Participant Workbook

This material is for training purposes only.
Welcome
Course Overview
Part One
Accident investigation definitions
Characteristics of an effective program

Part Two: The six-step process
Step 1: Preserving and documenting the accident scene
Step 2: Collecting the facts through interviews
Step 3: Developing sequence
Step 4: Determining causes

Part Three
Step 5: Developing effective recommendations
Tools and techniques to measure costs/benefits
Step 6: Writing the report
Form Groups
Introductions
Elect a group leader
Select a spokesperson
and recorder or
alternate responsibilities
Discuss and report:
Problems you have seen when thorough
accident investigation techniques are not
practiced, or
Positive results when thorough accident
investigations are conducted.
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Introduction to Accident Investigation
Objectives
After attending this workshop, the participants will be able to:
1.
2.
3.
Identify basic accident investigation concepts and describe the characteristics

of an effective accident investigation program.
Describe the six-step process for conducting accident investigations.
Conduct an accident investigation following the six-step procedure.
The basics
What is an accident?
_________________________________________________________
_________________________________________________________
________________________________________________________
What 2 key conditions must exist before an accident occurs?

_________________________________________________________
What causes most accidents?

According to the State of Oregon,
Hazardous conditions account for __% of all workplace accidents.
Unsafe/inappropriate behaviors account for __% of all workplace

accidents.
Uncontrollable acts account for ___% of all workplace accidents
Management is able to control factors that produce ____ % of all

workplace accidents.
What is the difference between accident investigation and

accident analysis?
_________________________________________________
_________________________________________________
_________________________________________________________
Does your organization conduct accident investigations for

the same reason as OSHA?
_____________________________________________
What do accidents cost your company?

Direct Insured Costs
Unseen
costs can
sink the
ship!
1.Workers compensation premiums

2. Miscellaneous medical expenses. Medical expenses
include doctor fees, hospital charges, the cost of medicines,
future medical costs, and ambulance, helicopter, and other
emergency medical services.
Indirect - Uninsured, Hidden Costs - Out of Pocket
Indirect costs are those costs not covered

by insurance. They arent as obvious as
direct costs, but can add up.
Average direct and indirect

accident costs
Non-Lost-time injury:
Lost- time injury:
Fatality:
Examples:
1. Lost time by fellow employees/supervisor.
2. Investigation of accident.
3. Schedule delays.
4. Legal fees.
5. Training costs for new/replacement workers.
6. Damage to tools and equipment.
7. Lower morale.
8. Increased absenteeism.
9. Poorer customer relations.
10. Others?
- Iceberg
$7,000
$28,000
$980,000
Using National Safety Council average

costs for 2000; includes both direct and
indirect costs; excludes property
damage.
Direct to Indirect Accident Cost

Ratios
Studies show that the ratio of indirect to direct
costs can vary widely, from a high of 20:1 to a
low of 1:1. Source: Business Roundtable,
1982.
The basics
Are accidents always unplanned?
____________________________________________________________
____________________________________________________________
____________________________________________________________
Whats the difference between an incident and an accident?

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Characteristics of an Effective Accident Investigation Program

An effective incident/accident analysis program includes:
1. Clearly stated and easy to follow written procedures.
2. Clearly assigned responsibility for conducting accident investigations.
3. All accident investigators will be formally trained on accident investigation
techniques and procedures.
4. Separation of the accident investigation from any potential disciplinary
procedures resulting from the accident. The purpose of the accident
investigation is to get at the facts, not find fault.
5. A written report, addressing the surface causes and root causes, with
recommendations to correct hazardous conditions and work practices, and
those underlying system weaknesses that "caused" them into existence.
6. Follow-up procedures to make sure short and long-term corrective actions
are completed.
7. An annual review of accident reports to make sure root causes are being
addressed and corrected, so that information about the types of accidents,
locations, trends, etc., can be gathered.
The basics
Who should investigate?
____________________________________________________________
____________________________________________________________
____________________________________________________________
Group Exercise - Evaluate a Sample Program
Instructions:
Review the following sample accident investigation program. Edit the program as
you think it should be written.
Does it meet the criteria you said was important?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
What should be added/changed?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Fix The System Incident/Accident Analysis Plan

1.0 General Policy
____________________ considers employees to be our most valued asset and as such we will ensure that all
incident and accidents are analyzed to correct the hazardous conditions, unsafe practices, and improve related
system weaknesses that produced them. This incident/accident analysis plan has been developed to ensure our
policy is effectively implemented.
____________________ will ensure this plan is communicated, maintained and updated as appropriate.
2.0 Incident/Accident Reporting

2.1 Policy. All employees will report immediately to their supervisor, any unusual or out of the ordinary
condition or behavior at any level of the organization that has or could cause an injury or illness of any kind.
Supervisors will recognize employees immediately when an employee reports an injury or a hazard that could
cause serious physical harm or fatality, or could result in production downtime.
2.2 _____________________ will ensure effective reporting procedures are developed so that we can quickly
eliminate or reduce hazardous conditions, unsafe practices, and system weaknesses.
3.0 Preplanning.
Effective incident/accident analysis starts before the event occurs by establishing a well thought-out
incident/accident analysis process. Preplanning is crucial to ensure accurate information is obtained before it is lost
over time following the incident/accident as a result of cleanup efforts or possible blurring of peoples
recollections.
4.0 Incident/Accident Analysis.

