Effective

Accident
Investigations

Jessica Schroder
Risk Management
Consultant

Aegis Corporation
Agenda
• The Basics
• Initiate the Investigation
• Document the Scene
• Perform Interviews
• Conduct Event Analysis
• Conduct Cause Analysis
• Develop Solutions
• Write the Report
Introduction
• Accidents occur every day across the country
• The BLS publishes a statistical summary of injuries and illnesses every year
• Failure of people, equipment, or surroundings to behave or react as expected cause most accidents
• Accident investigations determine how and why these failures occur
• Using the information gained via an investigation, a similar/more disastrous accident may be prevented
• Conduct accident investigations with accident prevention in mind
• Investigations are NOT to place blame
• Report the findings in a well-thought-out manner
• Ensure management will adopt recommendations for improving the safety program
What is an Accident
The final event in an unplanned series of unique events that results in
an injury or illness to an employee and may include property damage.
It is the final result or effect of a number of root causes.
• An "event," occurs when one person or thing performs an "action" (does
something)
• A person or thing (equipment, tools, materials, etc.) will do something that
results in a change
• An accident may be the result of many factors that have interacted in some
dynamic way
Accidents and Incidents

• Workplace accidents are part

of a broad group of events or
occurrences leading to a
physical or psychological injury
• Workplace incidents adversely
affect the completion of a task,
but do not result in an
employee injury
• Accidents cause injuries:
incidents do not
Accident Types
• 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, 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 their clothing or equipment is caught on an object that is either moving or stationary.
This may cause the person to lose their balance and fall, be pulled into a machine, or suffer some other harm.
• Caught-in: A person or part of them 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-surface: A person slips or trips and falls to the surface they are standing or walking on.
• Fall-to-below: A person slips or trips and falls to a level below the one they are walking or standing on.
• Overexertion: A person over-extends or strains themselves while performing work.
• Bodily reaction: Caused solely from stress imposed by free movement of the body or assumption of a strained or
unnatural body position.
• Overexposure: Over a period of time, a person is exposed to harmful energy (noise, heat, cold) or substances (toxic
chemicals/atmospheres).
Are Accidents Always Unplanned

• Accidents are unexpected,

unplanned events, and
unintentional
• Some accidents occur after being
ignored or tolerated for weeks,
months, or even years
• In those cases, the decision is
intentionally made to take the risk
• We can't say an accident is always
unplanned
Why Conduct the Accident Investigation

• If the recommendations include

identifying the employee(s) at fault,
the purpose of the process is to place
blame.

• If the recommendations focus on

identifying and correcting root-
causes, the purpose of the process is
to fix the system.
Fix the Program – Don’t Blame

• The result of the investigation

should not just identify safety
violations and assign fault
• The end product should identify
the underlying root causes: the
safety program weaknesses such
as inadequate supervision,
training, physical resources, or
psychosocial support
The Accident Investigation Program

• An effective accident
investigation program is guided
by standard written procedures
• Procedures are clearly stated
and easy to follow in a step-by-
step fashion
Procedures
• At least two competent persons investigate
• Accident investigators are properly trained on techniques and procedures
• The written investigation report addresses root causes of accidents
• The report makes recommendations to correct hazardous conditions, unsafe
practices, and improve program weaknesses
• The purpose of the accident investigation is to determine the facts, not the blame
• Discipline is a separate issue properly addressed by management/HR
• Surface causes for the accidents are corrected on the spot or as soon as possible
• Long-term system improvements are completed in a timely manner
• Information about the types of accidents, locations, trends, etc., is analyzed
• Everyone is informed of corrective actions and system improvements
• Training is conducted as needed
The Seven – Step Process

1. Secure the accident scene

2. Document the accident scene
3. Conduct interviews
4. Develop the sequence of events
5. Conduct surface and root cause analysis
6. Determine the solutions
7. Write the report
Step 1: Secure the Accident Scene
• As soon as possible to accurately gather facts
• At this point, you are not yet interested in what "caused" the accident
• Instead, focus on securing the scene so you can gather as much
pertinent information as possible
• Use yellow caution tape, place warning cones, post a guard
• Start the investigation when it is safe to do so
• You don't want to get in the way of emergency responders
• It is not safe to start if hazards have not been properly mitigated
Why Secure the Accident Scene

