LYCEUM OF THE PHILIPPINES UNIVERSITY – CAVITE

College of Engineering, Computer Studies and Architecture

Department of Engineering

Accident Investigation and Reporting

Leader: Abgao, Alvin

Member: Cequiña, Ryan
Dela Cruz, Charmaine Ericka
Gravillo, Kent Noel
Legaspi, Giamaica
Pidot, Riobelle

Submitted To:
Engr. John Paulo Agrimano

March 9, 2018

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TYPES OF ACCIDENT INVESTIGATIONS

1. Accident reports.
2. Accident-analysis reports

Accident report is completed when the accident in question represents only a minor incident. It
answers the following questions: who, what, where, and when. However, it does not answer the
why question. The Occupational Safety and Health Administration’s (OSHA’s) Form 301 can be
used for accident reports.

4 Basic steps of writing an accident report

1. Find the Facts: To prepare for writing an accident report, you have to gather and record
all the facts. ...
2. Determine the Sequence: Based on the facts, you should be able to determine the
sequence of events. ...
3. Analyze
4. Recommend

Accident-analysis report this level of report should answer the same questions as the regular
accident report plus one more—why. It is the process of determining the causes of accidents and
implementing corrective actions to prevent recurrence. An accident analysis is also sometimes
referred to as an accident investigation.

Accident analysis is performed in four steps:

1. Fact gathering: After an accident happened a forensic process starts to gather all
possibly relevant facts that may contribute to understanding the accident.
2. Fact Analysis: After the forensic process has been completed or at least delivered some
results, the facts are put together to give a "big picture." The history of the accident is
reconstructed and checked for consistency and plausibility.
3. Conclusion Drawing: If the accident history is sufficiently informative, conclusions can
be drawn about causation and contributing factors.
4. Counter-measures: In some cases, the development of counter-measures is desired or
recommendations have to be issued to prevent further accidents of the same kind.

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WHEN TO INVESTIGATE
The first thing to do when an accident takes place is to implement emergency
procedures. This involves bringing the situation under control and caring for the injured worker.
As soon as all emergency procedures have been accomplished, the accident investigation
should begin. Waiting too long to complete an investigation can harm the results. This is an
important rule of thumb to remember. Another is that all accidents, no matter how small, should
be investigated. Evidence suggests that the same factors that cause minor accidents cause major
accidents.
Further, a near miss should be treated like an accident and investigated thoroughly.

Reasons why it is important to conduct investigations immediately:

 Immediate investigations are more likely to produce accurate information. Conversely, the
longer the time span between an accident and an investigation, the greater the likelihood of
important facts becoming blurred as memories fade.

 It is important to collect information before the accident scene is changed and before
witnesses begin comparing notes. Human nature encourages people to change their stories to
agree with those of other witnesses.

 An immediate investigation is evidence of management’s commitment to preventing future

accidents. An immediate response shows that management cares.

WHAT TO INVESTIGATE
The purpose of an accident investigation is to collect facts. It is not to find fault. Finding
the causes of an accident and taking steps to control or eliminate it can help prevent similar
accidents from happening in the future.

The investigation process is "fact-finding" not "fault-finding". Fault finding can cause
reticence among witnesses who have valuable information to share. Causes of the accident
should be the primary focus.

Accident Investigation Guide

The investigation should be guided by the following words: who, what, when, where,
why, and how.

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Some of the SME recommends the following questions when conducting the investigation:

• What type of work was the injured person doing?

• Exactly what was the injured person doing or trying to do at the time of the accident?
• Was the injured person proficient in the task being performed at the time of the accident?
Had the worker received proper training?
• Was the injured person authorized to use the equipment or perform the process involved
in the accident?
• Were there other workers present at the time of the accident? If so, who are they, and
what were they doing?
• Was the task in question being performed according to properly approved procedures?
• Was the proper equipment being used, including personal protective equipment?
• Was the injured employee new to the job?
• Was the process, equipment, or system involved new?
• Was the injured person being supervised at the time of the accident?
• Are there any established safety rules or procedures that were clearly not being followed?
• Where did the accident take place?
• What was the condition of the accident site at the time of the accident?
• Has a similar accident occurred before? If so, were corrective measures recommended?
Were they implemented?
• Are there obvious solutions that would have prevented the accident?

