ACCIDENT

INVESTIGATION
Albert L. Asprec, M.D., M.O.H.
Investigations are conducted to :

•  Prevent recurrence
•  Comply with policies and regulatory
requirements
•  Improve Supervisor’s Management
Approach
•  Maintain employee awareness - HSE
All accidents must be
investigated:
• LTI
• Non-LTI
• Near Misses / Property damage
• Unsafe Acts / Conditions
Accident
Pyramid 1 LTI

10 Non-LTI

30 Property
Damage
600 Near
Misses
Near-Miss is an accident that:
• Did not happen
• Could happen
… it is still investigated
Team Effort
•  Safety officer
•  Occupational Health Physician
•  Nurse
•  Industrial Hygienist
• Management
• Union Representative
Managing the Accident Scene
Two Priorities:
• Care & Treatment of the Injured
• Elimination or control of
Remaining Hazards
Isolate the site
• To protect people from further
injury
• To preserve evidence and
valuable clues
Investigate immediately,
because:
• Operations are disrupted
• Memories fade
• Employees are at risk
Conducting the Investigation
1. Gather information
2. Analyze the facts
3. Make recommendations
Gathering Information
Preliminary Facts
• NOI, POI, DOI, TOI
• personnel involved
• property damage
• environmental harm
Sources of Information
• Witnesses
• Physical evidence at the scene
• Existing records
Witnesses
•  Victim
•  Those who heard what happened
•  Those who saw area prior to incident
•  Others with info about involved
individuals, equipment or
circumstances
Physical Evidence
Provides information about an
accident that witnesses may
overlook or take for granted
Sketches
To record important details at the
accident site for later study
Comfort Room

Electrocution
victim
Include everything that
could be important:
• Floor plan from overhead view
• Location of involved man,
machine, tool
• Size and location of transient
evidences (spills, dust,
footprints, skid marks)
1 6

4
2

AHU
3
5
 Photographs
• detail
• color differences
• complex shapes difficult to recall
Photographs

• General area
• Detailed shots
• Show scale on small objects
• Indicate reference point
• Better to take too many than too few
When photographing

•  show the scale of objects,

•  idea to indicate distances,
•  depth or height
If items have to be
removed from the scene
for detailed examination:
•  Log and Label
•  Secure storage & transport
•  Avoid contamination
•  Guard against tampering and loss
•  Appropriate HSE warnings
Environment (Work)

• Temperature conditions
• Illumination
• Noise
• Housekeeping
Existing Records

• Employee records
• Equipment records
• Job or Task records
• Previous Accident Investigation
reports
Analyzing the Facts
 Fault trees
 Process safety review
 Change analysis
Change Analysis
Compares how a job was actually
performed with the way it should
have been performed
Change Analysis
How it was How it should Prevailing
done be done conditions
(Action) (SOP) (Factors)

1.

2.

3.
4.
4.
Recommending Corrective
Actions
• Specific
• Measurable
• Attainable
• Realistic
• Time-bound
www.oshc.dole.gov
Follow-up -
It’s the best way to ensure that
recommendations are carried out
Report forms require four
basic types of information
• General information
• A Summary
• An Analysis
• Recommendations