OSHAcademy Course 702

Accident Investigation

OSHAcademy Course 702 – Effective Accident Investigation 1

 Objectives
After attending this workshop you should be able to:

1. Describe the primary reasons for conducting an accident

investigation.

2. Discuss employer responsibilities related to workplace accident

investigations.

3. Conduct the six step accident investigation procedure

This material, or any other material used to inform employers of compliance requirements of OSHA standards through simplification of the regulations should not be considered a substitute for
any provisions of the Occupational Safety and Health Act of 1970 or for any standards issued by OSHA. The information in this publication is intended for training purposes only.

OSHAcademy Course 702 – Effective Accident Investigation 2

 Incidents and accidents

What’s the definition of an accident?

Identify two key conditions that must be present for any accident to occur.

A Hazard and Exposure

OSHAcademy Course 702 – Effective Accident Investigation 3

 The basics

What’s the difference between accident investigation and

Analysis?

What's the purpose of an OSHA

investigation?
First - determine what happened to see if
the employer violated safety rules.

To gain the greatest benefit, why does the

employer conduct accident analysis?

First - determine what happened to see safety

management system weaknesses exist.

OSHAcademy Course 702 – Effective Accident Investigation 4

 The process

What are the basic steps in doing the accident investigation and report?

Step 1 - Secure the accident scene

Step 2 - Collect facts about what happened

Step 3 - Determine the sequence of events

Step 4 - Determine the causes

Step 5 - Recommend improvements

Step 6 - Write the report

OSHAcademy Course 702 – Effective Accident Investigation 5

 Step 1: Secure the Scene

When is it appropriate to begin the investigation?

What are effective methods to secure an accident scene?

OSHAcademy Course 702 – Effective Accident Investigation 6

 Step 2: Collect facts about what happened

List methods to document the scene and collect data about what
happened.

What documents will you be interested in reviewing?

Why?

OSHAcademy Course 702 – Effective Accident Investigation 7

 Interviewing

When is it best to interview? Why?

Who should we interview? Why?

Where should we conduct the interview?

OSHAcademy Course 702 – Effective Accident Investigation 8

 Cooperate, don’t intimidate

What are are effective interviewing techniques?

Always say this.. Why?

Always do this... Why?

Never say this… Why?

Never do this... Why?

OSHAcademy Course 702 – Effective Accident Investigation 9

 Team Exercise: Cooperation is the Key

Instructions. Your instructor has had an accident. Your team and the
instructor are located at the scene of the accident (classroom) and your
job now is to ask initial and follow-up questions to gather information
about the accident.

OSHAcademy Course 702 – Effective Accident Investigation 10

 Step 3: Develop the sequence of events

Each event in the unplanned accident process describes one:

Actor - The, object, person that is initiating action.

Action- The thing being done, behavior

“Dale slipped on a banana.”

“As Dale lay on the floor, a brick fell on his head .”

“Larry discovered Dale unconscious on the floor and

immediately began initial first aid procedures.”

OSHAcademy Course 702 – Effective Accident Investigation 11

 Team Exercise: Develop the sequence

Instructions. Use the information in the interview summaries below to

construct a sequence of events listing the events prior to, during and after
the accident they describe.

1. Determine the “injury event.”

2. List the events that led up to the injury.

OSHAcademy Course 702 – Effective Accident Investigation 12

 Step 4: Determine the causes

W. H. Heinrich's domino Theory

"The occurrence of an injury invariably results from a completed
sequence of factors, the last one of these being the accident itself."

Dan Petersen's Multiple Cause Theory

"Behind every accident there are many contributing factors, causes, and
subcauses. These factors combine in a random fashion causing
accidents."

What may be the cause(s) of the accident according to the multiple

causation theory?

What might be the solutions to prevent the accident from recurring?

