Accidents

Causation, Reporting
& Investigation
 Causation Theories

 Single Cause Domino Theory

 Multiple Causation
 Single Cause Domino
Theory
 Heinrich’s theory
 Each factor is the fault of the
factor that immediately precedes it
 A preventable injury is the natural
culmination of a series of events or
circumstances, which occur in a
fixed logical order
 Single Cause Domino
Theory

Ancestry & Social Fault of Person Unsafe Act or Accident Injury

Environment Condition
 Single Cause Domino
Theory
 If one of the dominoes is
removed then the chain of
events will be halted, and the
accident will not happen
 Element 3 (unsafe act and/or
mechanical or physical hazard)
is probably the easiest factor to
remove
 Single Cause Domino
Theory
 Bird & Loftus extended Heinrich’s theory to encompass
the influence of management in the cause & effect of
accidents
 They suggested a modified sequence as follows:
• Lack of management control, permitting
• Basic causes (personal & job factors), leading to
• Immediate causes (substandard practices or conditions), which
are the direct cause of
• The accident, which results in
• Loss (negligible, minor, serious or catastrophic
 This modified sequence can be applied to every
accident and is of basic importance to loss control
management
 Multiple Causation

 May be more than one cause, not only in

sequence, but occurring at the same time
 In accident investigation all causes must
be identified
 Usually simple accidents have a single
cause
 Major disasters normally have multiple
causes
 Multiple Causation

Cause a

Cause b Unsafe Act

Cause c

Injury or
Accident
Damage

Cause d

Unsafe
Cause e
Condition

Cause f
 Unsafe Acts

 Categories:
• Operating without clearance
• Operating at unsafe speed
• Rendering safety devices inoperative
• Using unsafe equipment, or using it unsafely
• Unsafe methods e.g. loading, carrying, mixing
• Adopting unsafe position or posture
• Working on moving or dangerous equipment
• Horseplay e.g. distracting, teasing, startling
• Failure to wear PPE
• Lack of concentration; fatigue or ill health
• Human Factors
 Unsafe Acts

 Unsafe acts can be active or passive:

• Active Unsafe Acts:
• Worker deliberately removes machine guard
• Passive Unsafe Acts:
• More difficult to deal with
• By pursuing an active safety policy, it is
possible to achieve a reduction in bad habit s
and hence accidents
 Unsafe Conditions

 Categories:
• Inadequate guarding
• Unguarded machinery
• Defective, rough, sharp, slippery, decayed, cracked surfaces
• Unsafely designed equipment
• Poor housekeeping, congestion
• Inadequate lighting, glare, reflections
• Inadequate ventilation, contaminated air
• Unsafe clothing or PPE
• Unsafe processes
• Hot, humid or noisy environment
 Unsafe Acts/Conditions

 The picture shows how unsafe acts & conditions may interact
to produce an accident. Accident potential is increased when
unsafe acts & conditions occur simultaneously. Of course, this
is not to say that an act or condition alone could not result in
an accident.

Potential
Accident

Unsafe Acts Unsafe

Conditions
 Accident Reporting

 Information should be kept for

all injuries, and preferably for
near misses
 The safety practitioner needs to
design a suitable form to ensure
that he gets the information
that he needs for investigations
 Accident Investigation
Records
 Format:
• Name & personal details of victim
• Date, day and time of accident
• Location of accident
• Occupation of victim
• Job being done at time
• Nature of injury or damage
• What inflicted the injury or damage
• Who had control of the cause of the injury or damage
• What actually happened
• Basic and immediate causes
• Immediate remedial action taken
• Recommendations to prevent recurrence
 Use of Investigation
Records
 Accident records are useless if they are used only to
count accidents. Detailed and thorough study of the
records as part of the normal ongoing accident prevention
programme should yield the following useful information:
• Relative importance of the various injury & damage sources
• Conditions, processes, machines and activities which cause
the injuries/damage
• The extent of repetition of each type of injury or accident in
each operation
• Accident repeaters, I.e. those workers who tend to be
repeatedly injured or are involved in more accidents
• How to prevent similar accidents in future
 Accident Investigation

 Could be carried out by:

• Safety Practitioner
• Management or Supervisor
• Safety Representative
• Inspector
 A joint investigation by company/safety rep is often a
good idea
 An investigation which does not discover what went
wrong, and produce some useful information and
recommendations for corrective action, is just a
waste of time
 Accident Investigation

 Initial Actions
• Questioning the victim
• Treatment of victim is first priority
• Immediate questioning may not be possible - they should be
allowed to collect their thoughts and control their nerves
• Witnesses & Conditions
• Investigator can usually go to accident scene and get a
fairly complete story from on-site conditions and witnesses
• In all serious accidents and in all other cases where
practicable, conditions at accident scene should remain
undisturbed until investigation is complete
 Investigators

 Immediate supervisor:
• Likely to know most about the situation
• Knows his own people better than anyone
• Has personal interest in determining
causes, as accidents affect the efficiency
and morale of his department
• Familiarity with staff could cause
problems
 Investigators