The answers to these questions should be carefully and copiously recorded. You may use
a recording device that will be helpful to dictate your findings. This approach allows you to
focus more time and energy on investigating and less on taking written notes. Also remember
that what may seem like a minor unrelated fact at the moment could turn out to be a valuable fact
later when all the evidence has been collected and is being analyzed.

Most Common Cause of the Accident

 Personal beliefs and feelings: Individual did not believe the accident would happen to him
or her; individual was working too fast, showing off, or being a know-it-all; individual had
personal problems that clouded his or her judgment, etc.
 Decision to work unsafely: Some people, for a variety of reasons, feel it is in their best
interest or to their benefit to work unsafely.
 Mismatch or overload: Individual is in poor physical condition; individual is fatigued;
individual has a high stress level; individual is mentally unfocused or distracted; the task
required is too complex or difficult, etc.

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 System failure: Lack of rules, regulations, procedures; failure to correct known hazards;
insufficient training for employees, etc.
 Traps: Poor design of workstations and processes can create traps that, in turn, lead to
unsafe behavior. Common cause includes defective equipment; failure to provide, maintain,
replace proper personal protective equipment, excessive temperature extremes; insufficient
lighting; and insufficient ventilation etc.
 Unsafe conditions: unsafe conditions created by the elements; unsafe conditions created by a
fellow employee, etc.
 Unsafe acts: individual chooses to ignore the rules; individual uses drugs or alcohol;
individual chooses an improper work method; individual fails to ask for information or other
resources needed to do the job safely; individual forgets a rule, regulation, or procedure etc.

WHO SHOULD INVESTIGATE?

Who should conduct the accident investigation? There is no simple answer to this
question, and there is disagreement among professional people of goodwill.

Factors considered in deciding how to approach accident investigations include:

 Size of the company

 Structure of the company’s safety and health program
 Type of Accident
 Seriousness of the accident
 Technical complexity
 Number of times that similar accidents have occurred
 Company’s management philosophy
 Company’s commitment to safety and health
After considering all the variables listed above, it is difficult to envision a scenario in which
the safety and health professional would not be involved in conducting an accident investigation.

If the accident is so serious that it has widespread negative implications in the community
and beyond, responsibility for the investigation may be given to a high-level manager or
corporate executive. In such cases, the safety and health professional should assist in conducting
investigation.

Regardless of the approached preferred by a given company, the safety and health
professional should play a leadership role in collecting and analyzing the facts and developing
recommendations.

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CONDUCTING THE INVESTIGATION
Investigating a worksite incident— a fatality, injury, illness, or close call— enables
employers and workers to identify and implement the corrective actions necessary to prevent
future incidents.

5 Steps to follow in conducting an accident investigation:

1. Isolate the accident site
2. Record all evidence
3. Photograph or videotape the scene
4. Identify witnesses
5. Interview witnesses

1. ISOLATE THE ACCIDENT SITE

This is to maintain as closely as possible the conditions that existed at the time of the
accident.

2. RECORD ALL EVIDENCE

It is important to make a permanent record of all pertinent evidence as quickly as possible.
There are three reasons for this;
• Certain types of evidence may be perishable.
• Evidences will more likely be disturbed, knowingly or unknowingly.

• If the isolated scene contains a critical piece of equipment, pressure will quickly mount to
get it back in operation.

Evidences can be recorded in a variety of ways like; written notes, sketches, photography,
videotape, dictated observations, and diagrams.

3. PHOTOGRAPH OR VIDEOTAPE THE SCENE

This step is an extension of the previous step. Modern photographic and video-taping
technology has simplified the task of observing and recording evidence.

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4. IDENTIFY WITNESSES
In identifying witnesses, it is important to compile a witness list. Names on the list should
be recorded in three categories;
• Primary Witnesses - they are the eyewitnesses to the accident.

• Secondary Witnesses - they are the witnesses who did not actually see the accident happen
but were in the vicinity and arrived on the scene very shortly after the accident.

