Accident/Incident Investigation United States Department of Labor, Occupational Safety & Health Administration
ANSI z10, Safety Management Systems
CFR 1910.119 (m) (1)
Gano, Dean L. Comparison of Common Root Cause Analysis Tools and Methods. 3rd Edition
Taiichi Ohno. Toyota production system: beyond large-scale production. Portland: Productivity Press
Recognize the purpose and benefits of an incident investigation.
Identify common practices to follow and information to be gathered during an investigation.
Describe documenting and reporting responsibilities.
Recognize the importance of and common practices for determining root cause.
Discuss the importance of implementing corrective actions.
Every day, more than 12 workers die on the job—over 4,500 a year.
An accident is an undesired event that results in personal injury or property damage, an incident that adversely affects completion of a task. ‘Near misses’ describe incidents where no property was damaged and no personal injury sustained, but where, given a slight shift in time or position, damage and injury easily could have occurred.
If the safety professional can identify, analyze and fix the unsafe behaviors and conditions behind a near miss, they can prevent incidents.
Each company should have its own emergency action plan, and key personnel should know how to activate it, and also know proper response procedures and protocols. Every employee should understand their role in an emergency.
Nothing should be changed or removed from the scene of an accident or incident unless necessary to protect against existing hazards. The scene should be maintained, as close as possible, to its condition at the time of the incident.
Timing is everything in incident investigation. The opportunity to collect evidence and accurately determine what happened decreases over time, so any investigation should begin as soon as it is safe to get started.
If the investigation isn’t prompt, environmental conditions could change. For example, water or chemicals may evaporate, instrument panel readings could be lost, and witnesses’ memories can get foggy.
Here are six simple, but vital questions when starting to collect data for an investigation:
When did it happen? Indicate the exact date and time as this may relate to shift-changes or work and break schedules.
Where did it happen?
What equipment, surrounding exposures, etc., played a part in the incident?
Who was involved? Include a list of witnesses.
Why might it have happened? What factors contributed to the incident?
How did it happen? How the incident occurred, including actions, sequences, procedures, etc.
Here are tools that help with investigations:
Chalk is perfect for temporarily marking where events occurred. It’s always helpful to mark locations and then take a picture as well, for reference.
Today, the smartphone is probably one of the most sophisticated investigative tools we possess, and workers probably have it with them on most occasions. If a worker is carrying a smartphone, they should use it to call for assistance, take pictures, record interviews, and reference emergency response protocol, etc.
If there aren’t smartphones around, perhaps because of sensitivity to the high-risk work environment, a camera could prove vital to any investigation. Wide area shots of the incident and numerous specific shots taken from multiple angles will document conditions as close as possible to the time of the incident and may reveal details that may otherwise be overlooked or forgotten. Examples of photo subjects might include tire prints, broken glass, spills, frayed insulation, gauges, etc. Take as many photos as may be needed for complete documentation.
A video camera provides a more detailed description of the incident. When using a video camera, narrate the footage with a description of each item and area recorded. When used for interviews, a video camera can help catch subtle facial expressions that might otherwise be missed.
A flashlight provides additional light when needed. Often, incidents happen at night or in dimly lit surroundings. A flashlight sheds additional light on clues.
Accurate measurements provide specific details about the incident scene, equipment and materials, and give crucial, objective perspective to investigators. For example, “The scissor lift was about halfway extended” does not reveal nearly as much meaningful detail as “The top rail of the scissor lift was 11 feet, 3 inches above the ground at the time of the incident.”
A ruler provides accurate measurements and can be used in photos to show scale and perspective. For example, getting photos with a ruler next to each of Larry’s tools should be able to indicate if he was using the appropriate tools or not.
Clipboard / Incident Investigation Forms
An incident investigation form guides the investigator through the process. It’s helpful in stressful situations to have a form to walk us through step by step.
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