• To prevent material evidence

from being removed or
relocated in some way

• Protect privacy
Things Disappear After an Accident
• Material Evidence
• Anything that might be important in helping us find out what happened
• Somehow, tools, equipment, and other items just seem to move
• The employer is anxious to "clean up" the accident scene so that people can get back to work
• Develop a procedure to protect material evidence so that it does not get moved or disappear
• If evidence disappears, it might be difficult to uncover the surface causes for the accident
• If you can't uncover the surface causes, it will be almost impossible to discover and correct the root causes

• Memory
• Accidents are traumatic events that result in both physical and psychological trauma
• As the length of time after an accident increases, thoughts/emotions distort what people believe they saw
and heard
• Conversations with others further distort reality
• After a while, the memory of everyone associated in any way with the accident will be altered in some way
• It's important to get written statements and conduct interviews as soon as possible
Reporting Accidents to OSHA
• OSHA Standard 29 CFR 1904.39, Reporting fatalities, hospitalizations,
amputations, and losses of an eye as a result of work-related incidents
• Within 8 hours after the death of any employee as a result of a work-
related accident, you must report the fatality to OSHA
• Within 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 accident, you must report the in-
patient hospitalization, amputation, or loss of an eye to OSHA
• By telephone or in person to the OSHA Office that is nearest to accident
• By telephone to the OSHA toll-free central telephone number, 1-800-321-OSHA
• Electronically using the reporting application located on OSHA's public website
OSHA Required Information
• Each fatality, in-patient hospitalization, amputation, or loss of an eye
• the establishment name;
• the location of the work-related accident;
• the time of the work-related accident;
• the type of reportable event (i.e., fatality, in-patient hospitalization, amputation,
etc);
• the number of employees who suffered a fatality, in-patient hospitalization,
amputation, or loss of an eye;
• the names of the employees who suffered a fatality, in-patient hospitalization,
amputation, or loss of an eye;
• your contact person and his or her phone number; and
• a brief description of the work-related incident
Step 2: Document the Accident Scene
• Once the scene has been secured, it's important to immediately begin
gathering evidence from as many sources as possible
• Determine what information is relevant
• You want to gather data that will help you determine what happened,
how it happened, and why it happened
• Identifying items which answer these questions is the purpose of
documenting the accident scene
• You won't be able to document the scene effectively unless you come
prepared
• Assemble an accident investigation kit
Sample Accident Kit
• Camera/video camera • Gloves
• High visibility plastic tape to mark off
• Tape measure area
• Clipboard & writing paper • First aid kit
• Graph paper • Identification tags
• Tape, bags, containers to secure
• Straight-edge ruler items
• Pens & pencils • Paint stick or chalk to mark the scene
• Accident investigation forms • Tarp (to keep the scene/investigators
dry)
• Flashlight • Personal protective equipment
Step 2: Document the Accident Scene
• Document as much as possible
• It's easy to discard information later if they prove not relevant
• It isn’t easy to dig up material evidence late in the investigation
• All items found at the scene should be considered important and
potentially relevant material evidence
• A team approach is the most efficient strategy to use when
investigating serious accidents
Methods to Document the Accident Scene
• Make and note personal observations
• Try to involve all of your senses (sight, hearing, smell, etc.)
• What is present and what is not?
• What equipment, tools, materials, machines, or structures appear to be broken, damaged, struck or otherwise involved in the
event?
• Look for gouges, scratches, dents, or smears
• If vehicles are involved, check for tracks and skid marks
• Look for irregularities on surfaces
• Are there any fluid spills, stains, contaminated materials or debris?
• Is something missing that should be present, such as fall protection?
• What about the environment?
• Were there any distractions, adverse conditions caused by weather?
• Record the time of day, location, lighting conditions, etc.
• Note the terrain (flat, rough, etc.).
• What is the activity occurring around the accident scene?
• Who is present and who is not?
• Measure distances and positions of anything and everything you believe to be of any value to the investigation
Get Initial Statements
• Ask witnesses for an initial statement giving
a description of the accident
• Try to obtain other information from the
witness including:
• names of other possible witnesses for
subsequent interviews;
• names of company rescuers or emergency
response service; and
• materials, equipment, and articles that may
have been moved or disturbed during the
rescue
Take Photos of the Accident Scene
• Start with distance shots and gradually move in closer as you take the photos
• Take photos at different angles to show the relationship of objects and minute
and/or transient details such as ends of broken rope, defective tools, drugs,
wet areas, or containers
• Take panoramic photos to help present the entire scene
• Take notes on each photo - include in the appendix of the report
• Identify the date, time, location, subject, weather conditions, etc.
• Place an item of known dimensions in the photo for hard-to-measure objects
• Identify the person taking the photos
• You may want to indicate the locations at which photos were taken on sketches
Take Videos of the Scene
• Begin recording as soon as you can safely do so without impeding emergency
responders
• The video will pick up details and conversations that can add valuable information
• Check with your supervisor to see what your company policy is regarding
recording
• Get the lay of the land by standing back a distance and zooming into the scene
• Capture the entire scene 360* to establish location by panning slowly in a circle
• Narrate what is being filmed: describe objects, size, direction, location, etc.
• If a vehicle was involved, record the direction of travel both coming and going
• Discuss with company mngt regarding capturing witness descriptions on camera
• Review the video to note any information you may have missed
Sketch the Accident Scene
• Sketches compliment the information in photos
• Good at indicating distances between the various elements of the
accident
• It is important to be as precise as possible when making sketches
• Basic components of a sketch:
• Documentation - date, time, location, identity of objects, victims, etc.
• Spatial relationships - measurements.
• Location of photographs
• Valuable because they reconstruct the accident in model form and
effectively show movement through time
Record Review
• Maintenance records • Medical records
• Training records • EMT reports
• Standard operating procedures • OSHA Logs
• Safety policies, plans, and rules • Loss runs
• Work schedules • Safety committee minutes
• Personnel records • Coroner's report
• Disciplinary records • Police report
Step 3: Conduct Interviews