4.1 All supervisors are assigned the responsibility for analyzing incidents and accidents in their departments. All
supervisors will be familiar with this plan and properly trained in analysis procedures.
4.2 Each department supervisor will immediately analyze all incidents that might have resulted in serious injury or
fatality. Supervisors will analyze incidents that might have resulted in minor injury or property damage within 4
hours from notification.
4.3 The supervisor will complete and submit a written incident/minor injury report through management levels to
the plant superintendent. If within the capability/authority of the supervisor, corrective actions will begin
immediately to eliminate or reduce the hazardous condition or unsafe work practice that might result in injury or
illness.
4.4 In cases of an incident/accident such as a fire, release, or explosion emergency, the supervisor will:
1. Secure or barricade the scene;
2. Immediately collect transient information;
3. Interview personnel.
5.0 Incident/Accident Analysis Team

5.1 Incident/Accident Analysis Team Makeup
If the supervisor determines that additional assistance is needed for investigation, a team will be compiled and may
include:
1. A third-line or higher supervisor from the section where the event occurred;
2. Personnel from an area not involved in the incident;
3. An engineering and/or maintenance supervisor;
4. The safety supervisor;
5. A first-line supervisor from the affected area;
6. Occupational health/environmental personnel;
7. Appropriate wage personnel (i.e., operators, mechanics, technicians); and,
8. Research and/or technical personnel.
Team member
Department
Shift
Phone
_____________________________ ___________________________
____
____________
_____________________________ ___________________________
____
____________
_____________________________ ___________________________
____
____________
_____________________________ ___________________________
____
____________
_____________________________ ___________________________
____
____________
5.2 The Incident/Accident Analysis Team Leader (Supervisor)

The Incident/Accident Analysis team leader will:
1. Control the scope of team activities by identifying which lines of analysis should be pursued, referred to
another group for study, or deferred;
2. Call and preside over meetings;
3. Assign tasks and establish timetables;
4. Ensure that no potentially useful data source is overlooked; and,
5. Keep site management advised of the progress of the analysis process.
6.0 Determining the Facts

A thorough search for the facts is an important step in incident/accident analysis. During the fact-finding phase of
the process, the supervisor or the team members will:
1. Visit the scene before the physical evidence is disturbed;
2. Sample unknown spills, vapors, residues, etc., noting conditions which may have affected the sample; (Be
sure you sample using proper safety and health procedures.)
3. Prepare visual aids, such as photographs, field sketches, maps, and other graphical representations with the
objective of providing data for the analysis.
4. Obtain on-the-spot information from eyewitnesses, if possible. Interviews with those directly involved and
others whose input might be useful should be scheduled soon thereafter. The interviews should be
conducted privately and individually so that the comments of one witness will not influence the responses
of others.
5. Observe key mechanical equipment as it is disassembled. Include as-built drawings, operating logs, recorder
charts, previous reports, procedures, equipment manuals, oral instruction, change of design records, design
data, records indicating the previous training and performance of the employees involved, computer
simulations, laboratory tests, etc.
6. Determine which incident-related items should be preserved. When a preliminary analysis reveals that an
item may have failed to operate correctly, was damaged, etc., arrangements should be made to either
preserve the item or carefully document any subsequent repairs or modifications.
7. Carefully document the sources of information contained in the incident report. This will be valuable
should it subsequently be determined that further study of the incident or potential incident is necessary.
7.0 Determining the Cause

It is critical to determine the cause(s) of the accident. Therefore, the investigation will uncover:
1. Direct causes
2. Hazardous conditions
3. Unsafe behaviors
The supervisor or team will use appropriate methods to sort out the facts, inferences, and judgments. Even when
the cause of an incident appears obvious, the investigation team will still conduct a formal analysis to make sure
any oversight, or a premature/erroneous judgment, is not made.
8.0 Recommending Corrective Actions and System Improvements

A recommendation for corrective action and system improvement will contain three parts:
1. The recommendation itself, which describes the actions and improvements to be taken to prevent a
recurrence of the incident.
2. The name of the person(s) or position(s) responsible for accomplishing actions and improvements.
3. The correction date(s).
9.0 Communicating Results

9.1 To prevent recurring incidents we will take two additional steps:
1. Document findings; and
2. Review the results of the analysis with appropriate personnel.
9.2 Incident documentation will address the following topics:
1. Description of the incident (date, time, location, etc.);
2. Facts determined during the analysis (including chronology as appropriate);
3. Statement of causes; and
4. Recommendations for corrective and preventive action (including who is responsible and correction date).
10.0 Review and approval

Appropriate operating, maintenance and other personnel will review all incident/accident analysis reports.
Personnel at other facilities will also review the report to preclude a similar occurrence of the incident.
Plan reviewed by __________________________________________ Date _______________________

__________________________________________ Date _______________________
__________________________________________ Date _______________________
Plan approved by __________________________________________ Date _______________________
The basics
Review
Lets review some of the important points about initiating the
accident investigation.
1. What two key conditions must exist before an accident occurs?
2. Are accidents always unplanned?
3. What are the characteristics of an effective incident/accident analysis program?
10
The Six-Step Process
Investigating Accidents
The three primary tasks of the accident investigator are to:
Gather useful information,

Analyze the facts surrounding the accident, and
Write the accident report.
Basic Steps for Conducting An

Accident Investigation/Analysis
Step 1 Preserve and document the scene
Step 2 Collect the facts through interviews
Step 3 Develop sequence of events
Step 4 Determine causes
Step 5 Recommend improvements
Step 6 Write the report
11
The first two steps in the procedure help you gather accurate information about the accident.
Step 1: Preserve and Document the Accident Scene
In this session, we take a look at strategies for preserving and documenting the
accident scene. Well learn why it is important to begin the investigation early-on,
when its safe to investigate. Next, well cover how to secure the accident scene
once the investigation has been initiated. Finally, youll learn what the law says about
reporting accidents to OSHA.
Why is it appropriate to begin the investigation immediately?

____________________________________________________
____________________________________________________
What are effective methods to secure an accident scene?

