1. Accident Investigation Basics Department of Administrative Services Loss Control Services
March, 2013

2. Prevent future incidents, injuries, accidents, etc.
Why Investigate?
Prevent future incidents, injuries, accidents, etc.
Identify and eliminate hazards.
Expose deficiencies in process and/or equipment.
Reduce injury and workers’ compensation costs.
Maintain worker morale.
Bullets will appear upon mouse click.
If time: Ask audience: Any other reasons to investigate? 2

3. What Is An Accident?
An unplanned, unwanted, but controllable event which disrupts the work process and causes injury
to people.
Most everyone would agree that an accident is unplanned and unwanted. The idea that an accident is controllable might be a new concept. An accident stops the normal course of events and causes property damage, or personal injury, minor or serious and occasionally results in a fatality.
Most everyone would agree that an accident is unplanned and unwanted. The idea that an accident is controllable might be a new concept. An accident stops the normal course of events and causes property damage or personal injury, minor or serious, and occasionally results in a fatality. 3

4. What Is An Incident?
An unplanned and unwanted event which disrupts the work process and has the potential of resulting in injury, harm, or damage to persons or property.
An incident may disrupt the work process, but does not result in injury or damage. It should be looked at as a “wake up call”. It can be thought of as the first of a series of events which could lead to a situation in which harm or damage does occur.
An incident disrupts the work process, does not result in injury or damage, but should be looked as a “wake up call”. Could be thought of as the first of a series of events which could lead to a situation in which harm or damage occurs. Employers should investigate an incident to determine the root cause and use the information to stop process and behaviors that could just as easily have resulted in an accident.
Example of an incident: A 50 lb carton falls off the top shelf of a 12’ high rack and lands near a worker. This event is unplanned, unwanted, and has the potential for injury.
Ask audience for example of a real incident that has occurred at their workplace. Then say: We will discuss why a policy that encourages resolution of incidents, near-misses, will be worth the time and effort.
Example of an incident: A 50 lb carton falls off the top shelf of a 12’ high rack and lands near a worker. This event is unplanned, unwanted, and has the potential for injury. 4

5. “The Tip of the Iceberg”
Accidents
“The Tip of the Iceberg”
Accidents or injuries are the tip of the iceberg of hazards.
Investigate incidents since they are potential “accidents in progress”.
Incidents
Don’t investigate only accidents. Incidents should also be reported and investigated. They were in a sense, “aborted accidents”.
Criteria for investigating an incident: What is reasonably the worst outcome, equipment damage, or injury to the worker? What might the severity of the worst outcome have been? If it would have resulted in significant property loss or a serious injury, then the incident should be investigated with the same thoroughness as an accident investigation.

6. First Aid or Property Damage
5 minutes
Major Injury or Death 1
The Incident Pyramid 10
Injury 30
First Aid or Property Damage
Notes:
Accident versus Incident
An accident is an undesirable event that causes harm. An incident is an event.
In the past, supervisors may have heard this distinction used in regards to workers’ compensation claims. At one time, our contract with a third party administrator required that we pay for each claim handled, rather than a flat fee for services. This led to some departments being very particular about what incidents were called in as claims. Today we call in all incidents where there is a potential the employee may seek medical attention for an on-the-job injury or illness.
Dr. Heinrich proposed a theory that for every 1 fatal workplace injury, there were 30 major injuries, and 300 minor injuries. Safety professionals later estimated that there were approximately 3000 near misses as well. In the early 970’s, the Insurance Company of America began to validate this theory by reviewing over 2 million workers’ compensation claims. The Incident Pyramid shown on this slide is the result of the research.
Working our way down the pyramid:
Stopping the majors, then the minors, property damage incidents, and near misses.
What is the primary cause of workplace injuries - Unsafe Acts or Unsafe Conditions?
Over 60 years ago, a researcher named Heinrich proposed the following injury ratio:
1 Major Injury : 29 Minor Injuries : 300 Near Miss Incidents
Heinrich also proposed that up to 88% of all near misses and workplace injuries resulted from UNSAFE ACTS.
Thirty years later, the Insurance Company of America conducted investigations and interviews for nearly 2 million accidents reported by nearly 300 companies. Their results showed what you see on this slide.
1 Major Injury : 10 Minor Injuries : 30 Property Damage Incidents : 600 Reported Near Miss Incidents
In addition, the research showed a much higher percentage of near misses and injuries caused by unsafe acts.
In FY 2001, we had 3,387 workers compensation claims (740 majors with indemnity paid > $3 million : 1442 minor : 1205 report incident only) filed for workplace incidents. Using the new ratio, we could have expected the following:
740 majors, 7400 Minors, 22,200 Property Damage, and 444,000 Near Misses.
Where have we focused our injury prevention efforts - preventing the Majors?
Where should they be focused? HEISENBERG UNCERTAINTY PRINCIPLE – Observation of a system can/will influence or change that system. Do not get what you expect, but what you inspect.
Most of the incidents are caused by unsafe behaviors of employees rather than unsafe conditions.
Statistics also show that:
2% of accidents are caused by Acts of Nature or uncontrollable factors.
3% are caused by unsafe conditions.
95% are caused by unsafe or inappropriate behaviors.
That translate into 98% being under the span of control of management. (This will be illustrated more during the discussion.) So, what should we be focusing on in regards to incident and accident reduction – facility inspections or worker observations? What was the Heisenberg Uncertainty Principle?
600
Near Misses
Management Systems
Interventions
Training
Sampling
Rewards
Enforcement
Feedback
Safe Practices
Goals
Involvement