OSHAcademy Course 702 – Effective Accident Investigation 13

 Strains

Burns
Cuts

Fails to enforce

L a c k o f v Ni soi omn i s s i o n s t a t e m e n t
Lack of time

Inadequate training
No recognition

No discipline procedures

No orientation process

Inadequate training plan

No accountability policy No inspection policy

OSHAcademy Course 702 – Effective Accident Investigation 14

17
 The causes of Injury, Illness and Accidents
1. Direct Cause of Injury

2. Surface Causes of the Accident

3. Root Causes of the Accident

Steps in root cause analysis

1. Injury cause analysis

2. Surface Cause analysis

3. Root Causes analysis

OSHAcademy Course 702 – Effective Accident Investigation - Accident Causes
15
 Team Exercise: “Getting to the roots by asking why, why,
why, why”

1. Analyze the injury event to identify and describe the direct cause of injury.

a. Describe the injury and it’s cause.

b. Identify the accident type.

OSHAcademy Course 702 – Effective Accident Investigation 16


No one is disciplined
Blade cuts Bob
The guard slows work
Corrective MX, blade is
broken
Others use the unguarded
saw
Replace blade
Bob decides to ignore
missing guard Ralph removes guard

Injury -1 -2 -3 -4 -5 -6 -7 -8

Bob saws wood Ralph doesn’t replace

guard

Bob behind schedule Ralph directed to stop and fix

chipper

Doesn’t want to make High priority emergency

Wood shipment
boss mad repair
arrives late

OSHAcademy Course 702 – Effective Accident Investigation 17

 Exercise: Digging up the roots

1. Enter the direct cause of injury within the circle below.

2. List one hazardous condition and unsafe behavior from the sequence of
events your group developed.

3. Determine contributing surface causes for the hazardous condition and

unsafe behavior.

4. Determine implementation and design root causes for contributing

surface causes.

OSHAcademy Course 702 – Effective Accident Investigation 18

 Step 5: Recommend corrective actions and
improvements

Use control strategies to make corrective actions

• Engineering Controls. Eliminate/reduce hazards through equipment redesign,

replacement, substitution, etc.
•

• Management Controls. Eliminate/reduce exposure to hazards by controlling

employee behaviors.

• Interim Measures. These include strategies that are used as a temporary fix
while permanent controls are being developed.

OSHAcademy Course 702 – Effective Accident Investigation 19

 Team Exercise: Recommending Corrective actions

Purpose: In this exercise you’ll develop and recommend immediate

actions to correct the surface causes of an accident.

Instructions. Using the control strategies as a guide, determine

corrective actions that will eliminate or reduce one of the hazardous
conditions or unsafe behaviors identified in the previous exercise.
Write your recommendation below.

OSHAcademy Course 702 – Effective Accident Investigation 20

 Recommend system improvements

Make improvements to policies, programs, plans, processes, and

procedures within one or more of the following elements of the safety
management system.

1. Management commitment

2. Accountability

3. Employee involvement

4. Hazard identification and control

5. Incident and accident analysis

6. Education and training

7. System evaluation

OSHAcademy Course 702 – Effective Accident Investigation 21

 Making system improvements might include some of
the following:
• Including "safety" in a mission statement.

• Improving safety policy so that it clearly establishes

responsibility and accountability.

• Changing a training plan to include using checklists.

• Revising purchasing policy to include safety considerations

as well as cost.

• Changing the safety inspection process to include all

supervisors and employees.

OSHAcademy Course 702 – Effective Accident Investigation 22

 Team Exercise: ”Fix the system...not the
blame"

Purpose: In this exercise you’ll develop and recommend one

improvement to make sure the case study accident does not recur.

Instructions. Develop and write a recommendation to improve one or

more policies, plans, programs, processes, procedures, and practices
identified as design weaknesses.

OSHAcademy Course 702 – Effective Accident Investigation 23

 Step 6: Write the report

SECTION I. BACKGROUND

SECTION II. DESCRIPTION OF

ACCIDENT

SECTION III. FINDINGS

SECTION IV. RECOMMENDATIONS

SECTION V: SUMMARY

SECTION VI: FOLLOW-UP: ACTIONS

SECTION VII: COMMENTS/ATTACHMENTS:

OSHAcademy Course 702 – Effective Accident Investigation 24

 The report is an open document until all actions are
complete!

Take Corrective Action

Conduct follow-up evaluation

Conduct annual review of reports

OSHAcademy Course 702 – Effective Accident Investigation 25

 That's it!

Be safe

OSHAcademy Course 702 – Effective Accident Investigation 26