__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
12

SAMPLE ACCIDENT INVESTIGATORS KIT
Essential
Camera*
Tape recorder and spare cassette tapes
Tape measure - preferably 100 foot
Clipboard and writing pad
Graph paper
Straight-edge ruler (Can be used as a scale reference in photos)
Pens, pencils
Accident investigation forms
Flashlight
Strings, stakes, warning tap
* Digital cameras are not generally recommended is there is a possibility of
legal action, as digital images can be easily altered.
Helpful
Accident investigators checklist
Magnifying glass
Sturdy gloves
High visibility plastic tapes to mark off area
First aid kit
Identification tags
Scotch tape and masking tape
Specimen containers; plastic bags with ties
Compass
Ten 4-inch spikes
Hammer
Paint stick (yellow/black)
Chalk (yellow/white)
Protractor
Video camera
Have a ready-and-waiting accident investigator's kit. You won't be able to fulfill

this purpose unless you come prepared so make sure an accident investigation
kit is available for use.
13
SKETCHING TECHNIQUES
1.
Make sketches large; preferably 8" x 10".
2. Makes sketches clear. Include information pertinent to the investigation.

3. Include measurements.
4. Print legibly. All printing should be on the same plane.
5. Indicate directions, i.e., N, S, E, W.
6. Always tie measurements to a permanent point, e.g., telephone pole, building.
7. Use sketches when interviewing people. You can mark where they were standing. Also,
the sketch can be used to pinpoint where photos were taken.
Example Sketch for a Fatality
Lumber Storage Area, ZYX Sawmill, Ltd.
N
Lumber Piles
Accident-Details
Time: 6.45 p.m.
Lighting: Dusk
Deceased: 61 Tall
Height
Height
Height
8 Ft.
8 Ft.
8 Ft.
Eye Level of Operator: 7

Top of Load: 94
Traveling Speed of Load:
Approx. 5 mph
Location of deceased (face down)

Photo
Location
PointEast
Very Poor Operator

Visibility
Direction of travel of deceased

Mr. J. Operator
Height
Height
Height
Height
Height
8 Ft.
8 Ft.
8 Ft.
8 Ft.
8 Ft.
22 Space
14

Accident Scenario Sketch Exercise
An employee of PC Pallet was fatally crushed by a falling stack of bundled

lumber while picking up building material (2x4 lumber that was 16-feet long)
at a material-handling facility of another company (RRC). The victim was
identifying the bundles of lumber that were going to be purchased by PC
Pallet, while an employee of RRC was operating a powered industrial truck
(forklift) to move bundled lumber in the stacks. Bundles of lumber were
arranged in a row with four stacks. The front stack was four bundles high
(approximately 11 feet). The second and third stacks were each 6 bundles
high (approximately 16.5 feet). The fourth stack was 4 bundles high
(approximately 11 feet). The top (fourth) bundle of the first/front stack had
been moved by a RRC forklift operator and placed on the PC Pallet truck,
which was parked approximately 36 feet from the stacked lumber bundles.
As the third bundle of the first stack was being moved by the forklift, the top
four bundles of the second stack shifted and three of these bundles fell over
the remaining two bundles of the first stack and fatally struck the victim, who
was standing approximately 14 feet from the front stack of lumber. The
stacked lumber was placed on an earthen surface that was damp and had
been exposed to snow and fluctuating temperatures during the past week. It
was reported that the stacks had been leaning forward prior to the accident.
Group Exercise: On a blank piece of paper, sketch the accident scene

for this scenario.
15

Group Exercise:
What documents will you be interested in interviewing?
That's right...you don't just review records, you "interview" them by
asking questions. If you ask . . . they will answer.
Record
_________
Why - What do you expect to find?

_______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________
_______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
_________ _______________________________________________________
16
DOCUMENT ANALYSIS
This document covers the four areas that should be reviewed in determining the
root cause of hazards, accidents and incidents. It is not uncommon to find factors
in each of the four areas: Management, Employee, Equipment and Environment.
Yes
No
Management Checklist
____ ____
1. Did supervisors detect, anticipate, or report an unsafe or hazardous condition?
____ ____
2. Did supervisors recognize deviations from the normal job procedure?
____ ____
3. Did supervisors and employees participate in job review sessions, especially for
those jobs performed on an infrequent basis?
____ ____
4. Were supervisors made aware of their responsibilities for the safety of their
work areas and employees?
____ ____
5. Were supervisors properly trained in the principles of accident prevention?
____ ____
6. Was there any history of personnel problems or any conflicts with or between
supervisors and employees or between employees themselves?
____ ____
7. Did supervisors conduct regular safety meetings with their employees?
____ ____
8. Were the topics discussed and actions taken during the safety meetings
recorded in the minutes?
____ ____
9. Were the proper resources (e.g., equipment, tools, materials, etc.) required to
perform the job or task readily available and in proper condition?
____ ____
10. Did supervisors ensure employees were trained and proficient before
assigning them to their jobs?
____ ____
11. Did management properly research the background and experience level of
employees before extending an offer of employment?
Question #
Comments:
_________
_______________________________________________________________________
_________
_______________________________________________________________________
_________
_______________________________________________________________________
_________
_______________________________________________________________________
17
DOCUMENT ANALYSIS
Employee Checklist
Yes
No
____ ____
1. Did a written or well-established procedure exist for employees to follow?
____ ____
2. Did job procedures or standards properly identify the potential hazards of job
performance?
____ ____
3. Were employees familiar with job procedures?
____ ____
4. Was there any deviation from the established job procedures?
____ ____
5. Did any mental or physical conditions prevent the employee(s) from properly
performing their jobs?
____ ____
6. Were there any tasks in the job considered more demanding or difficult than
usual (e.g., strenuous activities, excessive concentration required, etc.)?
____ ____
7. Was the proper personal protective equipment specified for the job or task?
____ ____
8. Were employees trained in the proper use of any personal protective

