information gathered to develop a detailed step -y step description of the accident. 3a/e sure the accident is documented in enough detail to ena-le an individual unfamiliar )ith the situation to envision the se@uence of events. Ao not ,ust descri-e the accident itself+ include a description of events that led up to the accident.

Analyze the accident

The next step is to determine the cause(s) of the accident. This is the most difficult step -ecause first the events must -e analy*ed to discover surface cause(s) for the accident+ and then+ -y as/ing =)hy> a num-er of times+ the related root causes are uncovered. emem-er+ surface causes are usually pretty o-vious and not too difficult to determine. Ho)ever+ it may ta/e a great deal more time to accurately determine the )ea/nesses in the management system+ or root causes+ that contri-uted to the conditions and practices associated )ith the accident. ore on surface causes The surface causes of accidents are those ha*ardous conditions and individual unsafe employee"manager -ehaviors that have directly caused or contri-uted in some )ay to the accident. Ha*ardous conditions may exist in any of the follo)ing categories: ; 3aterials ; 1nvironment ; 3achinery ; ?or/stations ; 1@uipment ; Facilities ; Tools ; <eople ; (hemicals ; ?or/load ItCs important to /no) that most ha*ardous conditions in the )or/place are the result of an unsafe -ehaviors that produced them. Individual unsafe -ehaviors may occur at any level of the organi*ation. Some example of unsafe employee"manager -ehaviors include: ; Failing to comply )ith rules ; Allo)ing unsafe -ehaviors ; Using unsafe methods ; Failing to train ; Ta/ing shortcuts ; Failing to supervise ; Horseplay ; Failing to correct ; Failing to report in,uries ; Scheduling too much )or/ ; Failing to report ha*ards ; Ignoring )or/er stress ore on root causes The root causes for accidents are the underlying system )ea/nesses that have someho) contri-uted to the existence of ha*ardous conditions and unsafe -ehaviors that represent surfaces causes of accidents. oot causes

al)ays pre#exist surface causes. Inade@uately designed system components have the potential to feed and nurture ha*ardous conditions and unsafe -ehaviors. If root causes are left unchec/ed+ surface causes )ill flourishD

!oot causes may "e separated into t#o categories$ ; System design #ea%nesses& 3issing or inade@uately designed policies+ programs+ plans+ processes and procedures )ill affect conditions and practices generally throughout the )or/place. Aefects in system design represent ha*ardous system conditions. ; System implementation #ea%nesses& Failure to initiate+ carry out+ or accomplish safety policies+ programs+ plans+ processes+ and procedures. Aefects in implementation represent ineffective management -ehavior. System Aesign ?ea/nesses ; 3issing or inade@uate safety policies"rules ; Training program not in place ; <oorly )ritten plans ; Inade@uate process ; 0o procedures in place System Implementation ?ea/nesses ; Safety policies"rules are not -eing enforced. ; Safety training is not -eing conducted ; Ade@uate supervision is not conducted ; Incident"Accident analysis is inconsistent ; Boc/out"tagout procedures are not revie)ed annually

Develop preventive actions

This is the most important piece of any investigation. All of the )or/ done to this point culminates )ith recommendations to prevent similar accidents from happening in the future. ecommendations should relate directly to the surface and root causes for the accident. These recommendations should include recommended actions such as: ; ; ; ; 1ngineering controls (for example+ local exhaust ventilation or use of an lift assisting device) ?or/ practice controls (for example+ pre#plan )or/ or remove ,e)elry and loose fitting clothing -efore operating machinery) Administrative controls (for example+ standard operating procedures or )or/er rotation) <ersonal protective e@uipment (for example+ safety glasses or respirators)

It is crucial that+ after ma/ing recommendations to eliminate or reduce the surface causes+ that the same procedure is used to recommend actions to correct the root causes. If root causes are not corrected+ it is only a matter of time -efore a similar accident occurs.

Summary
A successful accident investigation determines not only )hat happened+ -ut also finds ho) and )hy the accident occurred. Investigations are crucial as an effort to prevent a similar or perhaps more disastrous se@uence of events. esearch has sho)n that a typical accident is the result of many related and unrelated factors that someho) all come together at the same time. It is estimated that there are usually more than ten factors that contri-ute to a serious accident. Although+ this com-ination of factors normally ma/es an investigation very time consuming and resource intensive+ the good ne)s is that the accident can normally -e prevented -y removing only a fe) of the contri-uting factors. Attached is a typical accident"incident investigation form to assist you in determining surface and root causes as )ell as trac/ progress on preventative actions. Should you have additional @uestions on this su-,ect+ please feel free to call us at (4!&) E4'#F'5'.

Incident Investigation +orm

I'(ID)'* I'+,! A*I,' Time Aate of Accident Aay of ?ee/ GSG3GTG?GTGFGS Shift 7G%G'G Aepartment

I'-.!)D /)!S,'
0ame: Address: Age: <hone: Ho- Title: Supervisor 0ame: Bength of 1mployment at (ompany: Bength of 1mployment at Ho-: 1mployee (lassification: G Full Time G <art Time G (ontract G Temporary 0ature of In,ury G Iruising G Aislocation G Other (specify) G Strain"Sprain G Scratch"A-rasion G Internal G Fracture G Amputation G Foreign Iody emar/s: G Baceration"(ut G Iurn"Scald G (hemical eaction Treatment 0ame and Address of Treating <hysician or Facility G First Aid G 1mergency oom G [Link] Office 0 Hospitali*ation

In,ured <art of Iody:

DA AG)D /!,/)!*1
<roperty+ 1@uipment+ or 3aterial Aamaged Aescri-e Aamage

O-,ect or Su-stance Inflicting Aamage:

I'(ID)'* D)S(!I/*I,'
Aescri-e )hat happened (attach photographs or diagrams if necessary)

!,,* (A.S) A'A01SIS 2(hec% All that Apply3

Unsafe Acts Improper )or/ techni@ue Safety rule violation Improper <<1 or <<1 not used Operating )ithout authority Failure to )arn or secure Operating at improper speeds Iy#passing safety devices 9uards not used Improper loading or placement Improper lifting Servicing machinery in motion Horseplay Arug or alcohol use Unnecessary haste

Unsafe (onditions <oor )or/station design or layout (ongested )or/ area Ha*ardous su-stances Fire or explosion ha*ard Inade@uate ventilation Improper material storage Improper tool or e@uipment Insufficient /no)ledge of ,oSlippery conditions <oor house/eeping 1xcessive noise Inade@uate guarding of ha*ards Aefective tools"e@uipment Insufficient lighting

3anagement Aeficiencies Bac/ of )ritten procedures or policies Safety rules not enforced Ha*ards not identified <<1 unavaila-le Insufficient )or/er training Insufficient supervisor training Improper maintenance Inade@uate supervision Inade@uate ,o- planning Inade@uate hiring practices Inade@uate )or/place inspection Inade@uate e@uipment Unsafe design or construction Unrealistic scheduling

Unsafe act of others Other:

Inade@uate fall protection Other:

<oor process design Other:

I'(ID)'* A'A01SIS
Using the root cause analysis list on the previous page+ explain the cause(s) of the incident in as much detail as possi-le.

Ho) -ad could the accident have -eenK G 2ery Serious G Serious G 3inor

?hat is the chance of the accident happening againK G Fre@uent G Occasional G are

/!)4)'*I4) A(*I,'S
Aescri-e actions that )ill -e ta/en to prevent recurrence. Aeadline Iy ?hom (omplete

I'4)S*IGA*I,' *)A
Signature 0ame <osition