Accident Investigation

OR-OSHA 102
0102
OR-OSHA 102
Accident Investigation Procedures
Accident Investigation
Procedures
1
Steven J. Geigle, CSHM

Safety Training Specialist
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Oregon OSHA Pa
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503.292.0654
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steven.geigle@comcast.net
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OR-OSHA 102
Goals!
1. Describe the primary reasons for conducting

an accident investigation.
2. Discuss employer responsibilities related to
workplace accident investigations.
3. Conduct the six step accident investigation
procedure
OR-OSHA 102
Form Accident Analysis Teams!
OR-OSHA 102
The Basics
Whats the difference between

an incident and an accident?
OR-OSHA 102
What two key conditions must exist before

an accident occurs?
H_______________
OR-OSHA 102
and
E_________________
What causes the most accidents?
3 % of all
Hazardous conditions account for _____
workplace accidents.
Unsafe/inappropriate behaviors account for
95 % of all workplace accidents.
_____
2 % of all
Uncontrollable acts account for ____
workplace accidents
Management is able to control factors that
98 % of all workplace accidents.
produce ______
OR-OSHA 102
What is the difference between accident

investigation and accident analysis?
Blame
We investigate to fix the ____________
System
We analyze to fix the ____________
OR-OSHA 102
The six-step process

What are the basic steps for conducting an
accident investigation?
Secure the scene
Gather Information
Collect facts
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Secure the scene
Gather Information
Collect facts
Develop sequence
Analyze The Facts
Determine causes
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10

Secure the scene
Gather Information
Collect facts
Develop sequence
Analyze The Facts
Determine causes
Recommendations
Implement Solutions
Write the report
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Step 1: Secure the accident scene
Your primary goal is to begin gathering accident

information that can give critical clues into the
causes associated with the accident.
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When is it appropriate to begin the

investigation?
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13
What are effective methods to secure an

accident scene?
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14
Step 2: Collect facts about what

happened
In this step, you will use various tools and

techniques to collect pertinent facts about
the accident to determine the:
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Cause of injury. Harmful transfer of

energy causing injury.
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Cause of injury. Harmful transfer of energy

causing injury.
Surface Causes. Hazardous conditions

and unsafe employee/management
behaviors that produced or contributed
to the accident.
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Cause of injury. Harmful transfer of energy

causing injury.
Surface Causes. Hazardous conditions and
unsafe employee/management behaviors that
produced or contributed to the accident.
Root Causes. System weaknesses that

produced the surface causes for the
accident.
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18
List methods to document the accident

scene and collect facts about what
happened.
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19
What documents will help you determine

facts about the accident?
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20
OR-OSHA 102
Standard Operating Procedures

Job Hazard Analysis
MSDSheets
Training Records
Safety/Health Programs
Discipline Records
Inspection Records
Maintenance Records
Operator/Manufacturer Manuals
21
Interviewing
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Interviewing
When is it best to interview? Why?
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Interviewing
Who should we interview? Why?
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Interviewing

Who should we interview? Why?
Where should we conduct the interview?
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Cooperate, dont intimidate!
What are effective interviewing

techniques?
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What should we say and do?
Always explain the purpose

Be courteous & professional
Ask "what did you see and hear"?
Ask open-ended questions
Ask "what can we do to prevent this"?
Share interview notes
Actively listen
Bottom line: Treat them the same as you

would like to be treated!
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What should we NOT say and do?

Dont interrogate
Dont ask yes/no questions
Don't ask accusatory
questions
Don't ask "who's to blame"?
Dont ask leading questions
Dont withhold/conceal notes
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28
Team Exercise:
Cooperation is the Key
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Step 3: Develop the sequence of

events
In this step, we take the information we collected and
determine the events prior to, during, and after the
accident.
An accident is the final event

in an accident process
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30
Each event in the unplanned accident process

should identify one:
Actor - Individual or object
An actor initiates a change by performing or
failing to perform an action. An actor may
participate in the process or merely observe
the process.
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Each event in the unplanned accident process

should identify one:
Action Behavior the actor accomplishes
Actions may or may not be observable. An
action may describe something that is done
or not done.
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Circle the actor and action.

Beverly slipped on a banana.
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33
Dale slipped on a banana.
As Beverly lay on the floor, a

brick fell on her head .
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Dale slipped on a banana.
As Dale lay on the floor, a brick fell

on his head .
Sam discovered Beverly

unconscious on the floor and
immediately began initial first
aid procedures.
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Team Exercise: What happened next?