• After you have initially

documented the accident scene,
the next step is to start digging
for additional details by
conducting interviews
• The most difficult part of an
investigation
Seven “Rights” of the Interview Process
• The purpose of the accident investigation interview is to obtain an
accurate and comprehensive picture of what happened
• Be sure you ask the:
1. Right people the
2. Right questions at the
3. Right time in the
4. Right place in the
5. Right way for the
6. Right reason to uncover the
7. Right facts
Prepping for the Interview
• Determine who to interview
• Design your questions around the interviewee
• Interviews should occur as soon as possible
• People you may want to consider interviewing:
• The victim
• Co-workers
• Direct supervisor
• Manager
• Training department
• Personnel department
• Maintenance personnel
• Emergency responders
• Medical personnel
• Coroner
• Police
• The victim's spouse and family
Effective Interview Techniques
• Keep the purpose of the investigation in mind - determine the cause of the accident so that similar accidents will not recur
• Make sure the interviewee understands we don't want you or anyone else to get hurt like this again
• Do not interview more than one person at a time
• When others hear an interviewee's account of what happened, their own stories will probably change in some way
• First, ask for background information like name, job, and phone number
• Then, 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
• Approach the investigation with an open mind
• It will be obvious if you have preconceptions about the individuals or the facts
• Go to the scene - Just because you are familiar with the location or the victim's job, don't assume that things are always the same
• Conduct a private interview at the location or in 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
• Tell the interviewee that the information they give is important
• Be friendly, understanding, and open minded
• Be calm and unhurried
Techniques
• Don't ask leading questions; don't interrupt; and don't make expressions (facial, verbal of approval or disapproval)
• Do ask open-ended questions to clarify particular areas or get specifics
• Try to 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
• Notes should be taken very carefully, and as casually as possible
• Let the individual read your notes so that they can possibly fill in missing information and correct inaccuracies
• Give the interviewee a copy of the notes
• Have the interviewee initial that they have read and found the notes accurate
• 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 caused the accident and what can be done to make sure it doesn't happen
again
• Do not accept answers that accuse or place blame
• Conclude the interview with a statement of appreciation for their contribution
• Ask them to contact you if they think of anything else
• If possible, relay the outcome of the investigation to each person who was interviewed
Step 4: Conduct the Event Analysis