7. Investigate All Incidents and Accidents
Conduct and document an investigation that answers:
Who was present?
What activities were occurring?
What happened?
Where and what time?
Why did it happen?
Bullets will appear upon mouse click.
Briefly discuss the concept of “root causes”. Example: An employee gets cut. What is the cause? It is not just the saw or knife or the sharp nail. Was it a broken tool and no one reported? Did someone ignore a hazard because of lack of training, or a policy that discourages reporting? What are other examples of root causes? Enforcement failure, defective PPE, horseplay, no recognition plan, inadequate labeling.
Root causes should be determined. Example: An employee gets cut. What is the cause? It is not just the saw or knife or the sharp nail. Was it a broken tool and no one reported it? Did someone ignore a hazard because of lack of training, or a policy that discourages reporting? What are other examples of root causes? Enforcement failure, defective PPE, horseplay, no recognition plan, inadequate labeling? 7

8. The six-step process 2 minutes Gather information Analyze the facts
Accident
investigation
is “fact-finding”
not
fault-finding.
2 minutes
The six-step process
Gather information
Analyze the facts
Implement Solutions
Step 1: Secure the accident scene
Step 2: Collect facts about what happened
Step 3: Develop the sequence of events
Step 4: Determine the causes
Step 5: Recommend corrective actions & improvements
Step 6: Write the report
Mention the 6 steps and explain that we will cover each step as we go along.
“When is it appropriate to begin the investigation?”
There are a couple of options here. One is to discuss the question with the entire group. Option 2 is to have the small groups discuss and answer and then share with the rest of the class.
The main thing is to start the investigation as soon as possible.
“What are effective methods to secure an accident scene?”
See above options for group discussion
The scene may be coned, taped off, or guarded, or ?. Here, it is very important to stress that any hazardous situations be controlled before continuing with the investigation.
This is not always practical or practiced.
Talk with the injured worker and any witnesses.
Get any other information that might be helpful.
Training records
Inspections
Audits
Production charts or readouts
Maintenance Records

9. Actions At The Accident Scene
Check for danger
Help the injured
Secure the scene
Identify and separate witnesses
Gather the facts
Bullets will appear upon mouse click.
First, make sure you and others don’t become victims! Always check for still-present dangerous situations.
Then, help the injured as necessary
Secure the scene and initiate chains of custody for physical evidence
Identify witnesses and physical evidence
Separate witnesses from one another
If physical evidence is stabilized, then begin as quickly as possible with interviews
REMEMBER, BE A GOOD LISTENER
First, make sure you and others don’t become victims! Always check for still-present dangerous situations. Then, help the injured as necessary. Secure the scene and initiate chains of custody for physical evidence. Identify witnesses and physical evidence. Separate witnesses from one another If physical evidence is stabilized, then begin as quickly as possible with interviews. 9

