Incident Investigation
CONTENT
Defining accidents and incidents
Causes of accidents and incidents
Investigation accidents and incidents
Your role in preventing accidents and incidents and building a
positive ‘Living Safety’ culture
Accident VS Incident
Safety is about preventing accidents, so we
need to know what an accident is. An
accident is not the same as an incident.
• An accident is an undesired, unplanned
event that results in injury or loss.
• An incident can be defined as an
undesired ,unplanned event that does not
result in injury or loss. You could say its an
accident without the consequences
Very often the difference between a serious
injury and some minor damage is just
luck(eg.a piece of loose masonry that falls
from a building may just cause some minor
damage or could potentially kill someone
Often the difference is only luck
Bird’s Accident Theory
Frank Bird, a US safety researcher, discovered that for every
serious workplace accident there area a number of near
misses.
How many near misses do you think there are for every
serious workplace accident?
Answer: It is estimated that
there are 600 near misses
for every serious workplace
accident
Bird’s Accident Triangle
Each layer of the pyramid stands for
Reportable
At the top we have 1 serious accident
Minor Injuries
For every serious accident, there are 10
minor injuries
Incidents
For every serious accidents there are 30
incidents leading to property damage
Near misses
For every serious accidents there are 600
near misses
Although the ratios are often debated, the
principle that there are likely to be many
more near misses than serious accidents
cannot be disputed
What might cause an accident?
All accidents are caused by people
So people must be at the core of all
safety management techniques
Unsafe act
Basic cause of accident
Heinrich’s Domino theory
While there are many accident
causation theories, one we find
useful is Heinrich’s domino
theory.
In Heinrich’s domino theory,
the occurrence of an injury
results from a complicated
sequence of factors ,the last
one of these being the injury
itself.
According to this theory the
removal of any of the factors
will stop the chain of events
and thus the accident and
injury.
Heinrich’s Domino theory
Management Control
Case Study
Amal ,a maintenance technician is required to open and
close a valve to the city water,depending on the
availability of supply.This task happens approx. once a
week.The valve is situated 3.5meters from the floor.
It was often difficult to locate the correct ladder,and the
platform is the area was to move-so Amal used whatever
ladder he could find.This practice was accepted by his
supervisors as Amal was experienced.
On the day the incident occurred, Amal placed a 5 meter
ladder against the HVAC ducts which are under the water
supply valve.The ladder was too long for the task and
therefore not at the correct angle.It was not fixed or
supported
Amal climbed the ladder & closed the valve. Whilst
descending the ladder slipped. Amal fell 2 meters to the
floor. He suffered from cuts and broken bones.
Immediate and Underlying cause
Identify the immediate and underlying cause for this accident
Immediate causes Underlying causes
1.Not using the right type of ladder 1. Requirements for the task i.e.
2.No help taken for placing the Right ladders and equipment were
ladder in its position not considered
3.Permit to work for working at 2. Risk of the activity is not accepted
height its not taken properly
4.Hence safety belt is not used 3. Proper platform and railing not
provided
4. Design not considered for the
manual activity done
Human factors
Think of three actions that you could take to reduce the occurrence of unsafe
acts in your area.
1.Train people on differentiating the unsafe act and safe act
2.Encourage people to follow rules and identify and report unsafe acts
3.Identify the root causes for the unsafe acts and provide engineering
solution to prevent reoccurrences.
Investigating accident and incidents
• Investigate all accidents and incidents
• As soon as it is safe to do so
• At the scene, if possible
• To establish root cause, not blame
• To learn and prevent recurrence
5 Step Problem Solving template
Step 1- Summary
Step 2- Sequence & Findings
Step 3- 5M Evaluation
Step 4- 5 why Analysis
Step 5- CAPA
Example from case study
Accident statistics
• Use statistics to find problem and target resources
• Measure your site/department EHS performance
Carrying out an investigation
Identify whether these statement is true or false
TRUE FALSE
• Immediately send all those involves in the accident
home
• Immediately clean up where the accident occurred
to avoid anyone else being hurt
• Use the 5 step problem solving process as the
standard way of investigation
Investigation
In a typical accident investigation you will record the scene
as it was when the accident happened using sketched and
photos.
You should interview all witnesses including the injured
person. Avoid leading questions and allow the witness to
tell his or her own story of what happened.
Use the 5 step problem solving report to analyze what
went wrong.
The report should not only include the facts, but should
also include conclusions and recommendations.
Always define CAPA and appoint responsible persons and
target dates for these CAPAs
The report must be followed up but line managers to
ensure that the recommended actions have been taken
and are successful.
Part of investigation is to document it
Prevention
Since accidents are by definition undesired,
unplanned events, we cannot manage them
directly. We can only manage the factors that
contribute to accident causation.
The first causation is management control.
Control here implies the use of systematic
processes to manage risks so that they don’t
lead to accidents.
The second one is behavior and culture. It is
vital to consider people and not just the
hardware.
An effective accident prevention programme
therefore can only operate through effective
management systems and culture
What have you learnt?
• That most accidents are caused by unsafe acts
• The correct steps in accident/incident investigation
• Your role in preventing accidents and building a positive safety culture
