Risk Management

Safety: Model Program - Appendix E

Accident Investigation

An accident is an unplanned, undesired event that results in injury, illness or property damage. An accident investigation should determine what happened, how it happened, and why it happened. It should also lead to measures to prevent similar accidents.

An incident is an unplanned, undesired event that adversely affects completion of a task. Incidents have the potential to become accidents.

Investigation Criteria

All accidents and incidents should be investigated regardless of extent of injury or property damage. The extent of the investigation may vary but all accidents and incidents reflect potential hazards which should be identified and corrected.

Objectivity

The objective of any accident investigation is to identify the causal factors and recommend corrective actions. Investigators should avoid any emphasis on identifying the individual who could be blamed for the accident. This does not mean that unsafe acts, improper actions, poor judgments, or lack of knowledge of hazards should be ignored. Investigators must have the fortitude and objectivity to determine the facts and identify any management system defects.

Investigation Team

The size and makeup of the team should be dictated by the seriousness of the accident. Major property damage or fatalities may include outside officials or lawyers as well as supervisors and safety people. The qualifications of team members should include technical knowledge, familiarity with the job, objectivity, and analytical approach to problems. Investigators need advance training and preparation so they can act effectively and efficiently.

Back to top

Action Plan

Management should adopt a written plan for team investigations. The plan should provide for identification of the individual(s) with authority and capability to conduct the investigation, the means to notify other team members, equipment such as PPE to safely conduct the investigation, the means to secure the accident site, and audiovisual capabilities and other means to collect evidence. Potential members of the investigation team should be identified in advance. Management should adopt a notification procedure to assure that all investigation team members can respond to the accident in a timely fashion.

Immediate action is necessary to prevent further adverse consequences. The safety of employees, visitors, and the public must be the primary concern after an accident. Emergency rescue and medical help must be provided as soon as possible. It is important that rescue and medical personnel be protected during their activities to prevent further injury or illness. In most cases the accident scene should be isolated to protect other employees as well as prevent the evidence from being disturbed. The extent of the damage to equipment or buildings should also be evaluated to determine how it will affect other facility operations.

Depending upon the severity of the accident, the following activities may be necessary:

1. Visit the accident site before the evidence is disturbed.
2. Have the equipment to collect samples of chemical spills.
3. Document observations of the condition of the accident site. It is hard to predict what observations are important, so in this case, "more is better".
4. Photograph or video tape the accident scene from all angles.
5. Collect accident-related items such as broken equipment, tools, and other equipment which may have failed.
6. Identify and interview eye witnesses. Take statements as soon as possible so that recollections are strong and accurate. Ask questions without a preconception of the cause of the accident. Interviews should be done in private to prevent influence by others.
7. Identify and interview other persons who can provide pertinent information such as technical information or past operational history about the equipment.
8. Review other sources of information such as design specifications, drawings, maintenance records, job safety analysis, training or medical documentation.