All untoward incidents, which could not be prevented from occurrence, indicate that failures have occurred. It is essential to draw lessons from these incidents, improve the situation, and prevent similar occurrences in the future. Site personnel and work in-charge need easy, simple, and readily applicable techniques to learn and follow.
The purpose and reasons behind Accident Investigation can be summarized as follows:
• For legal reasons
• For claim management
• For staff morale
• For records, data gathering, and disciplinary uses.
Immediate Action:
The immediate action upon the occurrence of any accident is to save the affected persons and arrange for their rescue, first-aid, and requisite medical care. Simultaneously, or without delay, abnormal situations should be normalized and made safe, with minimal or no changes to the scene of the occurrence. Photographs should be taken to capture the original scene as far as possible, as this will facilitate incident investigation.
Once the immediate dangers have been dealt with and casualties attended to, a decision should be made regarding the type and level of investigation required.
Gathering Information:
Secure the scene as soon as possible to prevent it from being altered. Collect witness details quickly, before they start to leave the scene. In some cases, it may help to separate witnesses and ask them to wait in different areas to prevent collusion or contamination of their testimony. Collect factual information from the scene and record it.
- Photographs
- Sketches
- Measurements
- Videos
- Physical evidence
The investigator should come prepared with the appropriate equipment to record this information. Once the scene has been thoroughly examined, move on to the second source of information: witnesses. Witnesses often provide crucial evidence about what occurred before, during, and after the incident. Once witnesses have been interviewed, move on to the third source of information: documentation.
- Company policies
- Risk assessments
- Training records
- Safe system of work
- Permits-to-work
- Maintenance records
- Disciplinary records
- Internal accident report forms
- Logbook entries
- Computer printouts relevant to the situation
Analyzing Information:
The goal here is to draw conclusions about the immediate and root causes of the incident. These are the factors that contributed to the accident at the time and place of the incident. Underlying or root causes are the factors that lie behind the immediate causes, such as:
• Failure to adequately supervise workers
• Failure to provide appropriate PPE
• Failure to provide adequate training
• Lack of maintenance
• Inadequate checks or inspections
• Failure to carry out proper risk assessments
Identify Suitable Control Measures:
Once the immediate and underlying causes of the accident are known, appropriate control measures can be identified. Control measures must be identified to address both the immediate and underlying causes. Key questions to ask when identifying control measures include:
• If this action is taken, will it prevent this same accident from happening in exactly the same way at this location?
• If this action is taken, will it prevent other similar types of accidents from happening in similar locations in the future?
If the answer to both of these questions is “no,” then further control measures must be identified.
Plan the Remedial Actions:
An accident investigation should lead to corrective action. When preparing an action plan, immediate and interim control measures must be given suitable priorities and timelines. Unsafe conditions must not persist in the workplace. Dangerous practices and high-risk activities must be addressed immediately. This may mean taking machinery and equipment out of action, suspending certain work activities, or evacuating locations. These actions cannot wait until the investigation is completed—they must be implemented immediately to ensure safety while the investigation is in progress. Interim control measures may be introduced to allow work to proceed while longer-term solutions are pending.
Underlying causes often require significant time, money, and effort to remedy. Therefore, remedial actions that will have the greatest impact should be prioritized and completed first. There may be actions that need to be taken to address management weaknesses or achieve legal compliance, but which may not be as effective in preventing future accidents. These actions should still be implemented, but with lower priority.
For more guidance on effective accident investigation and staffing solutions, visit Core EHS Safety Staffing Services.