10. Begin Investigation Immediately
Investigation should be conducted by supervisor/manager.
It’s crucial to collect evidence and interview witnesses as soon as possible because evidence will disappear and people will forget.
This statement is true for both near-misses, mishaps (incidents) as well as accidents in which injuries or illnesses have resulted. 10

11. Fact Finding
Take notes on environmental conditions, air quality, witnesses
and physical evidence
Employees/other witnesses
Position of tools and equipment
Equipment operation logs, charts, records
Equipment identification numbers
Take samples
Note housekeeping and general working environment
Note floor or working surface condition
Take lots of pictures. Draw the scene if applicable.
Bullets will appear upon mouse click.
Some scenes are more delicate then others. If items of physical evidence are time sensitive address those first. If items of evidence are numerous then you may need additional assistance.
Some scenes will return to normal very quickly. Are you prepared to be able to recreate the scene from your documentation?
Consider creating a photo log. The log should describe the date, time, give a description of what is captured in the photo and directionality. Example: Photo # 4, February 1, 2004, 10:36 AM, Northeast corner of Warehouse Number 2, Row 11, Bin 14, showing carton that fell from top shelf. Note: crushed bottom corner of carton and wet area under carton on floor.
Link to sketch of bakery accident scene: Tell the audience how much information can be captured through a simple line drawing using stick figures. They don’t need to be an artist.
Some scenes are more delicate then others. If items of physical evidence are time sensitive address those first. If items of evidence are numerous then you may need additional assistance. Some scenes will return to normal very quickly. Are you prepared to be able to recreate the scene from your documentation?
Consider creating a photo log. The log should describe the date, time, give a description of what is captured in the photo and directionality. Link to sketch of accident scene. 11

12. Interview Witnesses Interview promptly after the incident
Choose a private place to talk
Keep conversations informal
Talk to witnesses as equals
Ask open ended questions
Listen. Don’t blame, just get facts.
Ask some questions you know the answers to
Your method and outcome of interview should include: who is to be interviewed first; who is credible; who can corroborate information you know is accurate; how to ascertain the truth bases on a limitation of numbers of witnesses. Be respectful, are you the best person to conduct the interview?
If the issue is highly technical consider a specialist, this may be an internal resource or it may be an outside resource.
Your method and outcome of interview should include: who is to be interviewed first, who is credible, who can corroborate information you know is accurate, how to ascertain the truth based on a limitation of the number of witnesses. Be respectful. Are you the best person to conduct the interview?
If the issue is highly technical, consider an internal or external specialist for assistance. 12

13. Analysis – Injury
Reconstruct the specific events prior to, during, and after the accident.
Analyze the injury event to identify and describe the direct cause of injury.
Describe the injury and its cause.
Identify the accident type.
Instructions
1.      Reconstruct the specific events prior to, during, and after the accident.
2.      Analyze the injury event to identify and describe the direct cause of injury.
The direct cause of injury is not the cause of the accident
If we examine the surface cause categories above, we find that each may somehow produce a harmful level of energy that may be transferred to our body directly causing an injury. The harmful transfer of energy is the direct cause of injury. Let's take a look at three examples:
·         If a harsh acid splashes on our face, we may suffer a chemical burn because our skin has been exposed to a chemical form of energy that destroys tissue. In this instance, the direct cause of the injury is harmful a chemical reaction. The related surface cause might be the acid (condition) or working without proper face protection (unsafe behavior).
·         If our workload is to too strenuous, force requirements on our body may cause a muscle strain. Here, the direct cause of injury is a harmful level of kinetic energy (energy resulting from motion), causing injury muscle tissue. A related surface cause of the accident might be fatigue (hazardous condition) or improper lifting techniques (unsafe behavior). The important point to remember here is that the "direct cause of injury" is not the same as the surface cause of the accident. To summarize:
·         The surface cause of the accident describes a condition or behavior. The result of the condition and/or behavior is the direct cause of injury...a harmful transfer of energy.
·         The direct cause of injury is the harmful transfer of energy. The direct result is injury.
a. Describe the injury and it’s cause. See examples below.
·         Laceration to right forearm resulting from contact with rotating saw blade.
·         Contusion from head striking against/impacting concrete floor.
·         Burn injury to right lower leg from contact by battery acid.
·         Impact following a fall from platform to lower level caused dislocation of right shoulder.
b. Identify the accident type.
      Struck-by
      Struck-against
      Contact-by
      Contact-with
      Caught-on
      Caught-in
      Caught-between
      Fall-to-surface
      Fall-to-below
      Over-exertion
      Bodily reaction
      Exposure
Cuts
Burns
Strains
Handouts have lists and other helps.

