RNK - NSC - Accident Reporting & Investigation

National Safety Council, India
Accident Reporting
and
Investigation
R N KhEMANI
NSC
ADVISER(TECHNICAL)
Accident Reporting
 As a general rule, all accidents, no matter how minor, should

be reported immediately and investigated as soon as
possible.
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Accident Reporting
 Employees must be made aware of their responsibility to report

any incident as soon as possible after it occurs.
 They must also be aware that when/if they report an incident, the
incident will be discussed with them, as to “When-Where-Who-
What-Why-How”.
 They will be expected to cooperate with the investigation, as the
goal is to find the root causes of the incident and abate it so it does
not occur again.
3
Accident Reporting
 REMEMBER: Failure to comply with the

company policy, such as the requirement to
report all accidents/incidents amounts to
violating the company policy.
 That could result in disciplinary action.
* * * 4
ACCIDENT
INVESTIGATION
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“ACCIDENTS don’t just happen,

…THEY ARE CAUSED !!!”
ACCIDENTS ARE CAUSED BY:

• Unsafe acts (e.g., working without a W.P.)
• Unsafe conditions (e.g., an unsecured ladder)
• Natural causes (e.g., earthquake)
7
What Causes Injuries?

According to Heinrich…
Acts of God Natural Causes
2% Unsafe Conditions
(Acts20%of God)
<2%
Unsafe Conditions
18%
Unsafe Acts
78%
Unsafe Acts
>80%
8
Unsafe Act
UNSAFE ACT
(unsafe work practice)…
You could
face
disciplinary
is any violation of (or action for
this kind of
departure from) an act.
accepted norm or correct

procedure or practice. It could
even
cost you
your job.
REPORT ALL UNSAFE
ACTS TO YOUR
FOREMAN
9
Unsafe Condition
UNSAFE CONDITION (hazard)…
is a physical or
mechanical condition
or circumstance that
permits, or is likely to
cause, an accident. Corroded Steel Stairs
10/46
Poor Housekeeping
Accident and Incident
 Accident: An unplanned, undesired event, not necessarily

resulting in injury or damage to property, but interrupts the activity in
process.
 Incident: An undesired event that may cause personal harm or

other damage (a near-miss or near-hit)
 With proper hazard identification and

evaluation, management commitment and
support, preventive and corrective procedures,
monitoring, evaluation and training, unwanted
events can be prevented.
11
Accident and Incident
An undesired event giving rise to death,

ill-health, injury, damage, or other loss
[OHSAS 18001: 1999]
The revised standard OHSAS 18001:
2007 uses the term “incident” which

includes the term “accident.”
However, many people associate the
term “incident” with near-miss cases.

12
Example of an Accident
 Accident is an unplanned, not

necessarily injurious or
damaging event that interrupts
the completion of an activity.
 Example: Working on a
machine with moving parts

without following the lockout
and tagout (LOTO) procedure,
resulting in a serious hand
injury. A hand injury due to contact
with the moving part of a
machine.
13
Example of an Incident (Near-Miss)

An unplanned and unwanted event which disrupts the
work process and has the potential of resulting in
injury, harm, or damage to persons or property.
 An incident may disrupt the work
process, but does not result in injury or
damage.
 It should be looked as a “wake-up call”.
 It can be thought of as the first of a
series of events which could lead to a
situation in which harm or damage does
occur.
Example of an incident: A 25kg carton falls

off the top shelf of a 3m high rack and lands
near a worker. This event is unplanned,
unwanted, and has the potential for injury.
ACCIDENT INVESTIGATION
 The ultimate purpose of investigations is to prevent future

incidents.
 Investigations must produce factual information leading to
corrective actions that prevent or reduce the number of
incidents.
 Investigations must be FACT FINDING not FAULT FINDING.
15
Accident Investigation
 The investigation concentrates on the facts surrounding the

incident.
 After the incident is fully investigated, responsibility will be fixed
where a fault has caused the injury.
 Disciplinary actions must not be from the investigating individual or
committee or the HR Department, but from the line management
for violating company policies/procedures.
16
 The purpose of an incident investigation is
two-fold:
1. Identify facts about each injury and the
incident that produced it and to record
those facts.
2. Determine a course of action to eliminate a
recurrence.
 The investigation includes the entire
sequence of events leading to the injury, as
far back in time as the investigator feels is
relevant.
17
As a rule of thumb, use the “5-Why” principle!
Simply ask “Why?” five (5) times.
Scenario: You slip and fall on the floor.

1. Why did you slip and fall near the water cooler? <Answer> …the floor was wet.
2. Why was the floor wet? <Answer> Because there was water on it.
3. Why was there water on the floor?