equipment?
___ _____
9. Did the employees use the prescribed personal protective equipment?
____ ____
10. Were employees trained and familiar with the proper emergency procedures,
including the use of any special emergency equipment?
____ ____
11. Was there any indication of misuse or abuse of equipment and/or materials
at the accident site?
____ ____
12. Is there any history or record of misconduct or poor performance for any
employee involved in this accident?
____ ____
13. If applicable, are all employee certification and training records current and
up-to-date?
____ ____
14. Was there any shortage of personnel on the day of the accident?
Question # Comments:
_________
_______________________________________________________________________
_________
_______________________________________________________________________
_________
_______________________________________________________________________
_________
_______________________________________________________________________
18
DOCUMENT ANALYSIS
Equipment Checklist
Yes
No
____ ____
1. Were there any defects in equipment (including materials and tools) that
contributed to a hazard or created an unsafe condition?
____ ____
2. Were the hazardous or unsafe conditions recognized by management,

employees, or both?
____ ____
3. Were the recognized hazardous conditions properly reported?
____ ____
4. Are existing equipment inspection procedures adequately detecting hazardous

or unsafe conditions?
____ ____
5. Were the proper equipment and tools being used for the job?
____ ____
____ ____
6. Were the correct/prescribed tools and equipment readily available at the job
site?
____ ____
7. Did employees know how to obtain the proper equipment and tools?
____ ____
8. Did equipment design contribute to operator error?
____ ____
9. Was all necessary emergency equipment readily available?
____ ____
10. Did emergency equipment function properly?
____ ____
11. Is there any history of equipment failure for the same or similar reasons?
____ ____
12. Has the manufacturer issued warnings, Safe-Alerts, or other such

information pertaining to this equipment?
____ ____
13. Were all equipment guards and warnings functioning properly at the time of
the accident?
Question #
Comments:
_________
_______________________________________________________________________
_________
_______________________________________________________________________
_________
_______________________________________________________________________
_________
_______________________________________________________________________
19
DOCUMENT ANALYSIS
Environment Checklist
Yes
No
____ ____
1. Did the location of the employees, equipment, and/or materials contribute to

the accident?
____ ____
2. Were there any hazardous environmental conditions that may have contributed
to the accident?
____ ____
3. Were the hazardous environmental conditions in the work area recognized by

employees or supervision?
____ ____
4. Were any actions taken by employees, supervisors, or both to eliminate or

control environmental hazards?
____ ____
5. Were employees trained to deal with any hazardous environmental conditions

that could arise?
____ ____
6. Were employees not assigned to a work area present at the time of the
accident?
____ ____
7. Was sufficient space provided to accomplish the job?
____ ____
8. Was there adequate lighting to properly perform all the assigned tasks
associated with the job?
____ ____
9. Did unacceptable noise levels exist at the time of the accident?
____ ____
10. Was there any known leak of hazardous materials such as chemicals,
solvents or air contaminants?
____ ____
11. Were there any physical environmental hazards, such as excessive vibration,
temperature extremes, inadequate air circulation, or ventilation problems?
____ ____
12. If applicable, were there any hazardous environmental conditions, such as

inclement weather, that may have contributed to the accident?
____ ____
13. Is the layout of the work area sufficient to preclude or minimize the possibility
of distractions from a passerby or from other workers in the area?
____ ____
14. Is there a history of environmental problems in this area?
Question #
Comments:
_________
______________________________________________________________________
_________
_______________________________________________________________________
_________
_______________________________________________________________________
_________
_______________________________________________________________________
20

Quiz
Lets review some of the important points about preserving and
documenting the accident scene.
1.
What's the most practical way to secure an accident scene?
2.
What might be the result if the investigation is not initiated as soon

as possible?
3.
If a workplace fatality or hospitalization of three or more employees

occurs, the affected employer must notify OSHA within _____.
a.
twenty-four hours c. eight hours
b.
sixteen hours
d. four hours
4.
When documenting the scene, one of the biggest challenges facing

the investigator is to:
a. determine who is to blame
b. determine what is relevant
c. determine who is in charge
d. determine who is liable
21
Step 2: Collect Facts through Interviews
Introduction
Once you have initially preserved and documented the accident scene, it becomes
important to start digging for details through the interview process. Conducting an
interview is perhaps the most difficult part of an investigation. This section will help
you understand how to organize the interview and obtain accurate information.
When is it best to interview? Why?

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Whom should we interview? Why?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Where should we conduct the interview?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
When should we NOT interview?
________________________________________________________
________________________________________________________
22

Group Exercise: Cooperation is the Key
Purpose. Gaining as much information as possible about

an accident is extremely important. Interviewing witnesses
is both a science and an art, and can make the difference
between a failed or a successful accident investigation.
This exercise will help you gain a greater awareness of those
interviewing questions you need to prepare for the
interview and help ensure your success as an investigator. Remember,
you must communicate a message of cooperation, not intimidation.
Instructions. Read the accident scenario provided. Your group is located at the
scene of the accident (classroom) and your job now is to ask follow-up questions to
gather information about the accident. Identify the person you are interviewing and
the questions you will ask.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Did You Get the Facts?
23
Mary Alice Conlin - Application Case Study (Page 1)
The accident occurred on a Walsh 55-ton full-revolution mechanical power

press. Mary Alice Conlin lost three fingers and part of her thumb on the
right hand when she reached into the press to extract a part.
The maintenance man did not secure the shield a week before the injury
event as he was in a hurry to get to another machine breakdown. Besides,
he needed a part to fix this press and had to wait for the part to be ordered.
The press was foot pedal operated with a point of operation guard. The foot
pedal was not guarded. The guard had a flip-up plexi-glass shield on the
front that was hinged, not fixed in place (secured). The employee (Mary
Alice) was removing a piece of metal that was stuck in the die. The guard
was flipped open. While removing the scrap part, she accidentally stepped
on the foot pedal. The employee lost 3 fingers and part of her thumb on the
right hand. She had been a press operator for 3 days. At approximately
9:00 a.m., employee #2 heard Mary Alice scream and ran to her while
shouting for help.
Employee #3, the designated first aider, heard the scream. He grabbed his
first aid kit and ran to Mary Alice to render first aid treatment. At
approximately 9:05 a.m., employee #2 ran to the supervisors office and the
rescue squad was called. Approximately 10 minutes later, the rescue squad
arrived and rendered treatment to stabilize Mary Alice who appeared to be
in shock. The rescue squad transported Mary Alice to the emergency room
at 9:30 a.m.
24
INTERVIEWING QUESTIONS
WHO?
WHERE?
Who was injured

