SOUTHERN LUZON STATE UNIVERSITY

COLLEGE OF ENGINEERING
MECHANICAL ENGINEERING DEPARTMENT

MCE27 – INCIDENT, ACCIDENT, INVESTIGATION AND

CASUAL FACTOR ANALYSIS

ASSIGNMENT NO.8

SIOCO, JOHN ANTHONY E.

BSME - V (GN)

ENGR. EFREN G. DAYA RATING :

OCTOBER 9, 2018
An accident investigation is an investigation into an undesired event that happens unexpectedly
and unintentionally and results in personal injury or in property damage.
An incident investigation is an investigation into an unplanned, undesired event that may not
cause injury or damage, but hinders the completion of a task.
An incident may not cause injury or damage the first time it happens but it has the potential in
the future to do so, hence the expression "near miss". In many cases, people refer to accident
and incident as one and the same.
An accident investigation systematically identifies event details and causal factors to determine
corrective measures.
As only 2% of all workplace incidents are thought to be unpreventable*, the primary purpose of
an investigation is to prevent future occurrences, not to place blame.
Beyond the primary purpose, the information obtained through the investigation should be
used to update and revise the investigator’s inventory of hazards, and/or the relevant safety
program(s) for hazard prevention and control. For example, a Job Hazard Analysis may be
generated or revised and employees (re)trained to the extent that it fully reflects the
recommendations made in the investigation report. Further, implications from the root cause(s)
of the accident should be analyzed for their potential impact on other operations and
procedures
BASIC STEPS FOR CONDUCTING AN INVESTIGATION
 Secure the scene.
 This is the beginning of your analysis. Your primary goal is to secure the scene as soon
as possible in order to prevent further injuries, ensure the well-being of the affected
employee, and to protect any critical physical clues from being spoiled.

 Collect the facts.

 Focus on finding the facts about the event. Remember to gather valid information
without drawing conclusions or assigning blame. Document your observations. Take
photos and check video surveillance if available. Interview employees and witnesses.
Review relevant records, such as maintenance, training, policies, procedures, etc.

 Develop the sequence of events.

 Review and accurately arrange the gathered information to determine the order of
events. Constructing an accurate timeline may be critical to an effective analysis.
Document what happened before, during and after the event. Arrange this
information to accurately determine the order of events.
  Determine potential causal factors.
 Every accident / incident is caused by a set of contributing factors. These factors
represent the surface or root causes that led to the event. The goal is to identify these
by analyzing how or why each consecutive event happened. Use the following diagram
as an example.

Events and Causal Factor Analysis

Events and Causal Factors Analysis (ECFA) is an important component in the accident investigation
repertoire of methods. It is designed as a standalone technique but is most powerful when applied
with other techniques found in the Management Oversight and Risk Tree (MORT) programme. ECFA
serves three main purposes in investigations:
1. assists the verification of causal chains and event sequences;
2. provides a structure for integrating investigation findings;
3. assists communication both during and on completion of the investigation.
 Event and casual factor charting is a written or graphical description for the time sequence of
contributing events associatedwith an accident. The charts produced in event charting consist the
following elements

Condition. A distinct state that facilitates the occurrence of an event. A condition may be equipment
status, weather, employee health, or anything that affects an event.

Event. A point in time defined by a specific action occurring.

Accident. Any action, state, or condition in which a system is not meeting one or more of its design
intents. Includes actual accidents and near misses. This event is the focus of the analysis.

Primary event line. The key sequence of occurrences that led to the accident. The primary event line
provides the basic nature of the event in a logical progression, but it does not provide all of the
contributing causes. This line always contains the accident, but it does not necessarily end with an
accident event. The primary event line can contain both events and conditions.

Primary events and conditions. The events and conditions that make up the primary event line.

Secondary event lines. The sequences of occurrences that lead to primary events or primary
conditions. The secondary event lines expand the development of the primary event line to show all
of the contributing causes for an accident. Causal factors are almost always found in secondary event
lines, and most event and causal factor charts have more than one secondary event line. Note that
the secondary event lines can contain both events and conditions.

Secondary events and conditions. The events and conditions that make up a secondary event line.

Causal factors. Key events or conditions that, if eliminated, would have prevented an accident or
reduced its effects. Causal factors are such things as human error or equipment failure, and they
commonly include the following:

 The initiating event for an accident

 Each failed safeguard
 Each reasonable safeguard that was not provided