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Accident & Incident Prevention
& Investigation

Objectives
 Understand the need to investigate Know
what to investigate Determine the causes
of accidents
 Identify the methods of investigation
 Understand the need to be thorough and
comprehensive
 Identify prevention methods and
Identify sources of assistance
What is an Accident and Near miss ?
“Accident” Any undesired, unplanned event which results
in physical injury or damage to property.
“Near miss” An event that does not lead to harm but does
have the potential to cause injury/illness or Sometimes both.
What’s in a name ?
 Accident
 Injury
Dangerous
Occurrence
Significant Incident
“Near-miss” accident
“Near-hit”
1
10
30
600
Serious or Disabling
Includes disabling & Serious Injuries
Minor Injuries
Any reported injury less than serious
Property Damage & Accidents
All Types
Accidents with no visible
Injury or Damage
(Critical Incidents)
Accident Ratio Study
Accident Causes
Unsafe Act
 an act by the injured person or
another person (or both) which
caused the accident; and/or
Unsafe Condition
 some environmental or hazardous
situation which caused the accident
independent of the employee(s)
Accident Causation Model
1. Results of the accident - (harm or
damage)
2. Incident - Contact (Accident)
3. Immediate causes (symptoms)
4. Basic causes (real problems)
Management Safety Policy & Decisions
Supervisory Performance
Personal Factors
Job Factors
Human Factor
Substandard
Practices
Substandard
Conditions
ACCIDENT
unplanned release of energy
and/or
hazardous material
Personal injury
Property damage
Uninsured Costs
Basic Causes
Immediat
e causes
Incident - Contact
Accident Results
CHAIN OF ACCIDENT CAUSATION
Results of Accident
Physical harm
(Injury or illness)
 multiple deaths
 death
 disabling, lost time, major
 serious
 minor
 notifiable
 compensata
ble
Property damage
 catastrophic
 major
 serious
 minor
Incident - Contact
 electricity
 plant & equipment
 noise or vibration
 hazardous substances
 radiation
 heat & cold
 animals or insects
 microbiological agents
 struck against
 struck by
 fall to below
 fall on same level
 caught on
 caught in
 caught between
 over exertion
 chemical contact
Contact with
Immediate Causes
 Operating with authority
 Use serviceable
equipment
 Use equipment
properly
 Use of PPE where
required
 correct lifting
Practice
 No drinking &
drugs
 No horseplay
 Secure equipment or
warnings
Standard Practices Standard Conditions
 Effective guards & devices
 Serviceable tools
& equipment
 Adequate warning
systems
 Good
housekeeping
 Non polluted
environment
noise
hazardous
substances
 Good illumination
& ventilation
Basic Causes
Personal Factors
 lack of knowledge or skill
 improper motivation
 physical or mental
conditions
 literacy or ability
(NESB)
Job Factors
 physical
environment
 sub-standard
equipment
 abnormal usage
 wear & tear
 inadequate
standards
 design &
maintenance
Supervisory Performance
 inadequate instructions
 failure of SOPs
 rules not enforced
 hazards not corrected
 devices not provided
Management Policy &
Decisions
 set measurable
standards
 measure work in
progress
 evaluate work-v-
standards
correct performance if necc.
Why Investigate ?
Legal Requirement
Establish Causes
Prevent Recurrences
Accurate record
(courts & enquiries)
Statistical data base
Accident Investigation
A systematic approach to accident investigation, the
identification of causal factors and implementation of
corrective actions is essential to a good H&S
program and management system Good procedures:
 provide information needed to determine injury rates,
identify trends or problem areas, permit comparisons and
satisfy Workers Compensation requirements;
 identify, without placing blame, the basic causal factors that
contributed directly or indirectly to each accident;
 identify deficiencies in management systems;
 suggest corrective action alternatives for a given accident;
 suggest corrective action alternatives for the management
system.
What, When & How to Investigate
What to
Investigate?
 all accidents & near
misses
 as soon as
possible
 scene interference
 survey of scene
 chronology of data
 measurements, maps
& sketches
 eyewitnesses
 reconstruction ?
 statistics & trends
 injury types & groups
Who should
Investigate?
 Supervisor ?
 WH&S Officer?
 WH&S Representative?
 Team?