You're conducting an analysis to

determine specifically how surface
causes (behaviors and conditions),
and the underlying root causes
(system weaknesses) contributed
to the accident
Analysis
• Accident Analysis
• When an accident occurs, we need to break down the accident into components
to determine how they relate to the whole accident

• Event Assessment and Analysis

• Once the individual events have been determined, you must assess each event to
identify the presence or absence of conditions and behaviors that led to the
current event
• Next, analyze the conditions and behaviors in each event to determine if they
somehow contributed to the accident
• Move on to the next event and complete the same assessment and analysis
process
Why Accidents Happen
Single Event Theory
• An accident is thought to be the result of a single, easily identifiable, unusual,
unexpected occurrence that results in injury or illness
• Some still believe this explanation to be adequate
• It's convenient to simply blame the victim when an accident occurs
• For instance, if a worker cuts her hand on a sharp edge of a work surface, her
lack of attentiveness may be explained as the cause of the accident
• ALL responsibility for the accident is placed squarely on the shoulders of the
employee
• An accident investigator who has adopted this explanation for accidents will
never look beyond perceived personal employee flaws to discover the
underlying system weaknesses that may have contributed to the accident
The Domino Theory
• An accident as a series of related
occurrences which lead to a final event
which results in injury or illness
• Like dominoes, the first domino falling
sets off a chain reaction of related events
that result in an injury or illness
• By eliminating any one of those actions or
events, the chain will be broken and the
future accident prevented
• This explanation still ignores important
underlying system weaknesses or root
causes for accidents
Multiple Cause Theory
• Accidents are not assumed to be simple events
• Rather a result of a series of random related or unrelated actions that somehow
interact
• Unlike the domino theory, the investigator realizes that eliminating one of the
events does not assure prevention of future accidents
• Many other factors may have contributed to an injury
• When the initiating events occur, they effect, the workplace conditions and actions
of others, setting in motion a potentially very complicated process that eventually
ends in an injury or illness
• The trick 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
Categories of Events
• Take the information you have gathered to
determine the events prior to, during, and
after the near miss/injury accident
• It is important to note that a serious injury
accident can easily be the result of many
events
• Events can occur anytime, anywhere, any
place, and to anyone
• It is possible that pertinent events may have
occurred many weeks or months before the
accident
Categories of Events
1. Actual Events: These are events that you are able to determine
actually occurred
2. Assumed Events: These are events that must have happened but
have not yet been verified. Assumed events are harder to establish.
3. Non-Events: If an event was supposed to happen, but did not, that is
a non-event.
4. Simultaneous Events: In some accident scenarios two or more
events occur at precisely the same time resulting in a hazardous
condition or set of unsafe behaviors that cause an injury.
Developing the Sequence of Events
• Accurately determine the sequence of events leading up to the accident
• More effectively understand why the accident event, itself, happened
• Once the sequence of events is developed, you can 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
Step 5: Conduct Cause Analysis
• Initial phase of the accident analysis - gathering information and
using it to break the accident down into an accurate sequence of
events
• Have a good mental picture of what happened
• Continue the analysis process by completing each of the following
three phases of analysis to determine what caused those events
• Injury Analysis to determine the direct cause of injury
• Event Analysis to determine the surface causes of the accident
• System Analysis to determine the root causes of the accident
Three Phases of Cause Analysis
• Injury Analysis: do not attempt to determine what caused the accident, rather focus
on trying to determine how harmful energy transfer caused the injury
• Surface Cause Analysis: Here you determine the hazardous conditions and unsafe
behaviors described in the sequence of events that dynamically interact to produce
the accident. The unique hazardous conditions and unsafe behaviors uncovered are
the surface causes for the accident and give clues that point to possible system
weaknesses.
• Root Cause Analysis: At this level, you're analyzing the weaknesses in the safety
program that contributed to the accident. You can usually uncover weaknesses
related to inadequate safety policies, programs, plans, processes, or procedures. Root
causes always pre-exist surface causes and may function through poor component
design to allow, promote, encourage, or even require systems that result in hazardous
conditions and unsafe behaviors.
Injury Analysis

• What is the Direct Cause of

Injury?