<Answer> It was coming out from underneath the water cooler.
4. Why was water coming out from under the water cooler?
<Answer> I don’t know. Let’s look. …There is a hole in the drain pipe.
5. Why is there a hole in the drain pipe? <Answer> It appears to be corroded.
Was this an UNSAFE ACT or UNSAFE CONDITION?

18
It was an Unsafe Condition, caused by an Unsafe Act:

 The rusted pipe was caused by lack of preventative maintenance, which was
an unsafe act.
 Why was preventive maintenance not done?

 Was there a preventative maintenance programme?
 Who was in charge of it?
 Why was it not checked?
 Should this be subject to disciplinary action?
19
Why investigate all incidents?
? ? ? Prevent recurrence
?
?
Heinrich’s pyramid –
300 : 29 : 1
H.W. Heinrich
Prevent losses
(Improve the Company's profitability)
20
Reasons to Investigate an Accident
Reasons to investigate a workplace accident include:

1. to find out the basic causes of the accident and to prevent
similar accidents in the future (the most important reason)
2. Identify and correct/eliminate unsafe conditions, acts or
procedures
3. to fulfill any legal requirements
4. to determine the cost of an accident
5. to determine compliance with applicable safety regulations
6. to process workers' compensation claims
7. to process insurance claims
21
 What is a properly performed incident investigation?

 Gathers factual information.
 Finds underlying causes.
 Does not seek to blame or find fault.
 Develops corrective action.
22
Causes of Accident
1. Direct Cause – Unplanned release of energy or hazardous

materials
2. Indirect Cause(s) – Unsafe acts and/or unsafe conditions
3. Root Cause(s) – Policies and decisions, personal factors,

environmental factors
23
Root Cause Analysis
 Root cause analysis is a systematic technique

that focuses on finding the real cause of a
problem and dealing with that, rather than just
dealing with its symptoms.
 A root cause is the cause that, if corrected,
would prevent recurrence of this and similar
occurrences.
 A root cause of a consequence is any basic
underlying cause that was not in turn caused by
more important underlying causes.
24
 Five steps to incident investigation:
1. Manage the incident site
2. Collect information
3. Analyse the facts to find root causes
4. Recommend corrective action
5. Follow-up of the corrective action
25
1. Managing the incident
Manage the incident:
1. Assist the injured employee(s)
2. Eliminate or control the risk of further injury
3. Preserve the accident scene

(a) Shut down equipment/plant
(b) Cordon off the site
26
2. Collecting the Information
 Collect information:
(1) “Who, What, When, Where, Why, and How”
(2) Physical evidence
(3) Witness statements
(4) Documentation
27
Interview Technique
• Ask open-ended questions.

 Ask: [5W + 1H]
 Who was injured?
 What happened?
 Where were you?
 When did it happen? (not
simply time)
 Why did it happen?
 How did it happen? • Interview one-on-one only in a
quiet room, no interruptions.
• Interview on site if necessary.
28
Closed-ended and Open-ended
Questions
 Closed-ended questions are those which can be
answered by a simple "yes" or "no."
 Open-ended questions are those which require more
thought and more than a simple one-word answer.
 Examples of closed-ended questions:
 Are you feeling better today?
 Do you know your role in an emergency?
 Was a work permit issued for cleaning the pump strainer?
 Examples of open-ended questions:

 How will you help the company if you are hired to work for us?
 What precautions have you taken for the confined space entry?
29
Advantages of Open-Ended
Questioning
 Open-ended questions allow respondents to include more
information, including feelings, attitudes and understanding of the
subject.
 This allows investigators to better access the information on an
issue.
30
Ask right questions…
“If you don’t ask the right questions, you don’t get the right
answers. A question asked in the right way often points to its
own answer. Asking questions is the ABC of diagnosis. Only the
inquiring mind solves problems.”
— Edward Hodnett
31
Collecting Information (Contd.)
 Collect physical evidence:

1. Photographs
2. Sketch of site
3. Physical condition of equipment and the
environment
4. Records
5. Witness statements
6. Injured person’s statement
(if possible)
32
Collecting Information (Contd.)
Record witness statements:
1. Explain the purpose of the investigation
2. Listen attentively
3. Ask open-ended questions
4. Safely reenact the incident
5. Get the witness statements signed
6. Solicit recommendations
33
Examining Documents
 Examine the relevant documents:
1. Training records
2. Maintenance records
3. Job descriptions
4. Job safety requirements
34
Analysis
Analyse the facts
 Purpose: Find the underlying causes
Examples:
1. Equipment
2. Methods/ Procedure
3. Personnel
4. Work environment
35
Find Facts, Not Faults