Training & Skills
 investigative & recording
skills
 technical knowledge
 interviewing skills
 report writing skills
Qualifications
Technical Knowledge
Objectivity
Analytical approach to
problems
Familiarity with the job,
process or operation
Tact in communicating
Intellectual honesty
Inquisitiveness & curiosity
Tool Kit
clipboard, paper (incl
graph) pens
camera & spare films
tape measure
cassette recorder &
spare tapes
reporting forms
hi-viz barrier tape for
scene
preservation
first aid kit
identification tags for
parts gloves (industrial &
medical) safety helmet
specimen containers
magnifying glass
compass
danger tags
yellow crayon
orange flouro
spray paint
torch with batteries
hi-viz orange vest
hearing & eye
protection
plastic containers for
samples
roll of paper
towelling
Let Us Begin !
Take all necessary steps to
provide emergency rescue and
medical help for the injured;
and
take those actions that will
prevent, or minimise the risk
of further accidents or
physical harm to the victim or
others
11. Action Plan
Identification of the individual who is in charge
and assigns responsibilities
Authority to conduct investigation
Securing the accident site for the duration of the
investigation, after rescue and damage control are
complete
Photographic support or capability
Procedures & equipment to ensure observation
and recording of fragile, perishable or transient
evidence (instrument readings, control panel
settings, weather & other environmental
conditions, chemical spills, stains, skid marks)
Development of a comprehensive report.
Determine the Facts
Visit accident
scene Take
samples Visual
records
Preserve accident
items Identify people
involved
Interview
witnesses Review
information
Finding Facts
(logic method)
What was the exact injury or damage ?
What was the damaging energy source ?
What event immediately preceded the damaging
event ?
What happened before that ?
What happened even before that ?
What happened in between ?
What else was going on at the
time of the
accident ?
Was anyone else involved ?
Interview witnesses
Interviewing Techniques
Put at ease
Assure “no blame”
Ask witness to relate their
account of the accident
Listen carefully
Ask questions - reinforce
Repeat if necessary
Ask witness for
suggestions for future
avoidance
Encourage further
contact
Be polite and thank
the
witness
A Good Report
Accuracy & completeness of information
Clarity & completeness of of the
description of the sequence of events
leading up to the accident
Correct identification of all causal factors
Clarity & completeness of all causal
factors
Recommendations made for corrective
actions to reduce or eliminate the
probability of recurrence of a similar
accident
Recommendations for corrective
actions
to improve management system
Timelines - specific time periods,
monitoring and responsibilities
Proper review and sign off
“A
GOOD
REPORT”
BY
CLEVER DICK
Documentation
Accident investigation Form
Witness Statements &
Records of Interview
Checklists:
 Victim(s)
 Witnesses
 Environment & Locations
 Equipment & Parts
 Documentation
Accident/Incident Record
Records
Specified forms
 records maintained
 periods
Notifiable injury - S.B.I.
 admitted as an “in-patient”
Times
 S.B.I. - within 24 hours
 death - immediately
Effects of Accidents
1. On the Victim
2. On the
Supervisor
3. On the Company
4. On the Nation
1. The Victim
Death
Pain & suffering
Permanent disability
Effects on family &
dependants
Loss of earnings
Extra expenditure
Inability to resume
occupation
Psychological effects
Feeling of uselessness
Fear of further injury
Social effects
Loss of sports or
hobby
2. The Supervisor
loss of trained worker
loss of production
extra work
investigations & reports
training new employee
loss of prestige by:
 management
 other workers
effects on promotion
worry (could I have prevented
it ?) Stress
3. The Company
loss of trained worker
loss of production
damage to machinery
damage to equipment
wasted materials
increased insurance
premiums
prosecutions
fines
civil actions
legal costs
loss of
prestige -
customers
The Nation
loss of section of
workforce
loss of production
increased cost of
production
effects on imports
effects on exports
effects on balance of
trade
the community
pays !
Prevention
Effective Management &
Supervision Commitment to
Accident Prevention Effective
Policy & Procedures Effective
Reporting & Recording
& “Toolbox”
Meetings
Regular
Consultation Risk
Assessments
Specific Training
Literature & Culture
Incentive
Schemes ?
Warning Signs
Increases in breaches of safety
procedures
 Increase in reportable incidents
 Technical concerns
 Friction or disputes
 ageing or suspect equipment
 Introduction of new procedures or
equipment
 New employees
 Age of employees
 Long periods of work
 Environmental issues
Resources
Safety Officers
Bureau of Emergency
Services Div Workplace
Health & Safety Workers
Compensation Board
Queensland Health
Doctors & Specialists
Rehabilitation
Experts
Prepared By
Jagadeesh Rao T
HSE Dept,SPPL