Instructions. Analyze the following
events developed from the Farley
Frames scenario. Determine those
events that need to be corrected.
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Step 4: Determine the causes
W. H. Heinrich's Domino Theory

Multiple Cause Theory
What may be the cause(s) of the accident
according to the multiple causation theory?
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What might be the solutions to prevent the
accident from recurring?
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What are the strengths and weaknesses of
this approach?
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39
Strains
Direct Cause of
Injury
Burns
Cuts
Un
gu
ard
ed
ma
ch
ine
Surface
Causes
lay
sep
r
o
H
azard
te a h
Crea
Bro
ken
too
ls
Defec
tive P
PE
zard
e a ha
Ignor
jury
rt in
o
p
e
r
s to
Fail
Untrained
worker
Fails to inspect
Chem
ical sp
ill
Fails to enforce
Lack of time
work
Inadequate training
No discipline procedures
No orientation process
Inadequate training plan
No accountability policy
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Fails to tr
ain
Lack of vision No mission statement
To much
No recognition
Inadequate labeling
Outdated hazcom program
No recognition plan
No inspection policy
Root
Causes
40
Direct Cause of Injury

The cause of injury describes the harmful
transfer of energy. May take the form of:
Acoustic - excessive noise and vibration
Chemical - corrosive, toxic, flammable,
reactive
Electrical - low/high voltage, current
Kinetic - energy transferred from impact
Mechanical - components that move
Potential - "stored energy" in objects
Radiant - ionizing and non-ionizing radiation
Thermal - excessive heat, extreme cold.
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Surface Causes of the Accident

Specific/unique hazardous conditions and/or
unsafe actions
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unsafe actions
Directly produce or contribute to the accident
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unsafe actions
They may exist/occur at any time and anywhere
and involve anyone.
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unsafe actions
and involve anyone.
They may or may not be controllable by
management
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unsafe actions
and involve anyone.
They may or may not be controllable by
management
If you're pointing at person or thing, it's probably a
surface cause.
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Root Causes of the Accident

Program design weaknesses - Failure to effectively
develop safety policies, programs, plans,
processes, procedures, practices
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Performance weaknesses - General failure to
effectively carry out safety policies, programs,
plans, processes, procedures, practices
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Result in common or repeated hazardous
conditions and unsafe/inappropriate performance
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49

Result in common or repeated hazardous
conditions and unsafe/inappropriate performance
If you're pointing a group or a written plan, policy,
procedure, it's probably a root cause.
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Steps in cause analysis
OR-OSHA 102
Analyze the injury event to identify and

describe the direct cause of injury/illness.
Laceration to right forearm resulting from

contact with rotating saw blade.
Contusion from head striking

against/impacting concrete floor.
51
2. Analyze events occurring just prior to the injury

event to identify those conditions and behaviors that
caused the injury (primary surface causes) for the
accident.
Examples:
Event x. Unguarded saw blade. (condition or
behavior?)
Event x. Working at elevation without proper fall
protection. (condition or behavior?)
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3. Analyze conditions and behaviors to determine

other specific conditions and behaviors
(contributing surface causes) that contributed to
the accident.
Examples:
Supervisor not performing weekly area safety
inspection. (condition or behavior?)
Fall protection equipment missing. (condition
or behavior?)
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4. Analyze each contributing condition and behavior to

determine if weaknesses in carrying out safety
policies, programs, plan, processes, procedures and
practices (inadequate implementation) exist.
Examples:
Safety inspections are being conducted
inconsistently.
Safety is not being adequately addressed during
new employee orientation.
Note: Oregon OSHA investigations site safety management
system performance failures.
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5. Determine implementation flaws to determine the

underlying design weaknesses.
Examples:
Inspection policy does not clearly specify
responsibility by name or position.
No fall protection training plan or process in place.
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Exercise: Digging up the roots
1. Write the cause of injury in the scenario.

2. List the direct surface cause condition and
unsafe behavior that caused the accident.
3. List possible contributing surface causes related
with the direct surface causes.
4. List possible design and performance root
causes contributing to surface causes.
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Step 5: Recommend Corrective

Actions & Improvements
The Hierarchy of Controls
Engineering Controls. Eliminate/reduce
hazards through equipment redesign,
replacement, substitution, etc.
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Step 5: Recommend Corrective

Actions & Improvements
The Hierarchy of Controls
Management Controls. Eliminate/reduce
frequency and duration of exposure to hazards
by controlling employee behaviors. Three
primary strategies:
q
q
q
q
OR-OSHA 102
Safe procedures and practices

Scheduling
Use of Personal Protective Equipment (PPE).
Interim measures.
58
Team Exercise:
Recommending Corrective
actions
Purpose: In this exercise youll develop and
recommend immediate actions to correct the
surface causes of an accident.
Instructions. Using the control strategies as a
guide, determine corrective actions that will
eliminate or reduce one of the hazardous
conditions or unsafe behaviors identified in the
previous exercise.
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Improvement strategies to fix the system