 Recognising Hazards
• Familiarity with plant, equipment and layout of
operations will assist in recognising hazards that have
been overlooked for some time
• Unsafe acts, as well as conditions, contribute towards
most accidents
• It is not sufficient merely to recommend fitting a guard
while overlooking the unsafe act, such as rendering the
guard ineffective or placing hands in the danger zone
• It is also insufficient to limit attention to an unsafe act if
fitting a better guard would reduce the likelihood of
injury
 Investigators

 Safety Practitioner
• Necessary in more serious cases
• Supervisor may not have necessary
authority
• Should seek assistance from local
supervisor
• Investigator must have authority to
go as far as is necessary to get to
the cause of the problem
 The Investigation

 Promptness
• As soon as possible after the event
• Facts will be easier to determine and more
details will be remembered by those involved
 Fire
• Helpful if investigator is present during the fire
• Investigator may gain useful information by
watching the activities of firemen
 The Investigation

 Evidence
• Depending on severity of any injuries or
damage, investigator should be present
during clear-up and reinstatement as
valuable clues may otherwise be missed
• Failing which, supervisor should take it
upon himself to collect the necessary
evidence
 The Investigation

 Equipment
• Photographic equipment
• Portable lights (electricity may be switched off or accident
scene may be poorly lit)
• Sketchpad, pencils and measuring equipment
• Record-keeping equipment e.g. notebook and cassette
recorder
• Sample collection equipment e.g. jars, paper bags, cartons
etc.
• Tools for cleaning debris or spillages should also be available
• Portable gas/vapour detecting equipment
 Accident Investigation
Procedure
1. Inspection of the accident scene to collect any
information relating to physical conditions of
the plant, equipment and building
2. Interview witnesses and others likely to give
information concerning any unsafe acts or
conditions which may have contributed to the
accident
3. Summarise all available evidence accurately in
a written report to management, recommending
future actions to prevent a recurrence
 Inspection of the Scene

 Careful, detailed look at accident scene, evaluating

and noting the following:
• Extent & severity of damage
• Damage to surrounding property
• Environmental conditions which may have had
some bearing on the accident, such as
temperature, ventilation, humidity and illumination
 Survey the accident scene to see if there are any
obvious dangerous physical conditions which may
have been responsible for the accident
 Inspection of the Scene

 In the case of spillages, splashes or other escapes

of poisonous, explosive, flammable or other
dangerous material, it may be necessary to take
samples for subsequent investigation
 Where machinery or other equipment has been
involved, it may be necessary to issue instructions
prohibiting the use or repair of it until the
investigation has been completed
 Talking with On-Site
Personnel
 Easy to upset people when asking questions about
what has been done, or what has not been done
 Casual remarks made during the site inspection
may be quite revealing and the investigator should
continue to talk to any personnel involved near the
scene of the accident
 This would also serve as an ideal opportunity to
explain the object of the exercise is to discover
and root out the causes so as to prevent a
repetition. It is not to apportion blame or to
criticise any individual
 Interviewing Witnesses

 Types of Witness
• Primary witness
• The victim
• Secondary witness
• Extremely rare, the eyewitness
• How many people really see the instant of an accident?
• Tertiary witness
• Can offer variety of corroborative statements regarding
the acts of people or environmental
 Interviewing Witnesses

 Putting witnesses at ease

• Explain fully purpose of investigation
• Encourage participation and involvement
• Show interest in any ideas they might have
about possible preventive measures
• Witness must be assured that the purpose of the
investigation is not to blame anyone, but to
attempt to find out the cause and thereby reduce
possibility of a recurrence
 Interviewing Witnesses

 Interview Location
• Best to carry out interviews at scene of
accident, as it is easier for those involved
to communicate effectively with “props”
close to hand
• Easier to explain what happened if
witnesses are able to point out specific
things and recall their actions related to
specific locations
 Interviewing Witnesses

 Question Phrasing
• Open ended question - what, where, when, how or
who
• Questions starting with why may put witness on the
defensive
• Typical questions:
• What happened? What did you see?What time was it?
• Where were you at the time? Where was the victim?
• When did you realise something was wrong?
• How did it happen? How were you involved?
• How could it have been prevented?
• Who else was involved? Who else saw it? Who reported it?
 Interviewing Witnesses

 Attitude
• “What happened” will often promote the fullest response
and it is vital the investigator listens, without interruption,
to the witness’s account of the accident
• If something is not understood, investigator should wait
until witness has completed his account before asking for
clarification
• Do not disagree with any of witness’s statement or make
any judgements on his evidence alone
• What a witness believes to have happened will depend to
some extent on just how he perceived the situation, even
though this might conflict with the actual facts
 Interviewing Witnesses

 Conclusion
• When witness’s account of accident has been
heard, investigator should repeat it to witness to
ensure account is fully understood
• Interview should be concluded on a positive note,
which is best achieved by discussing any ideas
he may have regarding prevention of a similar
occurrence - this will serve to reaffirm the
purpose of the interview and ensure the witness’s
further co-operation, should it be needed
Interviewing the Victim

 Ideally first to be interviewed

 Injuries may be serious, or may
be suffering from shock
 Should be interviewed at the
earliest opportunity
 General principles for
interviewing witnesses apply
 What Should be
Investigated
 ALL incidents/accidents should be
investigated
 Purpose is to find the cause, with the
intention of preventing a recurrence,
rather than apportioning blame
 An injury usually involves some degree
of blame falling on management,
supervision, victim or workers