14. System Implementation
Direct
Cause
“Accident” Weed
Primary
Surface
Causes
Secondary
Surface
Causes
The Accident Weed
Would you agree that many accidents we see are planned events?
Through poor system design, accidents may be unintentionally planned.
This weed illustrates the concept of system and incident analysis.
We must not concentrate on the flowers, but dig down into the roots of system weaknesses that allowed the event to occur.
Root Causes
System Design
Root Causes
System Implementation

15. WHY? x5 5 Simple Questions Analysis – Events
Analyze at least two events occurring just prior to the injury event to identify surface causes for the accident.
Determine the primary surface causes. Look for specific hazardous conditions and employee behaviors that caused the injury.
Determine secondary surface causes. These are also specific conditions and behaviors.
5 Simple Questions
Analyze at least two events occurring just prior to the injury event to identify surface causes for the accident.
Determine the primary surface causes. Look for specific hazardous conditions and employee behaviors that caused the injury.
·   Event # - Unguarded saw blade. (condition or behavior)
·   Event # - Working at elevation without proper fall protection. (condition or behavior)
·   Event # - Employee unaware of hazards of working with batteries. (condition or behavior)
Determine secondary surface causes. These are also specific conditions and behaviors.
·    Supervisor not performing weekly area safety inspection. (condition or behavior)
·      Fall protection equipment missing. (condition or behavior)
·     Responsible person not training on how to hook up harness. (condition or behavior)
Create another “Why” - Behaviors
Example: Speeding Ticket “WHY?”
Belief that speeding leads to better lifestyle
Unable to manage time
Unrealistic Dispatch
The Accident Weed
Identify primary surface causes – behaviors and conditions. Primary surface causes occur at or very close to the injury event.
Identify secondary or contributing surface causes – behaviors and conditions. A secondary surface cause is more distant in time and location and may involve employees at any level of the organization.
Analyze the surface and secondary causes (behaviors and conditions) to determine if system weaknesses in implementation exist.
Analyze the behaviors and conditions to determine if system weaknesses in design exist.
Fails to inspect
Unguarded machine
Horseplay
Fails to train
Too much work
Defective PPE
Fails to report injury
Create a hazard
Fails to enforce
Untrained worker
Broken tools
Ignore a hazard
Lack of time
Chemical spill
WHY? x5

16. The Five Whys
Basic Question – Keep asking, “What caused or allowed this condition/practice to occur?” until you get to the root causes.
The “five whys” is one of the simplest of the root cause analysis methods. It is a question-asking method used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the 5 Whys method is to determine a root cause of a defect or problem.
The following example demonstrates the basic process:
My car will not start. (the problem)
1) Why? - The battery is dead. (first why)
2) Why? - The alternator is not functioning. (second why)
3) Why? - The alternator belt has broken. (third why)
4) Why? - The alternator belt was well beyond its useful service life and has never been replaced. (fourth why)
5) Why? - I have not been maintaining my car according to the recommended service schedule. (fifth why and the root cause)
The five whys is one of the simplest of the root cause analysis methodolgies. It is a question asking method used to explore the cause/effect relationships underlying a particular problem. Ultimately, the goal of applying the 5 Whys method is to determine a root cause of a defect or problem. The following example demonstrates the basic process:
My car will not start. (the problem)
1) Why? - The battery is dead. (first why)
2) Why? - The alternator is not functioning. (second why)
3) Why? - The alternator belt has broken. (third why)
4) Why? - The alternator belt was well beyond its useful service life and has never been replaced. (fourth why)
5) Why? - I have not been maintaining my car according to the recommended service schedule. (fifth why, root cause)
Note that the questioning for this example could be taken further to a sixth, seventh, or even greater level. This would be legitimate, as the five in five whys is not gospel; rather, it is postulated that five iterations of asking why is generally sufficient to get to a root cause. The real key is to encourage the troubleshooter to avoid assumptions and logic traps and instead to trace the chain of causality in direct increments from the effect through any layers of abstraction to a root cause that still has some connection to the original problem.
5 Whys offers some real benefits at any maturity level:
Simplicity.  It is easy to use and requires no advanced mathematics or tools.
Effectiveness.  It truly helps to quickly separate symptoms from causes and identify the root case of a problem.
Comprehensiveness. It aids in determining the relationships between various problem causes.
Flexibility.  It works well alone and when combined with other quality improvement and trouble shooting techniques.  
Engaging.  By its very nature, it fosters and produces teamwork and teaming within and without the organization.
Inexpensive.  It is a guided, team focused exercise.  There are no additional costs.
Often the answer to the one “why” uncovers another reason and generates another “why.”  It often takes five “whys” to arrive at the root-cause of the problem.  You will probably find that you ask more or less than 5 “whys” in practice. 16

