Investigate causes for all dominoes usually starting with the last domino, Asking why the loss occurred then go to the unsafe condition then the unsafe act and finally the cause will be lack of control.
Who should undertake the investigation? Line managers (With help as appropriate from the H & S adviser / competent person, medical or nursing adviser and technical staff), Safety representatives (The best approach is joint inspection between employers and safety representatives).
Accident Investigators: Knowledge required (Operating procedures, Investigation procedure, Human factors and should be equipped with the right tools to do the job), Skills required (Observation, recording & Interviewing skills).
Accident Investigation will determine how and why of failures, Examine possible corrective action, Aid in the accident prevention and elimination of a clearly identified hazard, Most important – Investigation is not intended to place blame.
Be Prepared: Develop contingency plans prior to the accident, Designate an investigator. This person should only be responsible for investigating.
Eliminate the hazards: Control chemicals, De- energize, De- pressurize, Light it up, Shore it up, Ventilate.
Provide Care to the Injured: Ensure that medical care is provided to the injured people before proceeding with the investigation.
Isolate the Scene: Protect the evidence until investigation is complete. Barricade the area of the accident and keep everyone out. The only persons allowed inside the barricade should be Rescue / EMS, law enforcement and investigators.
Keep all notes and remarks: In a bound notebook or three ring binder Record pre-accident conditions, accident sequence & post accident conditions. Document victim location, witnesses, machinery, energy sources and other contributing factors.
Examples of things to be looked for: Dents, cracks, scrapes, splits, Spills or leaks Tire tracks, footprints, Scattered or broken parts of equipment, etc.
Diagram the scene: Use blank paper or graph paper, Mark the location of all pertinent items, equipment, parts, spills, persons, etc., Note distances and sizes, pressures and temperatures, Note direction, mark north on the map. Draw scaled sketches, Record measurements, Gather support documents such as maintenance records, reports, production schedules or process diagrams.
Take photographs: Photograph any items or scenes which may provide an understanding of what happened to anyone who was not there. Photograph any items which will not remain or which will be cleaned up as spills, tire tracks, footprints, etc., 35mm cameras, Polaroids and video cameras are all acceptable. Digital cameras are not recommended – digital images can be easily altered.
Interview witnesses: As soon as possible. 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. Let each witness speak freely and take notes without distracting the witness, use a tape recorder only with consent of the witness.
Use open questions (What did you see?, What happened?), Avoid multiple or complex questions, Avoid leading questions (Bad: Why was the forklift operator driving recklessly, Good: How was the forklift operator driving).
Use closed-ended questions later to gain more detail after the person has provided their explanation. Examples of closed questions that can be used: Where were you standing?, What time did it happen?
Do not make suggestions: If the person is stumbling over a word or concept, do not help them out. If the witness begins to offer reasons, excuses, or explanations, politely decline that knowledge and remind them to stick with the facts. Summarize what you have been told. Correct misunderstandings of the events between you and the witness.
Ask the witness / victim for recommendations to prevent recurrence. These people often have the best solutions to the problem.
Get a written, signed statement from the witness. It is best if the witness writes their own statement. Interview notes signed by the witness may be used if the witness refuses to write a statement.
Recording Interviews: Reasons for recording interviews: So you do not forget, No confusion between interviews, Avoid interruptions.
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. Identify the qualifications of each witness: name, address, occupation, years of experience.
Types of Witnesses: Primary Witness (The Victim), Secondary Witness (Anyone who saw the accident), Tertiary Witness (Anyone who didn’t see the accident & can give useful information).
Isolate Fact from fiction: Use NORMS-based analysis of information (Not an interpretation, Observable, Reliable, Measurable, Specific). If an item meets all five of above, it is a fact.
Investigation Report: An accident investigation is not complete until a report is prepared and submitted to the proper authorities.
Investigation Report Contents: Background Information, Where and when the accident occurred?, Description of incident and injuries, Sequence of events, Who and what were involved?, Operating personnel and other witnesses, Indirect causes (Unsafe acts and conditions), Basic cause (Management policies, personal or environmental factors), Recommendations to remedy Basic causes, Indirect causes and Direct causes, Implement Corrective Actions, Strict time table established. If referring to an individual actions, don’t use names in the recommendations, Good: All employees should, Bad: George should. Recommendation (s) must be communicated clearly and objectively Follow up conducted
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