 The purpose of investigation is to find facts that can lead to
preventive actions, not to find fault of persons.
 Investigators should look for deeper causes.
 The important point is that even in the most seemingly
straightforward accidents, seldom, if ever, is there only a
single cause.
36
Find Facts, Not Faults (Contd.)
For example, an "investigation" which

concludes that an accident was due to a
worker’s carelessness, and goes no further,
fails to seek answers to several important
questions such as:
 Was a safe work procedure being followed?
 If not, why not?
 Were safety devices in order?
 Was the worker trained?
37
Policy & Procedures

Environmental Conditions
Basic Causes
Equipment/Plant Design
Human Behavior
Unsafe Unsafe
Indirect Causes Conditions
Acts
Slip/Trip Fall
Direct Causes Energy Release
Pinched Between
ACCIDENT
Personal Injury
Property Damage
(Potential/Actual)
The “Accident Weed”
Hazardous Accident
Hazardous
Conditions Practices
Missing guard Horseplay
Poor housekeeping Safety rules ignored
Defective tools Didn’t follow procedures

Equipment failure
Did not report hazard
No MSDS’s Don’t know how
Purchasing unsafe equipment

Poor work procedures
Lack of supervision
No follow-up/feedback
Rules not enforced
Lack of Training
Lack of safety leadership
Poor safety management Poor safety leadership
Root Causes
Be objective…
 An inquiry that answers these and other related

questions will probably reveal conditions that are
more open to correction than the attempts to prevent
"carelessness".
40
 Avoid statements like:
“The employee was careless.”

Or
“The employee is accident-prone.”
41
 Recommend the corrective action.
1. Identify corrective actions
2. Assign responsibility
3. Establish
42
Corrective Actions:
“SMART”
 The corrective actions must be “SMART”
Specific and sustainable

Measurable
Achievable
Realistic
Time-bound
43
The Incident Analysis Process

Incident • Secure the area
• Identify witnesses
Collect
• Take measurements and photos
Preliminary Data • Report lost-time injuries/DO to DISH
• Conduct interviews
• Use Causal Factors Guideline (5 Whys)
Causal Factors
• Review injury or damage history
• Conduct risk assessment
Finalise Report • Tell the story
• Document key findings
• Document corrective action plan
Implement Plan • Identify owner
• Develop time-line
Provide Feedback • Follow up
• Trends
Analyse • Validate plan
Prevent Accidents
Accidents can be prevented by

eliminating the causes or creating
barriers (like providing machine guards
or using personal protective equipment).
Unless the root causes are eliminated,
or effective barriers created, the same
accidents will keep repeating.
Above cannot be done without proper
accident/ incident investigation
* * * * * 45
Thank you for

your attention
46

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National Safety Council, India

 As a general rule, all accidents, no matter how minor, should

 Employees must be made aware of their responsibility to report

 REMEMBER: Failure to comply with the

“ACCIDENTS don’t just happen,

ACCIDENTS ARE CAUSED BY:

What Causes Injuries?

departure from) an act.

accepted norm or correct

UNSAFE CONDITION (hazard)…

Accident and Incident

 Accident: An unplanned, undesired event, not necessarily

 Incident: An undesired event that may cause personal harm or

 With proper hazard identification and

Accident and Incident

An undesired event giving rise to death,

2007 uses the term “incident” which

term “incident” with near-miss cases.

 Accident is an unplanned, not

machine with moving parts

Example of an Incident (Near-Miss)

Example of an incident: A 25kg carton falls

 The ultimate purpose of investigations is to prevent future

 The investigation concentrates on the facts surrounding the

Simply ask “Why?” five (5) times.

Scenario: You slip and fall on the floor.

3. Why was there water on the floor?

5. Why is there a hole in the drain pipe? <Answer> It appears to be corroded.

Was this an UNSAFE ACT or UNSAFE CONDITION?

It was an Unsafe Condition, caused by an Unsafe Act:

 Why was preventive maintenance not done?

Why investigate all incidents?

Reasons to Investigate an Accident

Reasons to investigate a workplace accident include:

 What is a properly performed incident investigation?

1. Direct Cause – Unplanned release of energy or hazardous

2. Indirect Cause(s) – Unsafe acts and/or unsafe conditions

3. Root Cause(s) – Policies and decisions, personal factors,

Root Cause Analysis

 Root cause analysis is a systematic technique

 Five steps to incident investigation:

1. Manage the incident site

3. Analyse the facts to find root causes

4. Recommend corrective action

5. Follow-up of the corrective action

1. Managing the incident

Manage the incident:

1. Assist the injured employee(s)

2. Eliminate or control the risk of further injury

3. Preserve the accident scene

2. Collecting the Information

(1) “Who, What, When, Where, Why, and How”

(2) Physical evidence

(3) Witness statements

• Ask open-ended questions.

 Examples of open-ended questions:

Ask right questions…

Collecting Information (Contd.)

 Collect physical evidence:

Collecting Information (Contd.)

Record witness statements:

1. Explain the purpose of the investigation

3. Ask open-ended questions