• Important to understand the

nature of cause that resulted in
the injury so that you can clearly
describe what directly caused
the injury in terms of a "cause
and effect" relationship
Injury Analysis (Contiued)
• Injuries are always caused by the harmful transfer of energy to the employee
• The severity of the injury depends on the magnitude of the harmful energy
• Below are various forms of energy that can be harmful
1. Acoustic Energy - Excessive noise and vibration
2. Chemical Energy - Corrosive, toxic, flammable, or reactive substances
3. Electrical Energy - Low voltage (below 440 volts) and high voltage (above 440 volts)
4. Kinetic (Impact) Energy - Energy from "things in motion" and "impact," and are associated with the collision
of objects
5. Mechanical Energy - Cut, crush, bend, shear, pinch, wrap, pull, and puncture
6. Potential (Stored) Energy - Objects that are under pressure, tension, or compression; or objects that attract
or repulse one another
7. Radiant Energy - Infra-red, visible, microwave, ultra-violet, x-ray, and ionizing radiation
8. Thermal Energy - Excessive heat, extreme cold, sources of flame ignition, flame propagation, and heat
related explosions
Surface Cause Analysis
• Unique hazardous conditions and unsafe or inappropriate behaviors
that occur during the sequence of events that have caused or
contributed in some way to the accident
• Hazardous Conditions
• Unique things or objects that are somehow defective or unsafe
• Employee physical or psychological conditions such as fatigue or stress
• May also be unique defects in processes, procedures or practices
• May exist at any level of the organization
• Are the result of deeper root causes
Unsafe or Inappropriate Behaviors
• Most hazardous conditions in the workplace are the result of the unsafe or inappropriate
behaviors
• Characteristics of unsafe or inappropriate behaviors:
• Actions we take or don't take that increase risk of injury or illness
• May also be thought to be unique performance errors in a process, procedure or practice
• May exist at any level of the organization
• Are the result of deeper root causes
• Below are some examples of unsafe or inappropriate employee/manager behaviors.
• Failing to comply with rules • Allowing unsafe behaviors
• Using unsafe methods • Failing to train
• Taking shortcuts • Failing to supervise
• Horseplay • Failing to correct
• Failing to report injuries • Scheduling too much work
• Failing to report hazards • Ignoring worker stress
Root Cause Analysis
• The root causes for accidents are the underlying safety program weaknesses
that somehow contribute to the conditions and behaviors we have identified.
• System Design Root Causes: Inadequate design of one or more components of the
safety program. The design of safety program policies, plans, programs, processes,
procedures and practices is very important to make sure appropriate conditions,
activities, behaviors, and practices occur consistently throughout the workplace.
Ultimately, most surface causes will lead to system design flaws.
• System Implementation Root Causes: Inadequate implementation of one or more
components of the safety program. After each safety program component is
designed, it must be effectively implemented. You may design an effective safety
plan, yet suffer failure because it wasn't implemented properly. If you effectively
implement a poorly written safety plan, you'll get the same results. In either instance,
you'll eventually need to improve one or more policies, plans, programs, processes,
procedures or practices.
Hierarchy of Causes
• Most accidents in the workplace result from a hierarchy of causes:
• System weaknesses - root causes that contribute to unsafe behaviors and hazardous conditions for most
workplace accidents;
• Unsafe behaviors which are the surfaces causes for the majority of workplace accidents;
• Hazardous conditions which are the surfaces causes for only a small percentage of workplace accidents;
and
• Uncontrollable (unknowable) causes, which account for the least number of workplace accidents.
• Management system weaknesses contribute to the vast majority of all
accidents
• When you conduct accident investigations, assume contributing system
weaknesses exist because it's true for most accidents
• Do not close the investigation until you identify the root causes or prove they
don't exist
Step 6: Develop Solutions
• An accident investigation is generally thought to be a "reactive"
safety process
• If we propose recommendations that include effective immediate
corrective actions and system improvements, we may transform the
investigation into a valuable "proactive" process that helps to
prevent future injuries
• Develop engineering and administrative controls to eliminate or
reduce injuries
• Convince management to make changes
Recommendations