17. Benefit of Asking the Five Whys
Simplicity.  It is easy to use and requires no advanced mathematics or tools.
Effectiveness.  It truly helps to quickly separate symptoms from causes and identify the root case of a problem.
Comprehensiveness. It aids in determining the relationships between various
problem causes.
Flexibility.  It works well alone and when combined with other quality improvement
and trouble shooting techniques.  
Engaging.  By its very nature, it fosters and produces teamwork and teaming within and without the organization.
Inexpensive.  It is a guided, team focused exercise.  There are no additional costs.
Often the answer to the one “why” uncovers another reason and generates another “why.”  It often takes “five whys” to arrive at the root-cause of the problem.  You will probably find that you ask more or less than “five whys” in practice.

18. Direct Cause of Incident
Cuts
Burns
Strains
Implementation
Root Causes
Design
Hazardous Condition
Contributing conditions
Direct Cause of Incident
Unsafe Behaviors
Contributing Behaviors
Fails to inspect
Unguarded machine
Horseplay
Fails to train
Too much work
Defective PPE
Fails to report injury
Create a hazard
Fails to enforce
Untrained worker
Broken tools
Ignore a hazard
Lack of time
Chemical spill

19. Sequence of Events An accident is not “just one of those things”.
Accidents are predictable and preventable events.
They don’t have to happen.
Look for the chain of events leading up to the Incident.
Most workplace injuries and illness are not due to “accidents”. More often than not it is a predictable or foreseeable eventuality.
By “accidents” we mean events where employees are killed, maimed, injured, or become ill from exposure to toxic chemicals or microorganisms (TB, hepatitis, HIV).
A systematic plan and follow through of investigating incidents or mishaps and altering behaviors can help stop a future accident.
Let’s take the 50 lb carton falling 12 feet for the second time, only this time it hits a worker, causing injury. Predictable? Yes. Preventable? Yes. Investigating why the carton fell will usually lead to solution to prevent it from falling in the future.
Most workplace injuries and illness are not due to “accidents”. The term accident is defined as an unexpected or unintentional event, that it was “just bad luck”. More often than not it is a predictable or foreseeable “eventuality”.
By “accidents” we mean events where employees are killed, maimed, injured, or become ill from exposure to toxic chemicals or microorganisms (TB, Hepatitis, HIV, Hantavirus etc).
A systematic plan and follow through of investigating incidents or mishaps and altering behaviors can help stop a future accident.
Let’s take our mythical 50 lb carton falling 12’, for the 2nd time, only this time it hits a worker, causing injury. Predictable? Yes. Preventable? Yes. 19

20. Recommend Corrective Actions
Hierarchy of Hazard Controls
Elimination of Hazard Remove or reduce
Substitution less hazardous material or reduce energy – lower speed, force, amperage, pressure, temperature, and noise.
Engineering Controls
Warnings
Administrative Controls & Procedures – Remove or reduce the exposure
Personal protective equipment (PPE) – Put up a barrier
INTERIM MEASURES
Should also be taken if the risk cannot be engineered or managed right away.
Elimination - Design to eliminate hazards, such as falls, hazardous materials, noise, confined spaces, and manual material handling
2) Substitution • Substitute for less hazardous material • Reduce energy. For example, lower speed, force, amperage, pressure, temperature, and noise.
3) Engineering Controls • Ventilation systems • Machine guarding • Sound enclosures • Circuit breakers
• Platforms and guard railing • Interlocks • Lift tables, conveyors, and balancers
4) Warnings • Signs • Backup alarms • Beepers • Horns • Labels
5) Administrative Controls & Procedures • Safe job procedures • Rotation of workers • Safety equipment inspections • Changing work schedule • Training • Confined Space Entry
6) Personal Protective Equipment • Safety glasses • Hearing protection • Face shields • Safety harnesses and lanyards • Gloves • Respirators
Interim measures should also be taken if the risk cannot be engineered or managed right away.