Who saw the accident
Who was working with the employee
Who had instructed/assigned the employee
Who else was involved
Who else can help prevent recurrence
Where did the accident occur

Where was the employee at the time
Where was the supervisor at the time
Where were fellow workers at the time
Where were other people who were involved at
the time
Where were witnesses when accident occurred
WHAT?
WHY?
What was the accident

What was the injury
What was the employee doing
What had the employee been told to do
What tools was the employee using
What machine was involved
What operation was the employee performing
What instructions had the employee been given
What specific precautions were necessary
What specific precautions was the employee
given
What protective equipment should have been
used
What protective equipment was the employee
using
What had other persons done that contributed to
the accident
What problem or questions did the employee
encounter
What did the employee or witnesses do when the
accident occurred
What extenuating circumstances were involved
What did the employee or witnesses see
What will be done to prevent recurrence
What safety rules were violated
What new rules are needed
Why was the employee injured

Why and what did the employee do
Why and what did the other person do
Why wasnt protective equipment used
Why werent specific instructions given to the
employee
Why was the employee in the position
Why was the employee using the tools or
machine
Why didnt the employee check with the
supervisor when the employee noted
things werent as they should be
Why did the employee continue working under
the circumstances
WHEN?
HOW?
When did the accident occur

When did the employee start on that job
When was the employee assigned on the job
When were the hazards pointed out to the
employee
When had the employees supervisor last
checked on job progress
When did the employee first sense something
was wrong
How did the employee get injured

How could the employee have avoided it
How could fellow workers have avoided it
How could supervisor have prevented it - could it
be prevented
Why wasnt the supervisor there at the time
25
Quiz
Lets review some of the important points about collecting
information on the accident.
1.
What relevant information might be obtained by reviewing the

OSHA Injury and Illness records?
2.
What is the purpose of the interview process. How do you best

achieve that purpose?
3.
Which of the following is an effective interview techniques?

a. Ask "why-you" questions
b. Ask open-ended questions
c. Interview in a crowd
d. Encourage fault-finding
4.
Why is it important to repeat the facts and sequence of events back

to the interviewee?
26
Step 3: Develop the Sequence of Events

Group Exercise: Develop the Sequence
Use the information gathered about the accident described in
the interview exercise to construct a sequence of events
listing the events prior to, during, and after the accident.
Instructions. Determine the injury event and list the events that led up to the
injury. Once you start the sequence, ask "What happened next? to determine the next
event.
Event __
____________________________________________________________
Event __
__________________________________________________________________
Event __
__________________________________________________________________
Event __
__________________________________________________________________
Event __
____________________________________________________________
Event __
__________________________________________________________________
Event __
__________________________________________________________________
Event __
__________________________________________________
Event __
____________________________________________________________
Event __
____________________________________________________________
Event __
____________________________________________________________
Event __
____________________________________________________________
Event __
____________________________________________________________
27
Step 3: Develop the Sequence of Events

Quiz
Lets review some of the important points about developing a
sequence of events on the accident.
1.
An event occurs when one _______ performs an _______.
2.
Name the actor(s)/action(s) for the following: Robert used a wrench to pound
a nail.
3.
Developing the sequence of events is critical in the accident analysis process

to:
a. Find out who to interview
b. Fix the system
c. Place the blame
d. Document the scene
28
Step 4: Determine the Causes
Multiple Causation and the Accident Weed

Injury Analysis
or
1. Direct Causes ofInjury
the Injury
Always the harmfulIllness
transfer of energy.
Kinetic, thermal, chemical, etc.
Contact with, exposure too, etc.
Strains
Burns
Cuts
Conditions
Un
gu
Acts
ar
de
2. Indirect (Surface) Causes of Accident

m
ac
hi
ne
Ho
Bro
ken
te
Crea
too
ls
C h em
ical s
Ignore
pill
Defe
ctive
Untrained
No accountability policy
rt in
jury
Contributing Indirect Causes

Contributes to the accident
Unique hazardous condition
Inappropriate/unsafe behavior
Exists/occurs more distant from the accident
Exists/occurs anytime, anywhere by anyone
ain
Lack of vision No mission statement
Inadequate training plan
rd
Fails to tr
Too much
work
work
To much
No orientation process
a haza
Fails to enforce
Lack of time
No discipline procedures
ard
Fails to inspect
worker
Inadequate training
a h az
rep o
s to
Fail
PPE
Event Analysis
Primary Surface Causes
Produces the accident
Unique hazardous condition/unsafe behavior
Exists/Occurs close to the injury event
Involves the victim, possibly others
play
rse
3. Basic (Root) Causes of the Accident

No recognition
System Analysis
Inadequate system implementation
Failure to carry out safety policies, programs,
plans, processes, procedures, practices
Pre-exist indirect causes
Under control of management
Failure can occur anytime, anywhere
Produces common indirect causes
Inadequate labeling
Outdated hazcom program

No recognition plan
No inspection policy
Inadequate system design

Poorly written or missing policies, programs,
plans, processes, procedures, practices
Pre-exist indirect causes
Under top management control
Produces inadequate implementation
Any way you look at it, design is the key to

an effective safety management system.
If design is flawed, yet perfectly implemented, the
system fails. If design is perfect, yet
implementation is flawed, the system fails as a
result of design flaws in other related processes.
29
Steps in Root Cause Analysis: Three Levels of Cause Analysis

1. Injury Cause Analysis. Analyze the injury event to identify and describe the nature of the
harmful transfer of energy that caused the injury or illness.
Examples:
Laceration to right forearm resulting from contact with rotating saw blade.
Contusion from head striking against/impacting concrete floor.