Make improvements to policies, programs, plans,
processes, and procedures in one or more of the
following elements of the safety management system:
1.
2.
3.
4.
5.
6.
7.
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Management Commitment
Accountability
Employee Involvement
Hazard Identification/Control
Incident/Accident Analysis
Education/Training
System Evaluation
60
Making system improvements might

include some of the following:
Writing a comprehensive safety and health plan that
includes all safety management elements.
Improving a safety policy so that it clearly
establishes responsibility and accountability.
Changing a training plan to include demonstration.
Revising purchasing policy to include safety
considerations as well as cost.
Changing the safety inspection process to include all
supervisors and employees.
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61
Team Exercise: Fix the

system... not the blame
Purpose: In this exercise youll develop and
recommend one improvement to make sure the case
study accident does not recur.
Instructions. Develop and write brief
recommendations to improve one or more policies,
plans, programs, processes, procedures, and
practices identified as design weaknesses.
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Step 6: Write the report

A primary reason accident investigations fail to help
eliminate similar accidents is that some report forms
unfortunately address only correcting surface causes.
Root causes are often ignored.

The report should basically be the cleaned up
version of all of your hard work and efforts from Step
1 through Step 5!
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63
The report is an open document until all

actions are complete!
When the accident investigator completes the
report, he or she will give it to someone who must
do something with it.
Thats the job of the decision-maker..
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Before you run, let's review!
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That's it! Thanks for coming!
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Note: Optional slides from here on
437-001-0052 Reporting an Occupational Fatality,

Catastrophe, or Accident.
Employers must inform Oregon OSHA of all fatalities
or catastrophes within 8 hours, and accidents or
injuries resulting in a hospital admission with medical
treatment other than first aid within 24 hours after the
employer receives notification.
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437-001-0170 Determination of Penalty - Failure to

Report an Occupational Fatality, Catastrophe, or
Accident.
Failure to report an occupational fatality, catastrophe,
or accident: a penalty of not less than $250, nor more
than $7,000 shall be assessed.
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437-01-0760(3)(a)
Each employer shall investigate or cause to be
investigated every lost-time injury that workers suffer
in connection with their employment, to determine the
means that should be taken to prevent recurrence.
The employer shall promptly install any safeguard to
take any corrective measure indicated or found
advisable.
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437-001-0765(6)(g)
Accident investigation.
The safety committee must establish procedures for

investigating all safety-related incidents including injury
accidents, illnesses and deaths. This rule shall not be
construed to require the committee to conduct the
investigations.
OR-OSHA 102
70

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OR-OSHA 102

Accident Investigation Procedures

Steven J. Geigle, CSHM

Accident Investigation Procedures

1. Describe the primary reasons for conducting

Accident Investigation Procedures

Form Accident Analysis Teams!

Accident Investigation Procedures

Whats the difference between

Accident Investigation Procedures

What two key conditions must exist before

Accident Investigation Procedures

What causes the most accidents?

Accident Investigation Procedures

What is the difference between accident

Accident Investigation Procedures

The six-step process

Accident Investigation Procedures

The six-step process

Accident Investigation Procedures

The six-step process

Accident Investigation Procedures

Step 1: Secure the accident scene

Your primary goal is to begin gathering accident

Accident Investigation Procedures

When is it appropriate to begin the

Accident Investigation Procedures

What are effective methods to secure an

Accident Investigation Procedures

Step 2: Collect facts about what

In this step, you will use various tools and

Accident Investigation Procedures

Cause of injury. Harmful transfer of

Accident Investigation Procedures

Cause of injury. Harmful transfer of energy

Surface Causes. Hazardous conditions

Accident Investigation Procedures

Cause of injury. Harmful transfer of energy

Root Causes. System weaknesses that

Accident Investigation Procedures

List methods to document the accident

Accident Investigation Procedures

What documents will help you determine

Accident Investigation Procedures

Standard Operating Procedures

Accident Investigation Procedures

Accident Investigation Procedures

When is it best to interview? Why?

Accident Investigation Procedures

When is it best to interview? Why?

Who should we interview? Why?

Accident Investigation Procedures

When is it best to interview? Why?

Where should we conduct the interview?

Accident Investigation Procedures

Cooperate, dont intimidate!

What are effective interviewing

Accident Investigation Procedures

What should we say and do?

Always explain the purpose

Bottom line: Treat them the same as you

Accident Investigation Procedures

What should we NOT say and do?

Accident Investigation Procedures