21. Corrective Actions: The main reason for Incident Investigations
Here’s the key. Do you give…
(0) Advice: Stay out of trouble when you are out tonight.
(1) Action: Come home by 11:00.
(2) Plan: I’ll be staying up. See you at home by 11:00.
Levels of Actions
Direct action taken by worker or assistant
Single Use Plan – Get supervision at the workplace to get someone to do it.
Multiple Use Plan – Build the plan in writing, directing someone to do it. Plans should be pre-arranged, scheduled, and lead to an objective.
Recommending Corrective actions – Planning for safety
Writing corrective actions for accidents or any other workplace problem is critical to overcoming any deficiencies in our systems or our behaviors. But we normally measure dollars, or number of claims, and not the message we send with our corrective actions. Injuries, unplanned events, unsafe acts or conditions, or root causes will generate a corrective action. Let’s analyze some examples.
Advice: Stay out of trouble when you are out tonight.
Action: Come home by 11:00.
Plan: I will be staying up to see you when you come home at 11:00.
Levels of Actions
Direct action taken by worker or assistant
Single Use Plan – Give supervision at the workplace to get someone to do it.
Multiple Use Plan – Build the plan in writing, directing someone to do it.
Plans should be pre-arranged, scheduled, and lead to an objective.
Decide which of these 4 root causes best applies
Decide who didn’t:
Know Understand Believe Observe
Start with these clues to find a corrective action
Devise a Plan to
Teach Educate Persuade Assign
Decide which of these 4 root causes applies
Start with these clues to find a corrective action
Devise a Plan to:
1. Teach
2. Educate
Persuade
Assign
1. Know
2. Understand
3. Believe
4. Observe
Decide who didn’t:

22. Conclusions of Report Report conclusions should answer the following:
What should happen to prevent future accidents?
What resources are needed?
Who is responsible for making changes?
Who will follow up and insure changes are implemented?
What will be the future long-term procedures?
If additional resources are needed during the implementation of recommendations, then provide options. Having a comprehensive plan in place will allow for the success of your investigation. Success of an investigation is the implementation of viable corrections and their ongoing use.
Conclusions must always be based upon facts found during your investigation. If additional resources are needed during the implementation of recommendations then provide options. Having a comprehensive plan in place will allow for the success of your investigation. Success of an investigation is the implementation of viable corrections and their ongoing use.
The outcome of an investigation of the 50 lb. carton falling off the top shelf of the 12 ft. high rack might include correction of sloppy storage at several locations in the warehouse, moving unstable/heavy items to floor level, conducting refresher training for stockers on proper storage methods, and supervisors doing daily checks. 22

23. The report should include:
Write a Report
The report should include:
An accurate narrative of “what happened”?
How and Why the Accident Happened?
Who was involved?
What injuries occurred or what equipment was damaged?
How were the employees injured?
Clear description of unsafe act or condition.
Sequence of events.
Recommended immediate corrective action.
Recommended long-term corrective action.
Recommended follow up to assure fix is in place.
Recommended review to assure correction is effective.
Incident and Accident reports are a compilation of facts.
They include:
Writing an accurate narrative of “what happened”
Clear description of unsafe ACT or CONDITION
Recommended immediate corrective action
Recommended long-term corrective action
Recommended follow up to assure fix is in place
Recommended review to assure correction is effective.
The majority of the rest of this presentation will expand on the six points we just covered about how to investigate accidents and incidents. 23

24. Questions?
Contact Information
C. G. Lawrence, III, MS, CSP, REM, ARM-P
Chief Loss Control & Safety Officer
(404)
Hiram Lagroon, BS
(404)