1. Accident Investigation and Analysis OSHE 111, Spring 2016
Instructor: Mr. Chris Kuiper, CSP
Phone:

2. Review: Safety Audit & Inspection
Definition and purposes
Audit process
Field work components
Audit protocol and working papers
Audit program designs
Inspection
Purposes
Two different types
Inspection plans, tools, and important issues
Use of a checklist
Other measurement and testing requirements: e.g., toxicity parameters

3. Accident Investigation Overview
Methodical process to collect and interpret facts
Systematic analysis of nature and extent of mishaps and loss
Inquiry into how and why the mishap occurred
Alternatives to prevent recurrence

4. Purposes Prevent future accidents Identify root incident cause(s)
Provide legal or liability evidence to be used in injury/loss claims or law-suits

5. Types of Investigation
General
Related to most in-plant accidents
A supervisor looks into causes and writes a report
Conduct interviews and visual observations (photos and videos may also be included)

6. Types of Investigation
Special
Require particular knowledge and skills
Involve particular tools, instruments, and procedures.
Examples are fire investigations, aviation accidents, chemical accidents, etc.

7. Accident Investigation Difficulties
Bias: Individuals and groups which have vested interests in the results of the investigation
Workers involved
Unions
Employer/supervisor
Insurer
Federal/state agencies
Third party

8. Accident Investigation Difficulties
The physical evidence has been changed
Unintentional
Rescue
Cleanup
Restart
Intentional

9. Value of Accident Investigation
The value of an investigation increases with
The accuracy and trueness of the results
The quickness of the response

10. Which Accident to Investigate
High cost and high severity
High frequency
Great public interest
Great potential losses

11. When to Investigate
Investigate the incident as soon after the occurrence as possible.
Data and evidence disappear or deteriorate with time.
Witness recollections deteriorate with time, and details that may be important can be lost if investigations are delayed.

12. Conducting the Investigation
Composition of the accident investigation committee
Chairperson
If possible, a top management person from somewhere else in the organization: Less vested interested, more objective and neutral;
Supervisor is not always the best one: May be too close to the accident/incident, partially responsible, etc.

13. Accident Investigation Committee
Other committee members may include:
Safety and health professional
Supervisors of the unit
Workers, witnesses, etc.
Employee’s representative (if union)
Plant engineer
Specialist
Committee meetings done daily, until completed, to exchange information and coordinate results.

14. Preparation Response must be prompt: Requires preplanning.
Preparation requires an established procedure.
Procedure should already designate the chairman and an alternate, and the other members of the committee.

15. Investigation Tools/Equipment
Accident investigation forms/checklists, etc.
Camera, video camera, recorder, tapes, etc.
Sampling and testing instruments
Note taking materials
Other measuring tools

16. Investigation Activities
Initial actions:
Establish committee for field investigation
Assign tasks to committee members
Obtain briefing from person who has been in charge of the scene of the accident
Appoint a liaison with those at the site
Overview the actual scene of the accident
Perform a general survey of the accident scene

17. Initial Actions
Prevent unnecessary handling or moving of physical evidence
If available, find out what each witness saw or could contribute
Photograph evidence and the scene

18. Initial Actions
As needed, instruct committee members on investigation methods
Establish a command post
Finalize committee organization and plan
Assign additional tasks and revise previous instructions, if needed.

19. Continuing Tasks Collect and preserve evidence Interview witness
Prepare diagrams
Secure as-built drawings; procedures, manuals, and instructions; maintenance records; monitoring records; design data, etc.
Conduct re-enactment
Arrange for laboratory test, etc.

20. Interviewing Witnesses
Excellent source of first hand knowledge
Get preliminary statements as soon as possible from all witnesses
Locate the position of each witness on a master chart (including the direction of view)
Explain the purpose of the investigation (accident prevention) and put each witness at ease

21. Interviewing Witnesses
Let each witness speak freely and take notes without distracting the witness (use a tape recorder only with consent of the witness)
Use sketches and diagrams to help the witness
Emphasize areas of direct observation and label hearsay accordingly
Record the exact words used by the witness to describe each observation

22. Interviewing Witnesses
Word each question carefully and be sure the witness understands
Identify the qualifications of each witness (name, address, occupation, years of experience, etc.)
Supply each witness with a copy of their statements (signed statements are desirable)

23. Value of Witnesses Do not make prejudgments
Do not place total reliance on a single witness’ statements
Look for support of the observed facts

24. Value of Witnesses Causes for unreliable statements
People tend to see what they expected to see, and believe what they theorize happened.
They will fill in the gaps with what they think happened.
People have personal interests and biases, need to protect themselves, etc.

25. Accident Investigation Methods
Start with the final outcome of the accident
Work backward from that point
List information that contributed to the cause of the accident
Separate information into pertinent categories
Investigate multiple factors: Immediate causes and root causes

26. Investigation Report
An accident investigation is not complete until a report is prepared and submitted to the proper authorities.
The following slides list the suggestion of items to include in the report.

27. Investigation Report Background Information
Where and when the accident occurred
Who and what were involved
Operating personnel and other witnesses
Account of the accident (What happened?)
Sequence of events
Extent of damage
Accident type
Agency or source (of energy or hazardous material)

28. Investigation Report Discussion (Analysis of the accident: HOW & WHY)
Direct causes (e.g. energy sources; hazardous materials)
Indirect causes (e.g. unsafe acts and conditions)
Basic causes (e.g. management policies; personal or environmental factors)

29. Investigation Report Recommendations and corrective actions
Assign responsibility for each recommendation
Set target dates for completion
Verify damage/repair/replace cost estimates

30. More Information OSHA Incident Investigation
NIOSH Fatality Assessment and Control Evaluation (FACE) Program
U.S. Chemical Safety Board (CSB)
EPA Emergency Response