Accident Reporting & Investigation

Incidents can yield positive results if we learn from what went wrong and prevent a reoccurrence. To achieve this we need to investigate the circumstances that led to the incident and report, record, analyses and correct its effects. This requires personnel trained in accident reporting and investigation techniques all of which is an essential element of any effective safety management system. It is important to conduct accident investigations with accident prevention in mind. Investigations are NOT to place blame. Too often investigations degenerate into fingerprinting, blame fixing and fault-finding exercises because the persons involved do not understand the reasons for or real value which can be gained from good accident investigations. Accident/incident investigations are a tool for uncovering hazards that either were missed earlier or have managed to slip out of the controls planned for them.

There are indeed significant gains from good quality incident investigations: 

• Learn from what went wrong
• Determine the causes
• Prevent recurrence
• Improve the work environment
• Meet regulatory requirements
• Cost of incidents
• Moral Obligation
• Define trends
• Provision of information in case of litigation
• Reduction of operating costs by control of accidental losses
• Expression of concern by management

 Effective incident investigation:

• Establishes the facts (Who? What? When? Where? The size?)
• Analyses the facts isolating contributory factors:
• Identifies who or what was involved
• Identify what hazards were present?
• Establishes what controls failed?
• Identifies actions to prevent a recurrence
• Implements the corrective actions

You need to gather evidence from many sources including witnesses and observations during an investigation:

• Inspect the accident site before any changes occur
• Ensure Photographs of the scene are taken and video footage if possible before anything is moved, both of the general area and specific items.
• If there is a possibility that the accident could become a fatality the scene must remain undisturbed until viewed by HSA Inspector and Police where required.
• Arrange for survey plans of the site to be prepared. These should include:
• Locality Plan & details of accident site
• Detailed plan of view showing details after the accident and include such things as: Equipment used in rescue operations; Position of materials, ladders, equipment, etc. involved in the accident; Position from where photographs were taken; Position of persons involved in the accident (victims & witnesses), machinery, energy sources, and hazardous materials and other relevant information. Consider plant line up, valve alignment, tools labels, area signage, machinery, tools or equipment that could have contributed to the accident.
• A sectional view (if necessary). Any sections made are to be marked on the detailed plan
• Take evidence from witnesses at the scene and make note of any items for evidence (signed statements are desirable)
• Record pre-accident conditions, the accident sequence and post-accident conditions
• Check relevant equipment, maintenance and training records. Broken equipment, debris, and samples of materials involved may be removed for further analysis by appropriate experts.
• Check MSDS’s, codes of practice, procedures, pre-start checklists, permits, area rules and standards. Documents containing normal operating procedures, flow diagrams, maintenance charts, or reports of difficulties or abnormalities are particularly useful.
• Analyse condition of equipment materials with specialist input where necessary

Prepare a preliminary report detailing the circumstances of the accident within 24 hours and submit to relevant management.

Most of the information relating to an incident is likely to come from people so it is important that interviews are carried out as a calm, objective search for facts not an interrogation or cross examination to find the ‘guilty party’.

Having determined what happened, the next stage of the investigation involves the incident analysis:

• Determine what happened –immediate cause –unsafe practices/conditions (ask the question would the accident have happened if this particular factor was not present
• Determine why it happened basic causes –personal/job factors
• Cover deficiencies in the management system
• Would the accident have happened if this particular factor were not present?
• Determine appropriate remedial action based on the immediate and basic causes
• Apportion responsibility to implement corrective actions
• Report findings to senior management
• Follow-up and monitor corrective actions

In conclusion comprehensive procedures for accident investigation and analysis is an essential element of any effective safety management system best assured when you:

• Encourage a no-blame reporting culture
• Focus must be to improve working conditions and methods
• Approach with an open and objective mind
• All facts learnt corrective action taken
• Fact finding not fault finding
• Consider as an opportunity for employees and management to work together to correct an unacceptable situation
• Realise an incident will happen again if underlying causes are not corrected
• Delve deep to establish underlying causes do not accept all answers given at face value
• Be prepared to look beyond the injured person, his co-workers, supervisor, manager
• Consider communication skills and language barriers
• Get as much factual information as possible to get the complete picture