2. Indirect (Surface) Cause Analysis. Analyze events to determine specific hazardous
conditions and unsafe or inappropriate behaviors.
a.
For primary indirect causes. Analyze events occurring just prior to the injury
event to identify those specific conditions and behaviors that directly caused the
accident.
Examples:
Event x. Unguarded saw blade. (condition or behavior?)
Event x. Working at elevation without proper fall protection. (condition or

behavior?)
b.
For contributing indirect causes. Analyze conditions and behaviors to determine

other specific conditions and behaviors (contributing causes) that contributed to the
accident.
Examples:
Supervisor not performing weekly area safety inspection. (condition or

behavior?)
Fall protection equipment missing. (condition or behavior?)

3. Root Cause Analysis. Analyze system weaknesses contributing to indirect causes.
a.
For inadequate implementation. 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.

b.
For inadequate design. Analyze implementation flaws to determine the underlying

inadequate formal (written) programs, policies, plans, processes, procedures and
practices.
Examples:
Inspection policy does not clearly specify responsibility by name or position.
No fall protection training plan or process in place.
30
Class Exercise
List some of the possible causes of the accident according to the multiple
cause theory. Dont spend a lot of time on this exercise. There will be
additional exercises to determine direct, indirect and root causes of the
accident.
What may be the cause of causes of the accident according to the
multiple cause theory?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Direct Cause
Provide the information below for the accident scenario.
Injury Result
Caused by (transfer)
Object/Energy Source
_________________________________________________________
31
ACCIDENT TYPES THAT DESCRIBE TRANSFER OF ENERGY

STRUCK-BY. A person is forcefully struck by an object. The force of contact is
provided by the object. Example -- a pedestrian is truck by a moving vehicle.
STRUCK-AGAINST. A person forcefully strikes an object. The person provides the
force. Example -- a person strikes a leg on a protruding beam.
CONTACT-BY. Contact by a substance or material that by its very nature is harmful
and causes injury. Example -- a person is contacted by steam escaping from a pipe.
CONTACT-WITH. A person comes in contact with a harmful material. The person
initiates the contact. Example -- a person touches the hot surface of a boiler.
CAUGHT-ON. A person or part of his/her clothing or equipment is caught on an
object that is either moving or stationary. This may cause the person to lose his/her
balance and fall, be pulled into a machine, or suffer some other harm. Example a
person snags a sleeve on the end of a hand rail.
CAUGHT-IN. A person or part of him/her is trapped, stuck, or otherwise caught in
an opening or enclosure. Example -- a persons foot is caught in a hole in the floor.
CAUGHT-BETWEEN. A person is crushed, pinched or otherwise caught between
either a moving object and stationary object or between two moving objects.
Example -- a persons finger is caught between a door and its frame.
FALL TO SURFACE. A person slips or trips and falls to the surface he/she is
standing or walking on. Example -- a person trips on debris in the walkway and falls.
FALL-TO-BELOW. A person slips or trips and falls to a surface level below the one
he/she was walking or standing on. Example -- a person trips on a stairway and falls
to the floor level below.
EXERTION. Someone over-exerts or strains him or herself while doing a job.
Examples -- a person lifts a heavy object or a person repeatedly twists the torso to
place materials on a table. Interaction with objects, materials, etc., is involved.
BODILY REACTION. Caused solely from stress imposed by free movement of the
body or assumption of a strained or unnatural body position.. Example - a person
bends or twists to reach a valve and strains back.
EXPOSURE. Over a period of time, someone is exposed to harmful conditions.
Example -- a person is exposed to levels of noise in excess of 90 dBa for 8 hours.
32

Group Exercise: Event Analysis (Indirect cause)
Determine the primary indirect causes for the accident scenario.

Look for specific employee acts/behaviors and hazardous conditions
that caused the injury.
Examples
Event x. Unguarded saw blade. (act or condition?)
Event x. Working at elevation without proper fall protection. (act or condition?)
Event
Act(s)_____________________________________________________
Condition(s)________________________________________________
Event
Act(s)_____________________________________________________
Condition(s)________________________________________________
Event
Act(s)_____________________________________________________
Condition(s)________________________________________________
The contributing indirect causes are also specific acts/behaviors and

conditions.
Examples:
Supervisor not performing weekly area safety inspection. (act or condition?)
Fall protection equipment missing. (act or condition?)
Responsible person not trained on how to hook up harness. (act or condition?)
Event
Act(s)_____________________________________________________
Condition(s)________________________________________________
Event
Act(s)_____________________________________________________
Condition(s)________________________________________________
33

Group Exercise: System Analysis (Root Cause)
Get to the roots by asking Why? Why? Why?
Instructions. Analyze each indirect cause to identify
potential root cause(s) that contributed to or produced the
accident.
Determine system implementation weaknesses. Look for the common

behaviors that represent inadequate implementation of safety programs and
processes. Its important to understand that poor implementation of one program area
may be the result of poor implementation in another safety management program area:
Management commitment and accountability
Employee involvement
Worksite analysis
Hazard identification & control
Education & training
Safety system evaluation
System Implementation Root Causes
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
34
Group Exercise:
Determine system design weaknesses. Then ask why to determine the
inadequate/missing policies and plans that caused them. These are common
conditions.
Inspection policy does not clearly specify responsibility by name or position
No fall protection training plan or process in place
Procedures for administering corrective actions absent from the
accountability plan
System Design Root Causes
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
35

Team Exercise: Digging up the roots
1.
2.
3.
4.
Enter the direct cause of injury within the box below.