• Tertiary Witnesses - they are the witnesses who were not present at the time of the accident
nor afterward but may still have relevant evidence to present.

5. INTERVIEW WITNESSES
This is the step where witnesses should be interviewed, preferably in the following order:
primary witnesses first, secondary next, and tertiary last.

INTERVIEWING WITNESSES

• WHY DO WE INTERVIEW WITNESSES?

The techniques used for interviewing accident witnesses are designed to ensure that the
information is objective, accurate, as untainted by the personal opinions and feelings of
witnesses as possible, and able to be corroborated. For this reason, it is important to understand
the when, where, and how of interviewing the accident witnesses.

•When to Interview?

 Interviews should begin as soon as possible.

 why?
- Because first, a witness’s recollections will be best right after the accident.

- second, immediacy avoids the possibility of witnesses comparing notes and, as a

result, changing their stories

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• Where to Interview?

 The accident scene.

 why?
– Because experience has shown that the best way to promote accuracy is to
interview witnesses at the site of the accident. This puts the accident interview
in context in a setting that will help stimulate the memory.

 What if it is not possible to interview at the accident scene?

– Interviews should take place in a private setting elsewhere.
– Avoid the “principal’s office syndrome”.

•How to Interview?

 Put the witness at ease and to listen.

– Listen to what is said, how it is said, and what is not said.

 Ask questions in an open-ended format.

•Remain non-judgmental
•Be neutral
•Be objective

 Make sure to inform the witness if his/her statements will be recorded.

– Take time at the beginning of the interview to discuss unrelated matters long enough
to put the witness at ease and overcome the presence of the taping device.

TAKE NOTE: The recording of the statement can be asked to stop by the witness anytime before
and during an interview.

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REPORTING ACCIDENTS
An accident investigation should culminate in a comprehensive accident report. The
purpose of the report is to record the findings of the accident investigation, the cause or causes of
the accident, and recommendations for corrective action.

OSHA document 2056:

Employers of 11 or more employees must maintain records of occupational injuries and
illnesses as they occur. Employers with 10 or fewer employees are exempt from keeping such
records unless they are selected by the Bureau of Labor Statistics (BLS) to participate in the
Annual Survey of Occupational Injuries and Illnesses.
All injuries and illnesses are supposed to be recorded.
Injuries and illnesses must be recorded of they result in any of the following:

 Death
 One or more lost work days
 Restriction of motion or work
 Loss of consciousness
 Transfer to another job
 Medical treatment (more than first aid)
If an accident results in death of an employee or hospitalization of three or more employees,
a report must be submitted to the nearest OSHA office within 8 hours.

Accident report form varies from company to company. However, the information contained
in them is fairly standard. Regardless of the type form used, an accident report should contain at
least the information needed to meet the record-keeping requirements set forth by OSHA:

 Case number of the accident

 Victim’s department or unit
 Location and date of the accident
 Victim’s name, social security number, gender, age, home address, and telephone number
 Victim’s normal job assignment and length of employment
 Victim’s employment status at the time of accident
 Case numbers and names of others injured
 Type of injury and body part(s) injured
 Name, address, and telephone number of the physician called
 Name, address, and telephone number of the hospital which the victim was taken, etc.

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Why Some Accidents Are Not Reported
In spite of OSHA’s reporting specifications, some accidents still go unreported.
According to Cunningham and Kane,

The majority of accidents are not being reported. Articles in the Wall Street Journal
testify to this fact. Many firms failed to report to OSHA recordable incidents, presumably either
to avoid OSHA inspections that result from poor incident rates, or to achieve statistical goals.
The saddest part of non-reporting of accidents is that they are not investigated to determine and
eliminate the causes.
Some reasons why accidents go unreported:

1. Red tape
2. Ignorance
3. Embarrassment
4. Record-spoiling
5. Fear of repercussions
6. No feedback

Discipline and Accident Reporting

Fault finding is not the purpose of an accident investigation. However, an investigation
sometimes reveals that an employee has violated or simply overlooked safety regulations.
According to Kane and Cunningham:

Many companies condone nonconformance to safety rules as long as no injury results.