1. Immediate or short-term corrective actions to

eliminate or reduce the hazardous conditions and/or
unsafe behaviors related to the accident

2. Long-term system improvements to create or revise

existing safety policies, programs, plans, processes,
procedures and practices identified as missing or
inadequate in the investigation
The Hierarchy of Control Strategies
• Higher Priority Strategies that Control Hazards
• Elimination: Totally eliminate the hazard
• Substitution: Substitute the hazard with something less hazardous
• Engineering controls:
• Design: Design a tool so that it reduces the likelihood of a strain or sprain.
• Redesign: Change the design of a machine so that dangerous moving parts or electrical
circuits are out of reach.
• Enclosure: Place a machine guard around a dangerous moving part.
• Expectation is to first try to eliminate, substitute or engineer the
hazard so that it can no longer cause a serious injury
Lower Priority Strategies
• Less effective than elimination, substitution, and engineering
controls as they do not remove the hazard, rather they merely
attempt to reduce exposure to hazards by controlling behavior
• Warnings: Signs and labels
• Administrative controls: This control strategy also attempts to reduce
exposure by limiting the duration of exposure to a hazard
• Personal protective equipment (PPE): PPE places a barrier between workers
and the hazard
• As long as employees "behave" or comply with the warning signs,
administrative controls and wear PPE when required, these control
strategies will work
Recommend System Improvements
• Make every effort to improve safety program components to ensure
long term workplace safety.
• including "safety" in a mission statement;
• improving safety policy so that it clearly establishes responsibility and
accountability;
• changing a work process so that checklists are used that include safety
checks;
• including hands-on practice as part of the safety training program;
• revising purchasing policy to include safety considerations as well as cost; and
• changing the safety inspection process to include all supervisors and
employees
Key Questions
1. What exactly is the problem?
2. What is the history of the problem?
3. What are the solutions that would correct the problem?
4. Who is the decision-maker?
5. Why is the decision-maker involved with safety?
6. What will be the cost/benefits of corrective actions and system
improvements?
Estimating Insured and Uninsured Costs
• The uninsured costs for accidents will usually be greater than the
insured costs
• Uninsured costs can range from 1 to 20 times greater than the
insured costs
• For every $1 spent in insured costs, you'll pay an additional $1 to $20
in uninsured costs
• For every $1 in insured costs, you'll pay $1.50 in uninsured costs
Return on the Investment (ROI)
To determine the ROI in terms of sale), it's necessary to:

1. Estimate the total additional sales

required to cover the accident costs:

2. Estimate the savings in additional

sales if the recommendation is approved:

3. Estimate the return on investment (ROI):

Provide Options
1. First option - $$$ - Eliminate the hazard with primarily engineering
controls. Additional administrative controls if required.
2. Second option - $$ - Eliminate the hazard with primarily
administrative controls. Engineering controls if required.
3. Third option - $ - Reduce exposure to the hazard with administrative
controls and/or PPE.
Step 7: Write the Report
• Accurately assessed and analyzed the accident facts
• Developed effective corrective actions and system improvements
• Must report your findings
The Accident Report Form
Form that includes the identification of safety program weaknesses and
recommended improvements

• Section I. Background
• Section II. Description of the Accident
• Section III. Findings
• Section IV. Recommendations
• Corrects surface cause and root cause
• Section V. Summary
Items to Consider
• Background Information
• Accident Description
• Investigation Findings
• Surface causes
• Root causes
• Recommendations
• Corrective actions
• System improvements
• Report Summary
• Report Submitted
• Safety committee
• Decision-Maker
• Improvements Completed
• Corrective actions
• System improvements
Questions