List hazardous condition and unsafe behavior from the sequence of events.
Determine contributing causes for the hazardous
condition and unsafe act/behavior.
Determine implementation and design root causes for contributing causes.
Direct Cause of Injury
________________________________
________________________________
Hazardous Conditions
Unsafe Behaviors
__________________________________
_________________________________
__________________________________
_________________________________
Contributing conditions/behaviors
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
Implementation root causes

__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
Design Root Causes

__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
__________________________________
_________________________________
36
Here is another way to put the information together.

1. Injury Event (injury, illness, other losses). Pinpoint the problem and enter within 1st rectangle.
2. Sequence. Develop sequence of events from start to finish, based on interviews and physical evidence. Describe each
event as an occurrence with one noun/verb. Describe the events precisely as they happen. Enter into the 2nd rectangle.
3. Injury Analysis (direct cause). Analyze the injury event to identify and describe the direct cause of the injury and enter
within the 3rd rectangle.
4. Event Analysis (indirect cause-acts/conditions). After the sequence of events is established, the causes of each event
can be described. This involves asking why, why, why, why, why. You may decide not to ask questions for all events in the
sequence, just the ones critical for understanding the causes. Determine indirect causes (hazardous condition and unsafe
behavior) from the sequence of events. Enter within the 4th rectangle.
5. System Analysis (root cause). The last step is to find the root causes, the procedures, standards, controls that
management did not design or failed to implement. Continue asking why in order to develop the information needed to
establish the root causes. Root causes are usually not physical things. They are program and/or related behavioral
inadequacies. Determine system design and system implementation causes for each of the indirect causes. Enter in 5th
rectangle.
Fix the System . . Not the Blame!

The Situation
(injury, illness, other
losses)
1. Injury Event
2. Sequence of Events
Brakes failed and Ike

drove off the dock
Ike in hospital
1. Brake fluid leaked from master cylinder overnight
Forklift a total loss
2. Ike assigned to operate forklift, 2nd day on job; no training
Lost production
3. Brakes not checked before using forklift

4. Barrier guard removed from dock to install new conveyors
EPA involvement
5. Barrier guard not replac ed
Lawsuits
6. Brakes on forklift failed
7. Ike drove off the dock
8. Rescue squad transported Ike to hospital
9. Cleanup of hazardous materials started
10. EPA contacted
3. Injury Analysis
Direct Cause
Impact following a 12 foot fall
from dock to concrete floor,
causing a broken back
4. Event AnalysisIndirect Cause

(act or condition)
Not inspecting vehicle (act)
Ike not trained (condition)
Vehicle driven without
sufficient brake fluid
(condition)
5. System Analysis-Root
Cause (procedures,
standards, controls)
Operator not trained (implementation)
Protective barrier removed

from dock, presenting
exposure (condition)
Supervisor failed to inspect for
barrier (act)
37
Selection criteria less than adequate (design)

Maintenance procedures not adequate
(implementation/design)
No inspection policy (design)

Quiz
Lets review some of the important points about cause analysis.
1.
Which theory below states, An accident is the result of a series of related events:
Eliminate any one event and you prevent a future accident?
a. Single event theory
b. Domino theory
c. Multiple cause theory
d. System weakness theory
2.
The three phases of cause analysis are:
3.
The underlying safety system weakness are called the:
38
Step 5: Develop Recommendations

Group Exercise: Recommending Corrective Actions
Instructions: In this exercise youll develop and recommend immediate
actions to correct the surface causes of an accident. 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.
Recommendation: ________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Group Exercise: Recommendations for System Improvements

Fix the systemnot the blame
Instructions. Develop and write a recommendation to improve one or
more policies, plans, programs, processes, procedures, and
practices related to the accident scenario.
Recommendation:
_____________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
39
Answer the following six questions to help develop and justify recommendations.
1.
2.
3.
4.
5.
6.
Pinpoint the problem

What is the history of the problem?
Pinpoint the specific solution.
Who is the decision-maker?
What motivates the decision-maker?
What will be the cost/benefits if the recommendation is
approved and the predictable cost/benefits if not?
Determine the costs

To calculate direct cost, enter the following:
Most likely injury:
Total value of the insurance claim for injury or illness
To calculate indirect cost, multiply direct cost by a cost multiplier.

The cost multiplier that you use will depend on the size of the direct cost.
If your direct
cost is:
Use this cost

multiplier:
$0 - $2,999
$3,000 - $4,999
$5,000 - $9,999
$10,000 or more
Direct Cost
$
Cost Multiplier
4.5
1.6
1.2
1.1
=
Indirect Cost
What are the total direct and indirect accident costs?

Direct Costs $ ________ + Indirect Costs $ __________ = $_________
Return on Investment (ROI): Benefits = Costs minus investment
ROI = Benefits
=
Investment
40
Step 5: Develop Recommendations

Quiz
Lets review some of the important points about developing
recommendations.
1.
(Fill in the blank) When making recommendations, we need to propose

corrective actions ____ system improvements.
a. instead of
b. or
c. rather than
d. and
2.
Engineering controls include all of the following except:

a. Substitution
b. Enclosure
c. Rescheduling
d. Redesign
3.
Which control strategy is most effective in eliminating hazards?

a. Engineering Controls
b. Management Controls
c. PPE Control
d. Personnel Controls
4.
All of the following are safety management system improvements except:

a. Writing a new safety policy.
b. Establishing a proactive incentive program.
c. Placing a guard on a table saw.
d. Revising an accident investigation form.
41
ACCIDENT INVESTIGATION REPORT

Date:___________________
Accident Investigator(s) ___________________ Dept. ______________ Tel #____________________
____________________________________________________________________
Section I. BACKGROUND
WHO was involved or injured?
Employee:
Address:
Job Title:
Department:
Phone: Home: Work:
Date of birth: Date hired:
Male/Female
Name of physician or other health care professional:
Name/Location of Treatment Center:
Was employee treated in an emergency room: Yes/No
Was employee hospitalized overnight? Yes/No
Length of Service:
WHEN did accident/incident occur?