However, if the nonconformance results in accident involving an injury, the disciplinary boom is
promptly lowered. This inconsistency inevitably leads to resentment and failure to report
accidents and a hiding of accident problems.

TEN ACCIDENT INVESTIGATION MISTAKES TO AVOID

The amount of information you collect and how you collect it will go a long way toward
determining how effective your resultant corrective actions will be following a workplace
accident. According to William R. Coffee Jr., safety and health professionals should avoid the
following commonly made mistakes when investigating accidents.

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• Failing to investigate near misses.
A near miss is simply an accident that did not happen because of luck.
Consequently, investigating near misses can reveal critical accident prevention
information.

• Taking ineffective corrective action.

Ineffective corrective action is often the result of a cursory accident investigation.
When investigating, look for the root cause, not the symptoms. Corrective action based
on symptoms will not prevent future accidents.

• Allowing your biases to color the results of the investigation.

Look for facts and be objective when investigating an accident. Do not make
assumptions or jump to conclusions. One of the best ways to eliminate bias in accident
investigations is to use a standard, structured routine and to skip no steps in the routine.

• Failing to investigate in a timely manner.

Accident investigations should begin as soon as possible after the accident. The
longer you wait to begin, the more likely it is that evidence will be lost, corrupted, or
compromised. For example, once people start talking to each other about what they saw,
invariably their memories will be shaped by the opinions of their fellow workers and
witnesses. People walking through an accident scene can compromise the integrity of
the scene by unwittingly destroying evidence.

• Failing to account for human nature when conducting interviews.

Often what those involved in an accident as well as witnesses to an accident will
say during an interview will be shaped by their desire to escape blame, deflect blame to
someone else, or protect a friend. This is why it is important to interview witnesses and
others involved privately and individually, and to look for corroborating evidence to
support (or refute) their input.

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• Failing to learn investigation techniques.
Before investigating an accident, safety and health professionals should complete
specialized training or undertake self-study to learn investigation techniques such as
those presented in this chapter. An unskilled investigator is not likely to conduct a valid
investigation.

• Allowing politics to enter into an investigation.

The goal of an investigation is and must be to identify the root cause so that
appropriate corrective action can be taken. Personal likes, dislikes, favoritism, and
office politics will corrupt an investigation from the outset.

• Failing to conduct an in-depth investigation.

Everyone is in a hurry and investigating an accident was not on your agenda for
the day. In addition, there is sometimes pressure from higher management to “get this
thing behind us.” Such pressures and circumstances can lead to a rushed investigation in
which the goal is to get it over with, not to find the root cause of the accident. Surface-
level investigations almost ensure that the same type of accident will happen again.

• Allowing conflicting goals to enter into an investigation.

The ultimate goal of an accident investigation is to prevent future accidents and
injuries. However, even when that is your goal, there may be other people who have
different goals. Some may see the investigation as an opportunity to deflect blame,
others may see it as an opportunity to protect the organization from litigation, and some
may see it as a way to explain not meeting production quotas or performance standards.
Safety and health professionals should be aware that other agendas may be in play every
time an accident investigation is conducted. For this reason, objectivity, structure, and
routine are critical.

• Failing to account for the effects of uncooperative people.

One would think that employees and management personnel would automatically
want to cooperate in accident investigation to ensure that similar accidents are prevented
in the future. Unfortunately, this is not always the case. People will not always
cooperate for a variety of reasons—all growing out of the concept of perceived self-
interest. Further, the lack of cooperation will not always be overt. In fact, often it will be

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 covert (for example, a person you need to interview keeps putting you off or canceling
meetings). Safety and health professionals need to understand that self-interest is one of
the most powerful motivators of human beings and factor this into their planning for
accident investigations.

These 10 mistakes will probably never be completely eliminated from every

accident investigation. However, if safety and health professionals are aware of them,
they can at least ensure that such mistakes are minimized. The fewer of these mistakes
that are made during an accident investigation, the better the quality of the investigation
and the more likely that it will lead to effective corrective action.

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