The steps in accident investigation are simple: the accident investigators gather information, analyze it, draw conclusions, and make recommendations. Although the procedures are straightforward, each step can have its pitfalls. Preconceived ideas and beliefs may result in some incorrect assumptions and leave some significant facts uncovered. All possible causes should be considered and conclusions should not be drawn until all the information is gathered.
Before attempting to gather information, examine the site for a quick overview, take steps to preserve evidence, and identify all witnesses. In some situationsÂ an accident site must not be disturbed without prior approval from appropriate government officials such as the coroner, inspector, or police. Physical evidence is probably the most non-controversial information available. It is also subject to rapid change or obliteration; therefore, it should be the first to be recorded.
You may want to take photographs before anything is moved, both of the general area and specific items. Later careful study of these may reveal conditions or observations missed previously. Sketches of the accident scene based on measurements taken may also help in subsequent analysis and will clarify any written reports. Broken equipment, debris, and samples of materials involved may be removed for further analysis by appropriate experts. Even if photographs are taken, written notes about the location of these items at the accident scene should be prepared.
Although there may be occasions when you are unable to do so, every effort should be made to interview witnesses. In some situations witnesses may be your primary source of information because you may be called upon to investigate an accident without being able to examine the scene immediately after the event. Because witnesses may be under severe emotional stress or afraid to be completely open for fear of recrimination, interviewing witnesses is probably the hardest task facing an investigator.
A third, and often an overlooked source of information, can be found in documents such as technical data sheets, health and safety committee minutes, inspection reports, company policies, maintenance reports, past accident reports, formalized safe-work procedures, and training reports. Any pertinent information should be studied to see what might have happened, and what changes might be recommended to prevent recurrence of similar accidents.
Making the analysis and conclusions?
Investigating most of the facts about what happened and how it happened takes considerable effort to accomplish but it represents only the first half of the objective. Now comes the key question–why did it happen? To prevent recurrences of similar accidents, the investigators must find all possible answers to this question.
All possibilities and pertinent facts must be reviewed. There may still be gaps in understanding the sequence of events that resulted in the accident and further investigations may be required to fill these gaps in knowledge.
- When your analysis is complete, write down a step-by-step account of what happened (your conclusions) working back from the moment of the accident, listing all possible causes at each step. This is not extra work: it is a draft for part of the final report. Each conclusion should be checked to see if:
- it is supported by evidence
- the evidence is direct (physical or documentary) or based on eyewitness accounts, or
- the evidence is based on assumption.
This list serves as a final check on discrepancies that should be explained or eliminated.
Why should recommendations be made?
A set of well-considered recommendations designed to prevent recurrences of similar accidents should be developed following the conclusion of the investigation. Recommendations should be specific, constructive, get at root causes, and identify contributing factors.
Never make recommendations about disciplining a person or persons who may have been at fault. This would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future accident investigations.
Always communicate your findings with workers, supervisors and management. Present your information ‘in context’ so everyone understands how the accident occurred and the actions in place to prevent it from happening again.
What to do if the investigation reveals human error?
A difficulty that has bothered many investigators is the idea that one does not want to lay blame. However, when a thorough work site accident investigation reveals that some person or persons among management, supervisor, and the workers were apparently at fault, then this fact should be pointed out. The intention here is to remedy the situation, not to discipline an individual.
Failing to point out human failings that contributed to an accident will not only downgrade the quality of the investigation. Furthermore, it will also allow future accidents to happen from similar causes because they have not been addressed.
However never make recommendations about disciplining anyone who may be at fault. Any disciplinary steps should be done within the normal personnel procedures.
How should follow-up be handled?
Management is responsible for acting on the recommendations in the accident investigation report. The health and safety committee, if you have one, can monitor the progress of these actions.
Follow-up actions include:
- Respond to the recommendations in the report
- Develop a timetable for corrective actions.
- Monitor that the scheduled actions have been completed.
- Check the condition of injured worker(s).
- Inform and train other workers at risk.
- Re-orient worker(s) on their return to work.