Date of Injury or Illness:
Time of Accident: ___ AM/PM
Date Accident Reported:
Time Employee began work: ___ AM/PM
WHERE did the accident/incident occur?

Department:
Location:
Equipment:
WHAT happened?
What was employee doing just before accident occurred:
What happened:
What was the injury or illness:
What object or substance directly harmed the employee:
WITNESSES: Attach witness information and statements
42
Section II. DESCRIPTION OF ACCIDENT (Describe sequence of events prior to, during, and immediately
after the accident. Attach separate page if necessary)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Section III. FINDINGS AND JUSTIFICATIONS (Attach separate page if necessary)
Indirect Cause(s) Unsafe conditions and/or behaviors at any level of the organization;
& justification: Describe evidence or proof that substantiates your findings.
__________________________________________________________________________
__________________________________________________________________________
Root Cause(s) Missing/inadequate programs, plans, policies, processes, procedures; &

justification: Describe evidence or proof that substantiates your findings.
__________________________________________________________________________
__________________________________________________________________________
Section IV. RECOMMENDATIONS (Attach separate page if necessary)
1.
Immediate Corrective Actions (To eliminate or reduce the hazardous conditions/unsafe

behaviors that directly caused the accident.)
_______________________________________________________________________________
_______________________________________________________________________________
Results (Describe the intended results and positive impact of the change.)
_______________________________________________________________________________
2.
Long Term Corrections (policies, procedures, training, etc. to ensure unsafe conditions and/or
practices do not recur)
_______________________________________________________________________________
_______________________________________________________________________________
Results (Describe the intended results and positive impact of the change.)
_______________________________________________________________________________
Section V. SUMMARY (Brief review of the causes of the accident and recommendations for corrective
actions, including estimated costs of accident and costs and benefits of corrective action)
_______________________________________________________________________________
Section VI. REVIEW AND FOLLOW-UP ACTIONS (Appropriate, timely, etc.)
Immediate Corrective Actions Taken:
Responsible Individual:
Date Correction Due:
Date Closed:
Long Term (System Improvements) Made:
Responsible Individual:
Date Correction Due:
Date Closed:
Person(s) monitoring status of follow-up actions: _______________________
Prepared by __________________Title _________________ Date ________

Reviewed by _________________ Title _________________ Date ________
Reviewed by _________________ Title _________________ Date ________
Section VII. ATTACHMENTS (Photos, sketches, interview notes, etc.)
43
Step 6: Write the Report

Lets review some important points about writing the report.
1.
Your primary objective, as an accident investigator, is to:

a. inform the employer about options
b. place blame on those responsible
c. hold the employer accountable for compliance with OSHA
d. uncover the causal factors that contributed to the accident
2.
The accident report form should be designed to make it possible to determine:

a.
b.
c.
d.
3.
indirect causes
root causes
direct causes
All of the above
The accident report should not be considered closed until:

a. It is signed by the investigators
b. It is presented to management
c. All actions are complete
d. The accident is recorded on the OSHA forms
44
Putting It Together
Group Exercise:
Putting it All Together
Instructions: Now that youve been introduced to the sixstep process, its time to do an accident investigation on
your own. Using some of the training aids from the
course (Sequence of Events, Cause Analysis Diagram,
Report) conduct your own investigation. This exercise
will give you practice in completing using a lot of the
information gained from this course. Be thorough and
use extra paper if needed.
45

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Accident investigation definitions

Characteristics of an effective program

Step 1: Preserving and documenting the accident scene

Step 2: Collecting the facts through interviews

Step 3: Developing sequence

Step 4: Determining causes

Step 5: Developing effective recommendations

Tools and techniques to measure costs/benefits

Step 6: Writing the report

This material is for training purposes only.

Identify basic accident investigation concepts and describe the characteristics

What 2 key conditions must exist before an accident occurs?

What causes most accidents?

Hazardous conditions account for __% of all workplace accidents.

Unsafe/inappropriate behaviors account for __% of all workplace

Uncontrollable acts account for ___% of all workplace accidents

Management is able to control factors that produce ____ % of all

What is the difference between accident investigation and

Does your organization conduct accident investigations for

Introduction to Accident Investigation

This material is for training purposes only.

What do accidents cost your company?

1.Workers compensation premiums

Indirect - Uninsured, Hidden Costs - Out of Pocket

Indirect costs are those costs not covered

Average direct and indirect

Introduction to Accident Investigation

Using National Safety Council average

Direct to Indirect Accident Cost

This material is for training purposes only.

Whats the difference between an incident and an accident?

Characteristics of an Effective Accident Investigation Program

Introduction to Accident Investigation

This material is for training purposes only.

Group Exercise - Evaluate a Sample Program

Introduction to Accident Investigation

This material is for training purposes only.

Fix The System Incident/Accident Analysis Plan

2.0 Incident/Accident Reporting

4.0 Incident/Accident Analysis.

Introduction to Accident Investigation

This material is for training purposes only.

5.0 Incident/Accident Analysis Team

Introduction to Accident Investigation

This material is for training purposes only.

5.2 The Incident/Accident Analysis Team Leader (Supervisor)

6.0 Determining the Facts

7.0 Determining the Cause

Introduction to Accident Investigation

This material is for training purposes only.

8.0 Recommending Corrective Actions and System Improvements

9.0 Communicating Results

10.0 Review and approval

Plan reviewed by __________________________________________ Date _______________________

Introduction to Accident Investigation

This material is for training purposes only.

1. What two key conditions must exist before an accident occurs?

2. Are accidents always unplanned?

3. What are the characteristics of an effective incident/accident analysis program?

Introduction to Accident Investigation

This material is for training purposes only.

The Six-Step Process

Plan reviewed by ____________________ Date _